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Randomized Controlled Trial
. 2025 Feb 7;29(1):67.
doi: 10.1186/s13054-025-05270-5.

Liberal versus restrictive transfusion strategies in subarachnoid hemorrhage: a secondary analysis of the TRAIN study

Chahnez Taleb #  1 , Elisa Gouvea Bogossian #  2 , Carla Bittencour Rynkowski  3   4 , Kirsten Møller  5   6 , Piet Lormans  7 , Manuel Quintana Diaz  8 , Anselmo Caricato  9 , Luigi Zattera  10 , Pedro Kurtz  11   12 , Geert Meyfroidt  13 , Herve Quintard  14 , Maria Celeste Dias  15 , Angelo Giacomucci  16 , Charlotte Castelain  17 , Russell Chabanne  18 , Pilar Marcos-Neira  19 , Stepani Bendel  20 , Ahmed Subhy Alsheikhly  21 , Mohamed Elbahnasawy  22 , Samuel Gay  23 , Maximilian D'Onofrio  24 , Konstantin A Popugaev  25   26 , Nikolaos Markou  27 , Pierre Bouzat  28 , Jean-Louis Vincent  1 , Fabio Silvio Taccone  1 ; TRAIN Study Trial Group
Collaborators, Affiliations
Randomized Controlled Trial

Liberal versus restrictive transfusion strategies in subarachnoid hemorrhage: a secondary analysis of the TRAIN study

Chahnez Taleb et al. Crit Care. .

Abstract

Background: The optimal hemoglobin (Hb) threshold to trigger red blood cell transfusions (RBCT) in subarachnoid hemorrhage (SAH) patients is unclear. This study evaluated the impact of liberal versus restrictive transfusion strategies on neurological outcome in patients with SAH.

Methods: This is a pre-planned secondary analysis of the "TRansfusion Strategies in Acute brain INjured Patients" (TRAIN) study. We included all SAH patients from the original study that were randomized to receive RBCT when Hb levels dropped below 9 g/dL (liberal group) or 7 g/dL (restrictive group). The primary outcome was an unfavorable neurological outcome at 180 days, defined by a Glasgow Outcome Scale Extended score of 1-5.

Results: Of the 190 SAH patients in the trial, 188 (98.9%) had data available for the primary outcome, with 86 (45.3%) in the liberal group and 102 (53.6%) in the restrictive group. Patients in the liberal group were older than in the restrictive group, but otherwise had similar baseline characteristics. Patients in the liberal group received more RBCT and showed higher Hb levels over time. At 180 days, 57 (66.3%) patients in the liberal group and 78 (76.4%) in the restrictive group had unfavorable outcomes (risk ratio, RR 0.87; 95% confidence intervals, 95% CI 0.71-1.04). Patients in the liberal group had a significantly lower risk of cerebral ischemia (RR 0.63; 95% CI 0.41-0.97). In a multivariate analysis, randomization to the liberal group was associated with a lower risk of unfavorable outcome (RR 0.83, 95% CI 0.70-0.99).

Conclusions: A liberal transfusion strategy was not associated with a lower incidence of unfavorable outcome after SAH when compared to a restrictive strategy. However, in a multivariable analysis adjusted for confounders randomization to the liberal group was associated with lower risk of unfavorable outcome. The occurrence of cerebral ischemia was significantly lower in the liberal transfusion strategy group.

Trial registration: ClinicalTrials.gov number-NCT02968654 registered on November 16th, 2016.

Keywords: Acute brain injury; Anemia; Blood; Stroke.

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Conflict of interest statement

Declarations. Ethics approval and consent to participate: This is a secondary analysis of the TRAIN study. The TRAIN study was approved by the ethics committees in each hospital. The primary ethics committee, “Comite d’Ethique Erasme-ULB”, approved this multicentric study on the 14th of March 2016 (P2015/327). Written informed consent was obtained from a legal surrogate before enrollment. Whenever possible, deferred consent was also obtained from the patients who regained mental capacity. Consent for publication: Not applicable. Competing interests: Jean Louis Vincent is editor in chief of critical care. No other authors have reported competing interests.

Figures

Fig. 1
Fig. 1
Median daily lowest hemoglobin concentration at baseline and after randomization in the two groups. Baseline values were the last blood hemoglobin level measured before randomization. Day 1 was defined as the day after randomization. Bars indicate the 25th and 75th percentiles
Fig. 2
Fig. 2
Distribution of Glasgow Outcome Scale–Extended scores at 180 days after randomization in the restrictive and liberal group. Each cell corresponds to a score on the scale; the width of each cell represents the proportion of patients with equivalent scores. The vertical dashed line indicates the Glasgow Outcome Scale–Extended score used for dichotomization
Fig. 3
Fig. 3
Time to Death. This figure shows the survival curves, with data censored at 28 days, in the two groups in the intention-to-treat population. Kaplan–Meier analysis showed that the survival time did not differ significantly between the two groups (log-rank P = 0.99 by Mantel-Cox analysis)
See this image and copyright information in PMC

References

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