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Appropriateness of Allogeneic Red Blood Cell Transfusion: The International Consensus Conference on Transfusion Outcomes
Abstract
An international multidisciplinary panel of 15 experts reviewed 494 published articles and used the RAND/UCLA Appropriateness Method to determine the appropriateness of allogeneic red blood cell (RBC) transfusion based on its expected impact on outcomes of stable nonbleeding patients in 450 typical inpatient medical, surgical, or trauma scenarios. Panelists rated allogeneic RBC transfusion as appropriate in 53 of the scenarios (11.8%), inappropriate in 267 (59.3%), and uncertain in 130 (28.9%). Red blood cell transfusion was most often rated appropriate (81%) in scenarios featuring patients with hemoglobin (Hb) level 7.9 g/dL or less, associated comorbidities, and age older than 65 years. Red blood cell transfusion was rated inappropriate in all scenarios featuring patients with Hb level 10 g/dL or more and in 71.3% of scenarios featuring patients with Hb level 8 to 9.9 g/dL. Conversely, no scenario with patient's Hb level of 8 g/dL or more was rated as appropriate. Nearly one third of all scenarios were rated uncertain, indicating the need for more research. The observation that allogeneic RBC transfusions were rated as either inappropriate or uncertain in most scenarios in this study supports a more judicious transfusion strategy. In addition, the large number of scenarios in which RBC transfusions were rated as uncertain can serve as a road map to identify areas in need of further investigation.
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“This issue of inappropriateness of blood transfusion did not dramatically change during the past 20 yr.[27][28][29]”
From Point-of-Care Testing: A Prospective, Randomized Clinical Trial of Efficacy in Coagulopathic Cardiac Surgery Patients (2012) · cites this paper as [28]
Citations
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BackgroundSelf-citationManagement of Anemia in Patients with Inflammatory Bowel Disease
Kim, K. O. (2015) · Korean Journal of Gastroenterology · doi:10.4166/kjg.2015.65.3.145 · Cited by 4
Patient blood management: use of topical hemostatic and sealant agents.
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Nwosu, A. D. G., Onyekwulu, F. A., & Aniwada, E. (2019) · Patient Safety in Surgery · doi:10.1186/s13037-019-0216-2 · Cited by 11
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“9% of clinical scenarios, RBC transfusion appropriateness was uncertain [25].”
BackgroundA randomized study of a best practice alert for platelet transfusions
Murphy, C., Mou, E., Pang, E. M., Shieh, L., Hom, J., & Shah, N. (2021) · Vox Sanguinis · doi:10.1111/vox.13132 · Cited by 7
“Despite publication and promotion of these guidelines, clinical practices are not always consistent with the accumulated evidence [10, 11].”
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Chandrasekar, M., Balakrishnan, V., Ponnaiyan, A., & Ramachandran, T. (2021) · doi:10.25259/jhas_5_2021 · Cited by 7
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“Based on a review of the available evidence and consideration of common clinical scenarios that often lead to transfusion, a multidisciplinary group of transfusion experts rated allogeneic blood transfusion as inappropriate or as having uncertain benefits in the vast majority of the scenarios.(23) Moreover, allogeneic…”
Subramanian, V., Bharat, A., Vachharajani, N., Crippin, J., Shenoy, S., Mohanakumar, T., & Chapman, W. (2014) · HPB · doi:10.1111/hpb.12128 · Cited by 6
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“The authors found that interventions such as preoperative anemia management, intraoperative blood conservation techniques, and the use of erythropoiesis-stimulating agents were cost-effective, with a projected cost savings of up to $1,367 per patient (43).”
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“When this approach was applied to hemotherapy it has uncovered significant variations in allogeneic red cell transfusion between health institutions [4–6], particularly overuse of blood components or transfusions given for inappropriate reasons [7].”
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Kandane-Rathnayake, R., Isbister, J. P., Zatta, A. J., Aoki, N., Cameron, P., & Phillips, L. E. (2013) · ANZ journal of surgery · doi:10.1111/j.1445-2197.2012.06285.x · Cited by 4
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Chronic anemia due to gastrointestinal bleeding: when do gastroenterologists transfuse?
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Ultramassive transfusion: give blood, save a life
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BackgroundAre we begging a question or begging an answer?
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The obligation to stop hemorrhage is a basic tenet of care for any clinician. Introduction.
