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For Hospitalized Patients with Moderate Anemia, Study Supports Limiting Transfusions

Data from Kaiser Permanente supports long-term safety of limiting red blood cell transfusion in hospitalized patients with moderate anemia. 

Anemia is common in hospitalized patients and historically was treated with transfusion of red blood cells to prevent morbidity and mortality. But transfusions carry risks and costs. Previous clinical trial data suggest that for patients with moderate anemia, tolerating instead of treating the anemia with transfusion carries few short-term risks, though the long-term risk has not been thoroughly evaluated.

Now, a new study of Kaiser Permanente members has shown that tolerating moderate anemia is safe in the long-term. The study found that increases in moderate anemia following hospitalization was not associated with a rise in 6-month rehospitalization or mortality events, suggesting that strategies limiting red blood cells transfusions in these patients is safe.

Nareg Roubinian, MD, MPH, a Kaiser Permanente physician who also conducts research at Kaiser Permanente Northern California’s Division of Research.

“This study supports the long-term safety of practice recommendations to limit red blood cell transfusion and tolerate moderate anemia in a general medical and surgical population,” said the study’s lead author, Nareg Roubinian, MD, MPH, a Kaiser Permanente physician who also conducts research at Kaiser Permanente Northern California’s Division of Research. “Our study, along with other recent research in this area, should provide some reassurance to clinicians charged with the decision to discharge anemic patients from the hospital.”

The study, “Long-Term Outcomes Among Patients Discharged From the Hospital With Moderate Anemia,” was published Dec. 17 in the journal Annals of Internal Medicine.

Anemia has been associated with a poorer prognosis for conditions such as cancer, chronic kidney disease, and congestive heart failure, so care providers have assumed that anemia must be treated during hospitalization, especially in older patients with cardiovascular disease. However, limited evidence exists showing a benefit, and randomized clinical trial data show that less frequent red blood cell transfusion is safe in the short-term for hospitalized patients with moderate anemia.

To study the long-term safety of tolerating moderate anemia, the researchers analyzed a retrospective cohort of more than 400,000 Kaiser Permanente Northern California members and looked at the population’s prevalence of anemia and red blood cell transfusions at and 6 months after hospital discharge, as well as their rates of rehospitalization, morbidity, and mortality events.

The study found that moderate anemia (defined as hemoglobin levels between 7 and 10 grams/deciliter in this study) increased at the time of and following hospital discharge, while red blood cell transfusions decreased by 28 percent. The increase in moderate anemia was not accompanied by a rise in subsequent red blood cell use, rehospitalization, or mortality within 6 months of hospital discharge.

While this study’s data support the efficacy and safety of restrictive transfusion practice recommendations during and after hospitalization, additional studies are needed to replicate these findings in different populations and evaluate alternative treatments for moderate anemia in regard to patient symptoms and quality of life.

Gabriel Escobar, MD, research scientist at the Kaiser Permanente Northern California Division of Research and the senior author of the study.

“Our study also highlights the value of linking multiple data type, including transfusion records and severity of illness scores, to assess the safety of changes in practice in general, and transfusion practice in particular,” added Gabriel Escobar, MD, the senior author of the study.

The study was funded by the National Heart, Lung, and Blood Institute.

Additional co-authors from the Division of Research include Catherine Lee, PhD, Patricia Kipnis, PhD, Vincent X. Liu, MD, and adjunct investigator Dustin G. Mark, MD. Collaborators on the study include Edward L. Murphy, MD, University of California, San Francisco; Darrell J. Triulzi, MD, Institute for Transfusion Medicine ; Jeffrey L. Carson, MD, Rutgers Robert Wood Johnson Medical School; and Steven Kleinman, MD, University of British Columbia.

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