Red Blood Cell Transfusion and Mortality in Trauma Patients: Risk-Stratified Analysis of an Observational Study
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{"title"=>"Red Blood Cell Transfusion and Mortality in Trauma Patients: Risk-Stratified Analysis of an Observational Study", "type"=>"journal", "authors"=>[{"first_name"=>"Pablo", "last_name"=>"Perel", "scopus_author_id"=>"14631128400"}, {"first_name"=>"Tim", "last_name"=>"Clayton", "scopus_author_id"=>"26322352300"}, {"first_name"=>"Doug G.", "last_name"=>"Altman", "scopus_author_id"=>"7201380947"}, {"first_name"=>"Peter", "last_name"=>"Croft", "scopus_author_id"=>"16746161700"}, {"first_name"=>"Ian", "last_name"=>"Douglas", "scopus_author_id"=>"15029865900"}, {"first_name"=>"Harry", "last_name"=>"Hemingway", "scopus_author_id"=>"7004642497"}, {"first_name"=>"Aroon", "last_name"=>"Hingorani", "scopus_author_id"=>"7005545809"}, {"first_name"=>"Katherine I.", "last_name"=>"Morley", "scopus_author_id"=>"35354470700"}, {"first_name"=>"Richard", "last_name"=>"Riley", "scopus_author_id"=>"7201915531"}, {"first_name"=>"Adam", "last_name"=>"Timmis", "scopus_author_id"=>"7006508725"}, {"first_name"=>"Danielle", "last_name"=>"Van der Windt", "scopus_author_id"=>"7003393647"}, {"first_name"=>"Ian", "last_name"=>"Roberts", "scopus_author_id"=>"7202322087"}], "year"=>2014, "source"=>"PLoS Medicine", "identifiers"=>{"pui"=>"373397991", "sgr"=>"84903317340", "pmid"=>"24937305", "scopus"=>"2-s2.0-84903317340", "isbn"=>"1549-1277\\n1549-1676", "doi"=>"10.1371/journal.pmed.1001664", "issn"=>"15491676"}, "id"=>"7824ab06-55b2-39da-8a0d-63d53ee80c25", "abstract"=>"BACKGROUND: Haemorrhage is a common cause of death in trauma patients. Although transfusions are extensively used in the care of bleeding trauma patients, there is uncertainty about the balance of risks and benefits and how this balance depends on the baseline risk of death. Our objective was to evaluate the association of red blood cell (RBC) transfusion with mortality according to the predicted risk of death.\\n\\nMETHODS AND FINDINGS: A secondary analysis of the CRASH-2 trial (which originally evaluated the effect of tranexamic acid on mortality in trauma patients) was conducted. The trial included 20,127 trauma patients with significant bleeding from 274 hospitals in 40 countries. We evaluated the association of RBC transfusion with mortality in four strata of predicted risk of death: <6%, 6%-20%, 21%-50%, and >50%. For this analysis the exposure considered was RBC transfusion, and the main outcome was death from all causes at 28 days. A total of 10,227 patients (50.8%) received at least one transfusion. We found strong evidence that the association of transfusion with all-cause mortality varied according to the predicted risk of death (p-value for interaction <0.0001). Transfusion was associated with an increase in all-cause mortality among patients with <6% and 6%-20% predicted risk of death (odds ratio [OR] 5.40, 95% CI 4.08-7.13, p<0.0001, and OR 2.31, 95% CI 1.96-2.73, p<0.0001, respectively), but with a decrease in all-cause mortality in patients with >50% predicted risk of death (OR 0.59, 95% CI 0.47-0.74, p<0.0001). Transfusion was associated with an increase in fatal and non-fatal vascular events (OR 2.58, 95% CI 2.05-3.24, p<0.0001). The risk associated with RBC transfusion was significantly increased for all the predicted risk of death categories, but the relative increase was higher for those with the lowest (<6%) predicted risk of death (p-value for interaction <0.0001). As this was an observational study, the results could have been affected by different types of confounding. In addition, we could not consider haemoglobin in our analysis. In sensitivity analyses, excluding patients who died early; conducting propensity score analysis adjusting by use of platelets, fresh frozen plasma, and cryoprecipitate; and adjusting for country produced results that were similar.