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Restrictive versus liberal transfusion in patients with diabetes undergoing cardiac surgery: An open-label,
Nikhil Mistry1, Nadine Shehata2, Paula Carmona3
1Department of Anesthesia, St. Michael's Hospital, Institute of Medical Sciences, University of Toronto, Toronto, Ontario, Canada.
Insights
Restrictive transfusion strategies are safe for cardiac surgery patients with diabetes, showing similar outcomes to liberal strategies. This approach also more effectively reduces red blood cell transfusions in diabetic patients.
Area of Science:
- Cardiology
- Transfusion Medicine
- Diabetology
Background:
- Diabetes is a common comorbidity in patients undergoing cardiac surgery.
- The safety and efficacy of restrictive transfusion strategies in diabetic patients with cardiac disease remain under investigation.
Purpose of the Study:
- To investigate the association between diabetes, transfusion practices, and clinical outcomes in cardiac surgery.
- To evaluate the safety and effectiveness of restrictive transfusion thresholds in diabetic patients undergoing cardiac surgery.
Main Methods:
- The TRICS-III trial randomized 5092 patients undergoing cardiac surgery to either a restrictive (hemoglobin <75 g/L) or liberal transfusion strategy.
- Diabetes status was a pre-operative covariate, and outcomes were assessed at 6 months, including a composite of death, stroke, myocardial infarction, and renal failure.
- Secondary outcomes included 28-day transfusion and clinical events.
Main Results:
- Of 5092 patients, 1396 (27.4%) had diabetes. Patients with diabetes had higher cardiovascular disease burden.
- Diabetes did not modify the effect of restrictive transfusion on the primary composite outcome (all-cause death, stroke, myocardial infarction, new-onset renal failure).
- Restrictive transfusion strategies were more effective in reducing red blood cell transfusions in patients with diabetes compared to those without (P-interaction=0.04).
Conclusions:
- Restrictive transfusion thresholds are safe and effective for patients with diabetes undergoing cardiac surgery.
- The presence of diabetes does not alter the safety of restrictive transfusion strategies regarding major adverse clinical outcomes.
- Restrictive transfusion strategies enhance efficacy in reducing red blood cell utilization among diabetic patients.
Aim:
To characterize the association between diabetes and transfusion and clinical outcomes in cardiac surgery, and to evaluate whether restrictive transfusion thresholds are harmful in these patients.
Materials And Methods:
The multinational, open-label, randomized controlled TRICS-III trial assessed a restrictive transfusion strategy (haemoglobin [Hb] transfusion threshold <75 g/L) compared with a liberal strategy (Hb <95 g/L for operating room or intensive care unit; or <85 g/L for ward) in patients undergoing cardiac surgery on cardiopulmonary bypass with a moderate-to-high risk of death (EuroSCORE ≥6). Diabetes status was collected preoperatively. The primary composite outcome was all-cause death, stroke, myocardial infarction, and new-onset renal failure requiring dialysis at 6 months. Secondary outcomes included components of the composite outcome at 6 months, and transfusion and clinical outcomes at 28 days.
Results:
Of the 5092 patients analysed, 1396 (27.4%) had diabetes (restrictive, n = 679; liberal, n = 717). Patients with diabetes had more cardiovascular disease than patients without diabetes. Neither the presence of diabetes (OR [95% CI] 1.10 [0.93-1.31]) nor the restrictive strategy increased the risk for the primary composite outcome (diabetes OR [95% CI] 1.04 [0.68-1.59] vs. no diabetes OR 1.02 [0.85-1.22]; Pinteraction = .92). In patients with versus without diabetes, a restrictive transfusion strategy was more effective at reducing red blood cell transfusion (diabetes OR [95% CI] 0.28 [0.21-0.36]; no diabetes OR [95% CI] 0.40 [0.35-0.47]; Pinteraction = .04).
Conclusions:
The presence of diabetes did not modify the effect of a restrictive transfusion strategy on the primary composite outcome, but improved its efficacy on red cell transfusion. Restrictive transfusion triggers are safe and effective in patients with diabetes undergoing cardiac surgery.
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