Red blood cell transfusion in elderly patients: Hemoglobin thresholds and clinical outcomes

The optimal hemoglobin (Hb) threshold for red blood cell (RBC) transfusion in elderly patients is controversial. Guidelines favor restrictive strategies, but older adults may benefit from higher triggers.

To compare clinical outcomes between restrictive and liberal RBC transfusion strategies in elderly patients.

This single-center retrospective cohort study enrolled 106 patients aged ≥ 65 years who received RBC transfusions between January 2022 and June 2025. Patients were categorized into restrictive (Hb <7.0 g/dL; n = 53) and liberal (Hb <9.0 g/dL; n = 53) groups. The primary outcome was 30-day all-cause mortality; secondary outcomes included 90-day mortality, length of stay (LOS), ICU admission, acute kidney injury, major adverse cardiovascular events, and infection rates. Kaplan-Meier, Cox regression, and multivariate logistic regression were performed.

Baseline characteristics were comparable between groups. The restrictive group had numerically higher 30-day mortality than the liberal group, 22.6% versus 7.5%, P = .055, and 90-day mortality, 26.4% versus 11.3%, P = .082. Kaplan-Meier analysis showed better 90-day survival in the liberal group, log-rank P = .048. The restrictive group had longer hospitalization, 14.09 versus 10.38 days, P < .001, and more ICU admissions, 34.0% versus 13.2%, P = .022. Adjusted mortality associations favored the liberal strategy but were not statistically significant and were attenuated in sensitivity analyses.

In this small retrospective cohort, liberal transfusion was associated with shorter hospitalization and fewer ICU admissions, but mortality benefits were not statistically robust. Prospective studies are needed.