\\n\\nCONCLUSIONS: The association of transfusion with all-cause mortality appears to vary according to the predicted risk of death. Transfusion may reduce mortality in patients at high risk of death but increase mortality in those at low risk. The effect of transfusion in low-risk patients should be further tested in a randomised trial.\\n\\nTRIAL REGISTRATION: www.ClinicalTrials.gov NCT01746953.", "link"=>"http://www.mendeley.com/research/red-blood-cell-transfusion-mortality-trauma-patients-riskstratified-analysis-observational-study-6", "reader_count"=>33, "reader_count_by_academic_status"=>{"Professor > Associate Professor"=>5, "Researcher"=>4, "Student > Doctoral Student"=>3, "Student > Ph. D. Student"=>4, "Student > Postgraduate"=>5, "Other"=>2, "Student > Master"=>2, "Student > Bachelor"=>2, "Lecturer > Senior Lecturer"=>4, "Professor"=>2}, "reader_count_by_user_role"=>{"Professor > Associate Professor"=>5, "Researcher"=>4, "Student > Doctoral Student"=>3, "Student > Ph. D. Student"=>4, "Student > Postgraduate"=>5, "Other"=>2, "Student > Master"=>2, "Student > Bachelor"=>2, "Lecturer > Senior Lecturer"=>4, "Professor"=>2}, "reader_count_by_subject_area"=>{"Engineering"=>1, "Unspecified"=>3, "Nursing and Health Professions"=>1, "Medicine and Dentistry"=>23, "Agricultural and Biological Sciences"=>2, "Neuroscience"=>1, "Chemistry"=>1, "Social Sciences"=>1}, "reader_count_by_subdiscipline"=>{"Engineering"=>{"Engineering"=>1}, "Medicine and Dentistry"=>{"Medicine and Dentistry"=>23}, "Neuroscience"=>{"Neuroscience"=>1}, "Chemistry"=>{"Chemistry"=>1}, "Social Sciences"=>{"Social Sciences"=>1}, "Agricultural and Biological Sciences"=>{"Agricultural and Biological Sciences"=>2}, "Nursing and Health Professions"=>{"Nursing and Health Professions"=>1}, "Unspecified"=>{"Unspecified"=>3}}, "reader_count_by_country"=>{"Canada"=>1, "Netherlands"=>1, "United States"=>2, "United Kingdom"=>1}, "group_count"=>3}

Scopus | Further Information

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Figshare

  • {"files"=>["https://ndownloader.figshare.com/files/1537270"], "description"=>"<p>Interaction between RBC transfusion and predicted risk of death on the OR, <i>p<</i>0.0001 (chi-square <i> = </i>151).</p>a<p>Risk group determined according to model published in <a href=\"http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001664#pmed.1001664-Perel1\" target=\"_blank\">[10]</a>.</p>", "links"=>[], "tags"=>["Critical care and emergency medicine", "transfusion", "adjusted", "propensity"], "article_id"=>1059445, "categories"=>["Biological Sciences"], "users"=>["Pablo Perel", "Tim Clayton", "Doug G. Altman", "Peter Croft", "Ian Douglas", "Harry Hemingway", "Aroon Hingorani", "Katherine I. Morley", "Richard Riley", "Adam Timmis", "Danielle Van der Windt", "Ian Roberts"], "doi"=>"https://dx.doi.org/10.1371/journal.pmed.1001664.t005", "stats"=>{"downloads"=>1, "page_views"=>5, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Mortality_by_category_of_predicted_risk_of_death_and_red_blood_cell_transfusion_adjusted_for_propensity_score_/1059445", "title"=>"Mortality by category of predicted risk of death and red blood cell transfusion adjusted for propensity score.", "pos_in_sequence"=>0, "defined_type"=>3, "published_date"=>"2014-06-17 02:49:19"}
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  • {"files"=>["https://ndownloader.figshare.com/files/1537266"], "description"=>"<p>Data are presented as number, number (percent), or median (interquartile range).</p>a<p>From a logistic regression model fitting each covariate as a categorical or continuous variable. Predicted risk of death was not calculated for those with missing values.</p>", "links"=>[], "tags"=>["Critical care and emergency medicine", "transfusion"], "article_id"=>1059441, "categories"=>["Biological Sciences"], "users"=>["Pablo Perel", "Tim Clayton", "Doug G. Altman", "Peter Croft", "Ian Douglas", "Harry Hemingway", "Aroon Hingorani", "Katherine I. Morley", "Richard Riley", "Adam Timmis", "Danielle Van der Windt", "Ian Roberts"], "doi"=>"https://dx.doi.org/10.1371/journal.pmed.1001664.t001", "stats"=>{"downloads"=>1, "page_views"=>3, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Baseline_characteristics_by_transfusion_status_/1059441", "title"=>"Baseline characteristics by transfusion status.", "pos_in_sequence"=>0, "defined_type"=>3, "published_date"=>"2014-06-17 02:49:19"}
