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Red blood cell transfusion and mortality in trauma patients: risk-stratified analysis of an observational study.

Perel P, Clayton T, Altman DG, Croft P, Douglas I, Hemingway H, Hingorani A, Morley KI, Riley R, Timmis A, Van der Windt D, Roberts I, PROGRESS Partnersh - PLoS Med. (2014)

Bottom Line: As this was an observational study, the results could have been affected by different types of confounding.In addition, we could not consider haemoglobin in our analysis.In sensitivity analyses, excluding patients who died early; conducting propensity score analysis adjusting by use of platelets, fresh frozen plasma, and cryoprecipitate; and adjusting for country produced results that were similar.

View Article: PubMed Central - PubMed

Affiliation: Epidemiology & Population Health Faculty, London School of Hygiene & Tropical Medicine, London, United Kingdom.

ABSTRACT

Background: Haemorrhage is a common cause of death in trauma patients. Although transfusions are extensively used in the care of bleeding trauma patients, there is uncertainty about the balance of risks and benefits and how this balance depends on the baseline risk of death. Our objective was to evaluate the association of red blood cell (RBC) transfusion with mortality according to the predicted risk of death.

Methods and findings: A secondary analysis of the CRASH-2 trial (which originally evaluated the effect of tranexamic acid on mortality in trauma patients) was conducted. The trial included 20,127 trauma patients with significant bleeding from 274 hospitals in 40 countries. We evaluated the association of RBC transfusion with mortality in four strata of predicted risk of death: <6%, 6%-20%, 21%-50%, and >50%. For this analysis the exposure considered was RBC transfusion, and the main outcome was death from all causes at 28 days. A total of 10,227 patients (50.8%) received at least one transfusion. We found strong evidence that the association of transfusion with all-cause mortality varied according to the predicted risk of death (p-value for interaction <0.0001). Transfusion was associated with an increase in all-cause mortality among patients with <6% and 6%-20% predicted risk of death (odds ratio [OR] 5.40, 95% CI 4.08-7.13, p<0.0001, and OR 2.31, 95% CI 1.96-2.73, p<0.0001, respectively), but with a decrease in all-cause mortality in patients with >50% predicted risk of death (OR 0.59, 95% CI 0.47-0.74, p<0.0001). Transfusion was associated with an increase in fatal and non-fatal vascular events (OR 2.58, 95% CI 2.05-3.24, p<0.0001). The risk associated with RBC transfusion was significantly increased for all the predicted risk of death categories, but the relative increase was higher for those with the lowest (<6%) predicted risk of death (p-value for interaction <0.0001). As this was an observational study, the results could have been affected by different types of confounding. In addition, we could not consider haemoglobin in our analysis. In sensitivity analyses, excluding patients who died early; conducting propensity score analysis adjusting by use of platelets, fresh frozen plasma, and cryoprecipitate; and adjusting for country produced results that were similar.

Conclusions: The association of transfusion with all-cause mortality appears to vary according to the predicted risk of death. Transfusion may reduce mortality in patients at high risk of death but increase mortality in those at low risk. The effect of transfusion in low-risk patients should be further tested in a randomised trial.

Trial registration: www.ClinicalTrials.gov NCT01746953.

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Odds ratio of death for transfusion compared to no transfusion by risk category.
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pmed-1001664-g001: Odds ratio of death for transfusion compared to no transfusion by risk category.

Mentions: To explore the association of RBC transfusion with all-cause mortality further, we created ten groups of predicted risk of death containing approximately one-tenth of the primary outcome each. As can be seen in Figure 1, RBC transfusion showed a trend from a positive association (harmful) to a negative association (beneficial) with all-cause mortality according to predicted risk of death. RBC transfusion was associated with an increase in all-cause mortality at low predicted risk of death and a decrease in all-cause mortality at high predicted risk of death. The change in direction of the association of transfusion (from harmful to beneficial) with all-cause mortality occurred around a predicted risk of death of about 25%.


