Liberal versus restrictive blood transfusion strategy: 3-year survival and cause of death results from the FOCUS randomised controlled trial.

Carson JL, Sieber F, Cook DR, et al.
Lancet 2015;385:1183-1189.
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Review by : J.-F. Hardy
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Carson and colleagues report the long-term results of the FOCUS trial published in 2011. In FOCUS, 2016 elderly patients with a history of or risk factors for cardiovascular disease were randomly assigned to a liberal (10 g/dL) versus a restrictive (8 g/L) transfusion threshold after hip fracture surgery. A liberal transfusion strategy, as compared with a restrictive strategy, did not reduce rates of death or inability to walk independently on 60-day follow-up or reduce in-hospital morbidity.

The authors now report outcomes for these patients 3 years after surgery and transfusion. Their hypotheses were that, on one hand, a liberal transfusion strategy might be beneficial from a cardiovascular perspective but that, on the other hand, transfusion-induced immunomodulation might increase mortality from infections and cancer.

The two groups of patients were extremely well matched, survival at 3 years was the same in the two groups (a little less than 60%) and the primary causes of death were very similar in both groups. The results are reassuring inasmuch as a restrictive transfusion strategy was found to be safe in these elderly, high-risk patients.

Personally, I was disappointed that the authors did not observe increased benefits in patients who received less transfusions. Maybe, as mentioned by the authors, sample size was too small or follow-up too short. Other possible explanations include the age of patients (in the TRICC trial, a restrictive strategy was beneficial in younger patients) or the overall high mortality rate observed in these elderly patients (approximately 42%).

– Jean-Fran├žois Hardy

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