• Amit X Garg, Neal Badner, Sean M Bagshaw, Meaghan S Cuerden, Dean A Fergusson, Alexander J Gregory, Judith Hall, Hare Gregory M T GMT Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada., Boris Khanykin, Shay McGuinness, Chirag R Parikh, Pavel S Roshanov, Nadine Shehata, Jessica M Sontrop, Summer Syed, George I Tagarakis, Kevin E Thorpe, Subodh Verma, Ron Wald, Richard P Whitlock, C David Mazer, and TRICS Investigators and Perioperative Anesthesia Clinical Trials Group.
• Division of Nephrology, Department of Medicine, London Health Sciences Centre and Western University, London, Ontario, Canada; amit.garg@lhsc.on.ca.
• J. Am. Soc. Nephrol. 2019 Jul 1; 30 (7): 1294-1304.

BackgroundSafely reducing red blood cell transfusions can prevent transfusion-related adverse effects, conserve the blood supply, and reduce health care costs. Both anemia and red blood cell transfusion are independently associated with AKI, but observational data are insufficient to determine whether a restrictive approach to transfusion can be used without increasing AKI risk.MethodsIn a prespecified kidney substudy of a randomized noninferiority trial, we compared a restrictive threshold for red blood cell transfusion (transfuse if hemoglobin<7.5 g/dl, intraoperatively and postoperatively) with a liberal threshold (transfuse if hemoglobin<9.5 g/dl in the operating room or intensive care unit, or if hemoglobin<8.5 g/dl on the nonintensive care ward). We studied 4531 patients undergoing cardiac surgery with cardiopulmonary bypass who had a moderate-to-high risk of perioperative death. The substudy's primary outcome was AKI, defined as a postoperative increase in serum creatinine of ≥0.3 mg/dl within 48 hours of surgery, or ≥50% within 7 days of surgery.ResultsPatients in the restrictive-threshold group received significantly fewer transfusions than patients in the liberal-threshold group (1.8 versus 2.9 on average, or 38% fewer transfusions in the restricted-threshold group compared with the liberal-threshold group; P<0.001). AKI occurred in 27.7% of patients in the restrictive-threshold group (624 of 2251) and in 27.9% of patients in the liberal-threshold group (636 of 2280). Similarly, among patients with preoperative CKD, AKI occurred in 33.6% of patients in the restrictive-threshold group (258 of 767) and in 32.5% of patients in the liberal-threshold group (252 of 775).ConclusionsAmong patients undergoing cardiac surgery, a restrictive transfusion approach resulted in fewer red blood cell transfusions without increasing the risk of AKI.Copyright © 2019 by the American Society of Nephrology.

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