Transfusion Strategies for Acute Upper Gastrointestinal Bleeding
Por:
Villanueva, C, Colomo, A, Bosch, A, Concepcion, M, Hernandez-Gea, V, Aracil, C, Graupera, I, Poca, M, Alvarez-Urturi, C, Gordillo, J, Guarner-Argente, C, Santalo, M, Muniz, E, Guarner, C
Publicada:
3 ene 2013
Resumen:
BACKGROUND
The hemoglobin threshold for transfusion of red cells in patients with acute gastrointestinal bleeding is controversial. We compared the efficacy and safety of a restrictive transfusion strategy with those of a liberal transfusion strategy.
METHODS
We enrolled 921 patients with severe acute upper gastrointestinal bleeding and randomly assigned 461 of them to a restrictive strategy (transfusion when the hemoglobin level fell below 7 g per deciliter) and 460 to a liberal strategy (transfusion when the hemoglobin fell below 9 g per deciliter). Randomization was stratified according to the presence or absence of liver cirrhosis.
RESULTS
A total of 225 patients assigned to the restrictive strategy (51%), as compared with 65 assigned to the liberal strategy (15%), did not receive transfusions (P<0.001). The probability of survival at 6 weeks was higher in the restrictive-strategy group than in the liberal-strategy group (95% vs. 91%; hazard ratio for death with restrictive strategy, 0.55; 95% confidence interval [CI], 0.33 to 0.92; P = 0.02). Further bleeding occurred in 10% of the patients in the restrictive-strategy group as compared with 16% of the patients in the liberal-strategy group (P = 0.01), and adverse events occurred in 40% as compared with 48% (P = 0.02). The probability of survival was slightly higher with the restrictive strategy than with the liberal strategy in the subgroup of patients who had bleeding associated with a peptic ulcer (hazard ratio, 0.70; 95% CI, 0.26 to 1.25) and was significantly higher in the subgroup of patients with cirrhosis and Child-Pugh class A or B disease (hazard ratio, 0.30; 95% CI, 0.11 to 0.85), but not in those with cirrhosis and Child-Pugh class C disease (hazard ratio, 1.04; 95% CI, 0.45 to 2.37). Within the first 5 days, the portal-pressure gradient increased significantly in patients assigned to the liberal strategy (P = 0.03) but not in those assigned to the restrictive strategy.
CONCLUSIONS
As compared with a liberal transfusion strategy, a restrictive strategy significantly improved outcomes in patients with acute upper gastrointestinal bleeding. (Funded by Fundacio Investigacio Sant Pau; ClinicalTrials.govnumber, NCT00414713.)
Filiaciones:
Villanueva, C:
Autonomous Univ Barcelona, Hosp St Pau, Gastrointestinal Bleeding Unit, Dept Gastroenterol, Barcelona, Spain
Ctr Invest Biomed Red Enfermedades Hepat & Digest, Barcelona, Spain
Colomo, A:
Autonomous Univ Barcelona, Hosp St Pau, Gastrointestinal Bleeding Unit, Dept Gastroenterol, Barcelona, Spain
Ctr Invest Biomed Red Enfermedades Hepat & Digest, Barcelona, Spain
Bosch, A:
Autonomous Univ Barcelona, Hosp St Pau, Blood & Tissue Bank, Barcelona, Spain
Concepcion, M:
Autonomous Univ Barcelona, Hosp St Pau, Gastrointestinal Bleeding Unit, Dept Gastroenterol, Barcelona, Spain
Hernandez-Gea, V:
Autonomous Univ Barcelona, Hosp St Pau, Gastrointestinal Bleeding Unit, Dept Gastroenterol, Barcelona, Spain
Aracil, C:
Autonomous Univ Barcelona, Hosp St Pau, Gastrointestinal Bleeding Unit, Dept Gastroenterol, Barcelona, Spain
Graupera, I:
Autonomous Univ Barcelona, Hosp St Pau, Gastrointestinal Bleeding Unit, Dept Gastroenterol, Barcelona, Spain
Ctr Invest Biomed Red Enfermedades Hepat & Digest, Barcelona, Spain
Poca, M:
Autonomous Univ Barcelona, Hosp St Pau, Gastrointestinal Bleeding Unit, Dept Gastroenterol, Barcelona, Spain
Alvarez-Urturi, C:
Autonomous Univ Barcelona, Hosp St Pau, Gastrointestinal Bleeding Unit, Dept Gastroenterol, Barcelona, Spain
Gordillo, J:
Autonomous Univ Barcelona, Hosp St Pau, Gastrointestinal Bleeding Unit, Dept Gastroenterol, Barcelona, Spain
Guarner-Argente, C:
Autonomous Univ Barcelona, Hosp St Pau, Gastrointestinal Bleeding Unit, Dept Gastroenterol, Barcelona, Spain
Santalo, M:
Autonomous Univ Barcelona, Hosp St Pau, Semicrit Unit, Barcelona, Spain
Muniz, E:
Autonomous Univ Barcelona, Hosp St Pau, Blood & Tissue Bank, Barcelona, Spain
Guarner, C:
Autonomous Univ Barcelona, Hosp St Pau, Gastrointestinal Bleeding Unit, Dept Gastroenterol, Barcelona, Spain
Ctr Invest Biomed Red Enfermedades Hepat & Digest, Barcelona, Spain
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