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“…the scenario reported in the literature by Shander et al., 25 in which a signi fi cant portion of blood transfusions are considered inappropriate, 24 and the accumulation of evidence that indicates that greater restriction of transfusions promotes better clinical outcomes, 25 a new treatment…”
MethodCommunity-Based Hospitals Benefit From Restrictive Transfusion Practices
Hill, J., Dawson, J., Ramic, M., Manzo, J., & Pronovost, P. (2023) · Journal for Healthcare Quality · doi:10.1097/jhq.0000000000000376 · Cited by 1
Operating on Jehovah’s Witnesses: A Challenging Surgical Issue
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Evaluation of Blood Ordering Practice for Packed Red Blood Cells in A Tertiary Care Hospital
Thamarai Selvi, N., Krishna Prasanth, B., Anusha, A., & Begum, R. (2018) · International Journal of Blood Transfusion · doi:10.14302/issn.3070-1937.ijbt-18-2410 · Cited by 1
Point-of-Care Testing at Acute Cardiac Care brings Positive Outcome
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Ma, M., Yu, X.-R., Wang, Y., Huang, Y.-G., Lu, S., Tian, Y., & Bai, B. (2018) · Chinese medical sciences journal = Chung-kuo i hsueh k'o hsueh tsa chih · doi:10.24920/11807 · Cited by 1
Épargne transfusionnelle dans la population âgée hospitalisée
Meunier, T., François, A., Poisson, J., Gisselbrecht, M., Arlet, J., Ducot, L., Lahjibi-Paulet, H., Guen, J. L., Mercadier, E., Pouchot, J., et al. (2017) · doi:10.1016/j.revmed.2017.11.007 · Cited by 1
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[Fear of anemia or why don't we afraid of blood transfusion?].
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Defining the clinical need for rare red blood cells
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“Reported appropriateness varies widely with setting and criteria: a South Indian audit found red cell appropriateness as high as 90% [8], whereas an international consensus exercise judged only about 40% of allogeneic red cell transfusions clearly appropriate [9].”
Ionescu, A., Mihăilescu, A., Dumache, R., Capcelea, A., Turceanu, A. D., Albulescu, N., & Săndesc, M. A. (2026) · Hematology Reports · doi:10.3390/hematolrep18030037
“In oncologic surgical patients, ABT has been associated with elevated risks of thrombotic and embolic events, likely mediated by inflammatory and coagulation activation [9,13].”
Evidenced based blood transfusion as an integral indicator of quality in cardiac surgery
Zyuzin, V. S. (2026) · Russian Journal of Cardiology and Cardiovascular Surgery · doi:10.17116/kardio20261903141
Pawar, A., Naqvi, A., Tomar, A., Dubey, R., Kumar, M., Jagani, R., Dimri, U., Kushwaha, N., & Kumar, S. (2026) · Medical Journal Armed Forces India · doi:10.1016/j.mjafi.2026.03.012
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“However, a significant percentage of transfusions performed are often identified as inappropriate [5,6], thus contributing to adverse events such as acute immune hemolytic reactions, bloodborne infections, transfusion associated circulatory overload (TACO) and transfusion-related acute lung injury…”
Xu, J.-N., Bai, J., Pan, H.-X., & Zhou, Z.-D. (2024) · Medicine · doi:10.1097/md.0000000000037646
“[7,40] In fact, studies have pointed to considerable differences in the decisions of each anesthesiologist and surgeon regarding PBT, and the overuse of blood transfusions is not uncommon.”
Saving Blood for the Bleeding.
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Advancing Patient Blood Management: Evaluation of Ferric Derisomaltose in a Tertiary Hospital
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“The practitioners should be focused on the effort to avoid the harm as soon as possible both produced by computerized and by human error [15].”
BackgroundRizoli, S., Parreira, J. G., & Rezende-neto, J. (2023) · Panamerican Journal of Trauma, Critical Care & Emergency Surgery · doi:10.5005/jp-journals-10030-1413
“Inappropriate blood transfusions are becoming more common in trauma resuscitation, 9 as well as their consequences such as acute lung injury, multiple organ failure, thromboembolic events, increase in costs, and resource utilization, among others.”
De rol van reticulocyten bij preoperatieve anemie
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“Although allogeneic blood transfusions are now safer because of improved detection methods, allergic reactions, cross-matching or transfusion errors, and potential risk factors of infections around the prosthesis, and even death still occur [30-32].”
BackgroundUsing Data to Support Patient Blood Management
Frank, S., & Wasey, J. O. (2017) · doi:10.1002/9781119129431.ch37
Limiting Allogenic Blood Transfusions
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Ellerbroek, V., Cuca, C., Weber, C., & Meybohm, P. (2015) · Klinikarzt – Medizin im Krankenhaus · doi:10.1055/s-0035-1549411
Patient blood management to reduce transfusion need.