  • {"files"=>["https://ndownloader.figshare.com/files/1537264"], "description"=>"<p>Odds ratio of death for transfusion compared to no transfusion by risk category.</p>", "links"=>[], "tags"=>["Critical care and emergency medicine", "transfusion", "compared"], "article_id"=>1059439, "categories"=>["Biological Sciences"], "users"=>["Pablo Perel", "Tim Clayton", "Doug G. Altman", "Peter Croft", "Ian Douglas", "Harry Hemingway", "Aroon Hingorani", "Katherine I. Morley", "Richard Riley", "Adam Timmis", "Danielle Van der Windt", "Ian Roberts"], "doi"=>"https://dx.doi.org/10.1371/journal.pmed.1001664.g001", "stats"=>{"downloads"=>4, "page_views"=>6, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Odds_ratio_of_death_for_transfusion_compared_to_no_transfusion_by_risk_category_/1059439", "title"=>"Odds ratio of death for transfusion compared to no transfusion by risk category.", "pos_in_sequence"=>0, "defined_type"=>1, "published_date"=>"2014-06-17 02:49:19"}
  • {"files"=>["https://ndownloader.figshare.com/files/1537265"], "description"=>"<p>Interaction between RBC transfusion and predicted risk of death on the OR, <i>p = </i>0.013.</p>a<p>Risk group determined according to model published in <a href=\"http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001664#pmed.1001664-Perel1\" target=\"_blank\">[10]</a>.</p>", "links"=>[], "tags"=>["Critical care and emergency medicine", "occlusive"], "article_id"=>1059440, "categories"=>["Biological Sciences"], "users"=>["Pablo Perel", "Tim Clayton", "Doug G. Altman", "Peter Croft", "Ian Douglas", "Harry Hemingway", "Aroon Hingorani", "Katherine I. Morley", "Richard Riley", "Adam Timmis", "Danielle Van der Windt", "Ian Roberts"], "doi"=>"https://dx.doi.org/10.1371/journal.pmed.1001664.t008", "stats"=>{"downloads"=>1, "page_views"=>4, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Vascular_occlusive_events_fatal_and_non_fatal_by_category_of_predicted_risk_of_death_and_red_blood_cell_transfusion_/1059440", "title"=>"Vascular occlusive events (fatal and non-fatal) by category of predicted risk of death and red blood cell transfusion.", "pos_in_sequence"=>0, "defined_type"=>3, "published_date"=>"2014-06-17 02:49:19"}
  • {"files"=>["https://ndownloader.figshare.com/files/1537273", "https://ndownloader.figshare.com/files/1537274"], "description"=>"<div><p>Background</p><p>Haemorrhage is a common cause of death in trauma patients. Although transfusions are extensively used in the care of bleeding trauma patients, there is uncertainty about the balance of risks and benefits and how this balance depends on the baseline risk of death. Our objective was to evaluate the association of red blood cell (RBC) transfusion with mortality according to the predicted risk of death.</p><p>Methods and Findings</p><p>A secondary analysis of the CRASH-2 trial (which originally evaluated the effect of tranexamic acid on mortality in trauma patients) was conducted. The trial included 20,127 trauma patients with significant bleeding from 274 hospitals in 40 countries. We evaluated the association of RBC transfusion with mortality in four strata of predicted risk of death: &lt;6%, 6%–20%, 21%–50%, and &gt;50%. For this analysis the exposure considered was RBC transfusion, and the main outcome was death from all causes at 28 days. A total of 10,227 patients (50.8%) received at least one transfusion. We found strong evidence that the association of transfusion with all-cause mortality varied according to the predicted risk of death (<i>p-</i>value for interaction &lt;0.0001). Transfusion was associated with an increase in all-cause mortality among patients with &lt;6% and 6%–20% predicted