Red blood cell transfusion and mortality in trauma patients: risk-stratified analysis of an observational study.

Perel P, Clayton T, Altman DG, Croft P, Douglas I, Hemingway H, Hingorani A, Morley KI, Riley R, Timmis A, Van der Windt D, Roberts I, PROGRESS Partnersh - PLoS Med. (2014)

Odds ratio of death for transfusion compared to no transfusion by risk category.
© Copyright Policy
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4060995&req=5

pmed-1001664-g001: Odds ratio of death for transfusion compared to no transfusion by risk category.
Mentions: To explore the association of RBC transfusion with all-cause mortality further, we created ten groups of predicted risk of death containing approximately one-tenth of the primary outcome each. As can be seen in Figure 1, RBC transfusion showed a trend from a positive association (harmful) to a negative association (beneficial) with all-cause mortality according to predicted risk of death. RBC transfusion was associated with an increase in all-cause mortality at low predicted risk of death and a decrease in all-cause mortality at high predicted risk of death. The change in direction of the association of transfusion (from harmful to beneficial) with all-cause mortality occurred around a predicted risk of death of about 25%.

Bottom Line: As this was an observational study, the results could have been affected by different types of confounding.In addition, we could not consider haemoglobin in our analysis.In sensitivity analyses, excluding patients who died early; conducting propensity score analysis adjusting by use of platelets, fresh frozen plasma, and cryoprecipitate; and adjusting for country produced results that were similar.

View Article: PubMed Central - PubMed

Affiliation: Epidemiology & Population Health Faculty, London School of Hygiene & Tropical Medicine, London, United Kingdom.

ABSTRACT

Background: Haemorrhage is a common cause of death in trauma patients. Although transfusions are extensively used in the care of bleeding trauma patients, there is uncertainty about the balance of risks and benefits and how this balance depends on the baseline risk of death. Our objective was to evaluate the association of red blood cell (RBC) transfusion with mortality according to the predicted risk of death.

Methods and findings: A secondary analysis of the CRASH-2 trial (which originally evaluated the effect of tranexamic acid on mortality in trauma patients) was conducted. The trial included 20,127 trauma patients with significant bleeding from 274 hospitals in 40 countries. We evaluated the association of RBC transfusion with mortality in four strata of predicted risk of death: <6%, 6%-20%, 21%-50%, and >50%. For this analysis the exposure considered was RBC transfusion, and the main outcome was death from all causes at 28 days. A total of 10,227 patients (50.8%) received at least one transfusion. We found strong evidence that the association of transfusion with all-cause mortality varied according to the predicted risk of death (p-value for interaction <0.0001). Transfusion was associated with an increase in all-cause mortality among patients with <6% and 6%-20% predicted risk of death (odds ratio [OR] 5.40, 95% CI 4.08-7.13, p<0.0001, and OR 2.31, 95% CI 1.96-2.73, p<0.0001, respectively), but with a decrease in all-cause mortality in patients with >50% predicted risk of death (OR 0.59, 95% CI 0.47-0.74, p<0.0001). Transfusion was associated with an increase in fatal and non-fatal vascular events (OR 2.58, 95% CI 2.05-3.24, p<0.0001). The risk associated with RBC transfusion was significantly increased for all the predicted risk of death categories, but the relative increase was higher for those with the lowest (<6%) predicted risk of death (p-value for interaction <0.0001). As this was an observational study, the results could have been affected by different types of confounding. In addition, we could not consider haemoglobin in our analysis. In sensitivity analyses, excluding patients who died early; conducting propensity score analysis adjusting by use of platelets, fresh frozen plasma, and cryoprecipitate; and adjusting for country produced results that were similar.

Conclusions: The association of transfusion with all-cause mortality appears to vary according to the predicted risk of death. Transfusion may reduce mortality in patients at high risk of death but increase mortality in those at low risk. The effect of transfusion in low-risk patients should be further tested in a randomised trial.

Trial registration: www.ClinicalTrials.gov NCT01746953.

Show MeSH
Related in: MedlinePlus