Team reports long-term effects of blood management


Photo by Elise Amendola

Blood for transfusion

An initiative that reduced red blood cell (RBC) transfusions and increased moderate anemia in hospital did not adversely impact patients long-term, according to an analysis.

Researchers found that an increase in moderate in-hospital anemia did not increase subsequent RBC use, readmission, or mortality over the next 6 months.

However, authors of a related editorial argued that additional factors must be assessed to truly determine the effects of moderate anemia on patient outcomes.

The study and the editorial were published in the Annals of Internal Medicine.

Study: Long-term outcomes

Nareg H. Roubinian, MD, of Kaiser Permanente Northern California in Oakland, and colleagues sought to evaluate the impact of blood management programs—starting in 2010—that included blood-sparing surgical and medical techniques, increased use of hemostatic and cell salvage agents, and treatment of suboptimal iron stores before surgery.

In previous retrospective cohort studies, the researchers had found that blood conservation strategies did not impact in-hospital or 30-day mortality rates, which was consistent with short-term safety data from clinical trials and other observational studies.

Their new report on longer-term outcomes was based on data from Kaiser Permanente Northern California for 445,371 adults who had 801,261 hospitalizations with discharges between 2010 and 2014.

In this cohort, moderate anemia (hemoglobin between 7 g/dL and 10 g/dL) at discharge occurred in 119,489 patients (27%) and 187,440 hospitalizations overall (23%).

Over the 2010-2014 period, RBC transfusions decreased by more than 25% in the inpatient and outpatient settings. In parallel, the prevalence of moderate anemia at hospital discharge increased from 20% to 25%.

However, the risks of subsequent RBC transfusions and rehospitalization after discharge with anemia decreased during the study period, and mortality rates stayed steady or decreased slightly.

Among patients with moderate anemia, the proportion with subsequent RBC transfusions within 6 months decreased from 18.9% in 2010 to 16.8% in 2014 (P<0.001), while the rate of rehospitalization within 6 months decreased from 36.5% to 32.8% over that same time period (P<0.001).

The adjusted 6-month mortality rate likewise decreased from 16.1% to 15.6% (P=0.004) over that time period among patients with moderate anemia.

“These data support the efficacy and safety of practice recommendations to limit red blood cell transfusion in patients with anemia during and after hospitalization,” the researchers wrote.

However, they also said additional studies are needed to guide anemia management, particularly since persistent anemia has impacts on quality of life that are “likely to be substantial” and linked to the severity of that anemia.

This study was supported by a grant from the National Heart, Lung, and Blood Institute. Dr. Roubinian and several coauthors reported grants from the National Institutes of Health.

Editorial: Aim to treat anemia, not tolerate it

Dr. Roubinian and his colleagues’ findings warrant some scrutiny, according to Aryeh Shander, MD, of Englewood Hospital and Medical Center in New Jersey, and Lawrence Tim Goodnough, MD, of Stanford University in California.

“Missing here is a wide spectrum of morbidity outcomes and issues related to diminished quality of life that do not reach the level of severity that would necessitate admission but nonetheless detract from patients’ health and well-being,” Drs. Shander and Goodnough wrote in a related editorial.

They also noted that transfusion rate is not a clinical outcome, adding that readmission and mortality are important outcomes, but they do not accurately or fully reflect patient well-being.

While blood management initiatives may be a safe practice, as the study suggests, proper management of anemia after discharge may actually improve outcomes, given the many consequences of anemia, Drs. Shander and Goodnough wrote.

The pair suggested that, instead of again testing whether restricting transfusions is acceptable because of lack of impact on outcomes, future studies could evaluate a “more sensible” hypothesis that proper anemia management, especially post-discharge, could improve outcomes.

“Let’s increase efforts to prevent and treat anemia properly, rather than requiring patients to tolerate it,” Drs. Shander and Goodnough wrote.

Dr. Shander reported consulting fees from Vifor and AMAG. Dr. Goodnough reported having no relevant financial disclosures.

Next Article: