Effects of restrictive red blood cell transfusion on the prognoses of adult patients undergoing cardiac surgery: a meta-analysis of randomized controlled trials

Qi-Hong Chen, Hua-Ling Wang, Lei Liu, Jun Shao, Jiangqian Yu, Rui-Qiang Zheng, Qi-Hong Chen, Hua-Ling Wang, Lei Liu, Jun Shao, Jiangqian Yu, Rui-Qiang Zheng

Abstract

Purpose: Restrictive red blood cell transfusion strategies remain controversial in patients undergoing cardiac surgery. We performed a meta-analysis to assess the prognostic benefits of restrictive red blood cell transfusion strategies in patients undergoing cardiac surgery.

Methods: We identified randomized clinical trials through the 9th of December 2017 that investigated a restrictive red blood cell transfusion strategy versus a liberal transfusion strategy in patients undergoing cardiac surgery. Individual patient data from each study were collected. Meta-analyses were performed for the primary and secondary outcomes. The risk of bias was assessed using the Cochrane Risk of Bias Tool. A trial sequential analysis (TSA)-adjusted random-effects model was used to pool the results from the included studies for the primary outcomes.

Results: Seven trials involving a total of 8886 patients were included. The TSA evaluations suggested that this meta-analysis could draw firm negative results, and the data were sufficient. There was no evidence that the risk of 30-day mortality differed between the patients assigned to a restrictive blood cell transfusion strategy and a liberal transfusion strategy (odds ratio (OR) 0.98; 95% confidence interval (CI) 0.77 to 1.24; p = 0.87). Furthermore, the study suggested that the restrictive transfusion strategy was not associated with significant increases in pulmonary morbidity (OR 1.09; 95% CI 0.88 to 1.34; p = 0.44), postoperative infection (OR 1.11; 95% CI 0.95 to 1.3; p = 0.58), acute kidney injury (OR 1.03; 95% CI 0.92 to 1.14; p = 0.71), acute myocardial infarction (OR 1.01; 95% CI 0.80 to 1.27; p = 0.78), or cerebrovascular accidents (OR 0.97; 95% CI 0.72 to 1.30; p = 0.66).

Conclusions: Our meta-analysis demonstrates that the restrictive red blood cell transfusion strategy was not inferior to the liberal strategy with respect to 30-day mortality, pulmonary morbidity, postoperative infection, cerebrovascular accidents, acute kidney injury, or acute myocardial infarction, and fewer red blood cells were transfused.

Keywords: Cardiac surgery; Liberal transfusion strategy; Meta-analyses; Prognosis; Restrictive transfusion strategy.

Conflict of interest statement

Ethics approval and consent to participate

Not applicable.

Consent for publication

All authors have agreed to the publication of this manuscript.

Competing interests

The authors declare that they have no competing interests.

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Figures

Fig. 1
Fig. 1
Flow diagram of the identified trials. RCT randomized controlled trial
Fig. 2
Fig. 2
Risk of bias summary. Review of the authors’ judgements about each risk of bias item for each included study. Red indicates high risk, green indicates low risk, blank indicates unclear
Fig. 3
Fig. 3
Trial sequential analysis for mortality in the randomized controlled trials with a two-sided boundary and an incidence of 2.78% in the control arm and an incidence of 1.42% in the treatment arm
Fig. 4
Fig. 4
Funnel plot of the mortality demonstrating that no publication bias existed
Fig. 5
Fig. 5
Effect of restrictive red blood cell transfusion on postoperative mortality in adult patients undergoing cardiac surgery: a meta-analysis of randomized controlled trials

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