Lynn, S. (2015) · JAAPA : official journal of the American Academy of Physician Assistants · doi:10.1097/01.jaa.0000455656.27295.2c
Modern Patient Blood Management in Arthroplasty
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“…thrombotic events, organ dysfunction, infections, delayed wound healing, and increased length of hospital stay; transfusion has also been associated with cancer recurrence and insurgence of non- Hodgkin lymphoma (for comprehensive reviews, see Vamvakas and Blajchman 2009 ; Shander et al. 2011 ).”
BackgroundCritically ill and septic patient: is red blood cell transfusion adding to the Domino Effect?
Watkins, T. C., & Clark, C. T. (2013) · Journal of Infusion Nursing · doi:10.1097/nan.0b013e318282a6cd
Principles of Patient Blood Management
Shander, A., & Goodnough, L. (2013) · doi:10.1002/9781118520093.ch34
Self-citationIsbister, J. P. (2012) · Vox Sanguinis · doi:10.1111/j.1423-0410.2012.01608.x
Self-citation[Damage control, haemoglobin and hypothermia].
Mion, G., Noël, A. L., Mérat, S., Ausset, S., & de Rudnicki, S. (2012) · Annales Francaise d'Anesthesie et de Reanimation · doi:10.1016/j.annfar.2011.11.021
Pediatric blood banking principles and transfusion medicine practices
Al-Ghafry, M., & Josephson, C. (2022) · Lanzkowsky's Manual of Pediatric Hematology and Oncology · doi:10.1016/b978-0-12-821671-2.00014-3
Patient Blood Management in Critically Ill
Choorapoikayil, S., Zacharowski, K., Füllenbach, C. S., & Meybohm, P. (2018) · doi:10.1007/978-3-319-93572-0_21
Role of Blood Bank, Transfusion Services, and Pharmacy in ICU Patients with Hematologic Challenges
Cruz, J. E., Nemeth, J., & Burga, A. M. (2018) · Springer eBooks · doi:10.1007/978-3-319-93572-0_20
Metadata
- Authors
- Shander, A., Fink, A., Javidroozi, M., Erhard, J., Farmer, S. L., Corwin, H., Goodnough, L. T., Hofmann, A., Isbister, J., Ozawa, S., & Spahn, D. R.
- Affiliations
- Englewood Hospital and Medical Center (US)
- Dartmouth–Hitchcock Medical Center (US)
- Stanford Medicine (US)
- Royal North Shore Hospital (AU)
- University Hospital Zurich (CH)
- Corresponding author
- Shander, Aryeh
- ORCID
- Venue
- Transfusion Medicine Reviews
- Publisher
- Elsevier BV
- Published
- 2011-07
- Volume
- 25
- Issue
- 3
- Pages
- 232-246.e53
- ISSN
- 0887-7963 (ISSN-L)
- OpenAlex
- W2069058457
- Cited by
- 216
- References
- 0
- Citations by year
- 2026: 6 · 2025: 5 · 2024: 10 · 2023: 7 · 2022: 9 · 2021: 13 · 2020: 5 · 2019: 13 · 2018: 12 · 2017: 17 · 2016: 13 · 2015: 25 · 2014: 27 · 2013: 34 · 2012: 14
- FWCI
- 16.81
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Transfusion Medicine Reviews (publishedVersion)
- PubMed (publishedVersion)
- UWA Profiles and Research Repository (UWA) (submittedVersion)
- eSpace (Curtin University) (submittedVersion)
- Zurich Open Repository and Archive (University of Zurich) (submittedVersion)
- Funders
- Eli Lilly and Company
- AstraZeneca
- Novo Nordisk
- Topics
- Health Sciences › Medicine › Hematology › Blood transfusion and management
- Health Sciences › Medicine › Critical Care and Intensive Care Medicine › Trauma, Hemostasis, Coagulopathy, Resuscitation
- Health Sciences › Medicine › Hematology › Blood groups and transfusion
- Keywords
- allogeneic red blood cell transfusion, transfusion appropriateness, hemoglobin threshold, transfusion thresholds, comorbidities, elderly patients, transfusion outcomes, expert consensus
- MeSH terms
- Adult, Age Factors, Aged, Aged, 80 and over, Algorithms, Humans, International Cooperation, Middle Aged, Quality of Health Care, Transplantation, Homologous, Treatment Outcome, Erythrocyte Transfusion
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