Liberal versus restrictive transfusion strategies in subarachnoid hemorrhage: a secondary analysis of the TRAIN study
Chahnez Taleb, Elisa Gouvêa Bogossian, Carla Bittencourt Rynkowski, Kirsten Møller, Piet Lormans, Manuel Quintana‐Díaz, Anselmo Caricato, Luigi Zattera, Pedro Kurtz, Geert Meyfroidt, Hervé Quintard, Maria Celeste Dias, Angelo Giacomucci, Charlotte Castelain, Russell Chabanne, Pilar Marcos-Neira, Stepani Bendel, Ahmed Subhy Alsheikhly, Mohamed Elbahnasawy, Samuel Gay, Maximilian D’Onofrio, К. А. Попугаев, Νικόλαος Μάρκου, Pierre Bouzat, Jean‐Louis Vincent, Fabio Silvio Taccone, for the TRAIN Study Trial Group, Marco Antonio Cardoso Ferreira, Rafael Badenes, Christian Baastrup Søndergaard, Kirsten Colpaert, Letícia Petterson, Claudia Díaz, Andrés Saravia, Ahmad Bayrlee, Laura Nedolast, Hussam Elkambergy, Haamid Siddique, Jihad Mallat, Nahla AlJaberi, Samer Shoshan, Ayo Mandi, Bruno De Oliveira, Malligere Prasanna, Rehan Haque, Dnyaneshwar Munde, Sara Chaffee, Fatma Alawadhi, Jamil Dibu, Eija Junttila, Teemu M. Luoto, Simona Šteblaj, Jacques Créteur, D. Durand, Caroline Abbenhuijs, Nancy Itesa Matumikina, Filippo Annoni, Leda Nobile, Miguel Ulloa Bersatti, Igor Yovenko, Alexander Tsarev, Jasperina Dubois, Evy Voets, Luc Janssen, Luigi Zattera, Leire Pedrosa, Berta López, Ainhoa Serrano, Nekane Romero-García, Xavier Wittebole, Antonio Maria Dell’Anna, Camilla Gelormini, Eleonora Stival, Pilar Marcos-Neira, Regina Roig Pineda, Lara Bielsa Berrocal, Maite Misis del Campo, Jorge Mejía-Mantilla, Ángela Marulanda, Wojciech Dąbrowski, Rune Damgaard Nielsen, Markus Harboe Olsen, Helene Ravnholt Jensen, Ida Møller Larsen, Roberta T. Tallarico, Umberto Lucangelo, Maria Isabel Gonzalez Perez, Carole Ichai, Karim Asenhoune, Karim Lakhal, Charlotte Fernandez-Canal, Samuel Gay, Marie Lebouc, David Bougon, Étienne Escudier, Michel Sirodot, Albrice Levrat, Alix Courouau, Jacques Duranteau, Aurore Rodrigues
Abstract
BACKGROUND: The optimal hemoglobin (Hb) threshold to trigger red blood cell transfusions (RBCT) in subarachnoid hemorrhage (SAH) patients is unclear. This study evaluated the impact of liberal versus restrictive transfusion strategies on neurological outcome in patients with SAH. METHODS: This is a pre-planned secondary analysis of the "TRansfusion Strategies in Acute brain INjured Patients" (TRAIN) study. We included all SAH patients from the original study that were randomized to receive RBCT when Hb levels dropped below 9 g/dL (liberal group) or 7 g/dL (restrictive group). The primary outcome was an unfavorable neurological outcome at 180 days, defined by a Glasgow Outcome Scale Extended score of 1-5. RESULTS: Of the 190 SAH patients in the trial, 188 (98.9%) had data available for the primary outcome, with 86 (45.3%) in the liberal group and 102 (53.6%) in the restrictive group. Patients in the liberal group were older than in the restrictive group, but otherwise had similar baseline characteristics. Patients in the liberal group received more RBCT and showed higher Hb levels over time. At 180 days, 57 (66.3%) patients in the liberal group and 78 (76.4%) in the restrictive group had unfavorable outcomes (risk ratio, RR 0.87; 95% confidence intervals, 95% CI 0.71-1.04). Patients in the liberal group had a significantly lower risk of cerebral ischemia (RR 0.63; 95% CI 0.41-0.97). In a multivariate analysis, randomization to the liberal group was associated with a lower risk of unfavorable outcome (RR 0.83, 95% CI 0.70-0.99). CONCLUSIONS: A liberal transfusion strategy was not associated with a lower incidence of unfavorable outcome after SAH when compared to a restrictive strategy. However, in a multivariable analysis adjusted for confounders randomization to the liberal group was associated with lower risk of unfavorable outcome. The occurrence of cerebral ischemia was significantly lower in the liberal transfusion strategy group. TRIAL REGISTRATION: ClinicalTrials.gov number-NCT02968654 registered on November 16th, 2016.