Recent evidence favours specific guidance on transfusion strategies in the older population

Abstract

Background: The proportion of the population aged 65 and above is growing worldwide. Many diseases relevant to transfusion outcomes increase in prevalence with age. Until recently, little evidence has been available regarding transfusion outcomes in geriatric patients. Restrictive transfusion strategies are increasingly used in healthcare, yet much of the evidence supporting such strategies is drawn from observational studies, and does not focus on the geriatric cohort. Paediatric patients are recognised as having distinctive transfusion requirements compared to adults due to differences in physiology, and specialist paediatric patient blood management guidelines have been developed. Our study explores the available evidence on transfusion in older patients, to ask whether age-specific blood management guidance is needed for this group. Aims: This study aimed to identify and review the evidence relating to transfusion outcomes in patients aged 65 years and older. It explored issues of harm vs benefit associated with transfusion, and whether restrictive or liberal transfusion strategies have been shown to be beneficial in older adults. Methods: A literature review was undertaken using search criteria and strategies pre-defined by the investigators. The review focussed on evidence relating to transfusion outcomes in patients aged 65 years and above. Included evidence was classified as Level I (systematic reviews, meta-analyses), Level II (randomised control trials (RCT)) and Level III (observational) studies. Results: Ninety-eight articles were included in the analysis. Most papers reported Level III evidence (78%), with fewer examples of Level II (20%), and least of Level I (2%) studies. Several geriatric-relevant papers reporting RCTs were published in 2015 and 2016, and thus their evidence is yet to be incorporated into published Level I evidence or guidelines. Most reports from observational studies (Level III evidence) supported restrictive transfusion strategies, and associated transfusion with poorer outcomes in geriatric patients. By contrast, eight RCTs (Level II evidence) found liberal transfusion strategies provided better outcomes for older patients, and three were equivocal. None of this higher-level evidence supported restrictive transfusion approaches in older patients. Equivalent or better outcomes for older adults identified by RCTs related to rates of mortality, cardiovascular complications, infections, and post-operative delirium. Summary/Conclusions: The results of this review indicate that caution should be used regarding restrictive transfusion approaches in older adults, and that liberal transfusion strategies may facilitate better outcomes in this cohort. The results of transfusion studies involving the broader adult population may be misleading in relation to the geriatric cohort. Further research is needed to explore the reasons older adult patients may be impacted differently by transfusion than the younger cohort. Our findings suggest that specific guidance for transfusion in older adults is warranted in patient blood management guidelines.L616917360 <br />