risk of death (odds ratio [OR] 5.40, 95% CI 4.08–7.13, <i>p&lt;</i>0.0001, and OR 2.31, 95% CI 1.96–2.73, <i>p&lt;</i>0.0001, respectively), but with a decrease in all-cause mortality in patients with &gt;50% predicted risk of death (OR 0.59, 95% CI 0.47–0.74, <i>p&lt;</i>0.0001). Transfusion was associated with an increase in fatal and non-fatal vascular events (OR 2.58, 95% CI 2.05–3.24, <i>p&lt;</i>0.0001). The risk associated with RBC transfusion was significantly increased for all the predicted risk of death categories, but the relative increase was higher for those with the lowest (&lt;6%) predicted risk of death (<i>p-</i>value for interaction <i>&lt;</i>0.0001). As this was an observational study, the results could have been affected by different types of confounding. In addition, we could not consider haemoglobin in our analysis. In sensitivity analyses, excluding patients who died early; conducting propensity score analysis adjusting by use of platelets, fresh frozen plasma, and cryoprecipitate; and adjusting for country produced results that were similar.</p><p>Conclusions</p><p>The association of transfusion with all-cause mortality appears to vary according to the predicted risk of death. Transfusion may reduce mortality in patients at high risk of death but increase mortality in those at low risk. The effect of transfusion in low-risk patients should be further tested in a randomised trial.</p><p>Trial registration</p><p><a href=\"http://www.ClinicalTrials.gov\" target=\"_blank\">www.ClinicalTrials.gov</a><a href=\"http://clinicaltrials.gov/ct2/show/NCT01746953\" target=\"_blank\">NCT01746953</a></p><p><i>Please see later in the article for the Editors' Summary</i></p></div>", "links"=>[], "tags"=>["Critical care and emergency medicine", "transfusion", "risk-stratified", "observational"], "article_id"=>1059448, "categories"=>["Biological Sciences"], "users"=>["Pablo Perel", "Tim Clayton", "Doug G. Altman", "Peter Croft", "Ian Douglas", "Harry Hemingway", "Aroon Hingorani", "Katherine I. Morley", "Richard Riley", "Adam Timmis", "Danielle Van der Windt", "Ian Roberts"], "doi"=>[nil, nil], "stats"=>{"downloads"=>29, "page_views"=>43, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/Red_Blood_Cell_Transfusion_and_Mortality_in_Trauma_Patients_Risk_Stratified_Analysis_of_an_Observational_Study/1059448", "title"=>"Red Blood Cell Transfusion and Mortality in Trauma Patients: Risk-Stratified Analysis of an Observational Study", "pos_in_sequence"=>0, "defined_type"=>4, "published_date"=>"2015-04-12 17:44:43"}
  • {"files"=>["https://ndownloader.figshare.com/files/1537272"], "description"=>"<p>Interaction between RBC transfusion and predicted risk of death on the OR, <i>p<</i>0.0001 for each continent grouping.</p>a<p>OR for RBC transfusion versus no RBC transfusion. Risk group determined according to model published in <a href=\"http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001664#pmed.1001664-Perel1\" target=\"_blank\">[10]</a>.</p>", "links"=>[], "tags"=>["Critical care and emergency medicine", "transfusion", "geographical"], "article_id"=>1059447, "categories"=>["Biological Sciences"], "users"=>["Pablo Perel", "Tim Clayton", "Doug G. Altman", "Peter Croft", "Ian Douglas", "Harry Hemingway", "Aroon Hingorani", "Katherine I. Morley", "Richard Riley", "Adam Timmis", "Danielle Van der Windt", "Ian Roberts"], "doi"=>"https://dx.doi.org/10.1371/journal.pmed.1001664.t007", "stats"=>{"downloads"=>1, "page_views"=>5, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Mortality_with_red_blood_cell_transfusion_by_risk_category_and_geographical_region_/1059447", "title"=>"Mortality with red blood cell transfusion by risk category and geographical region.", "pos_in_sequence"=>0, "defined_type"=>3, "published_date"=>"2014-06-17 02:49:19"}
  • {"files"=>["https://ndownloader.figshare.com/files/1537271"], "description"=>"<p>Interaction between RBC transfusion and predicted risk of death on the OR, <i>p<</i>0.0001 (chi-square <i> = </i>188 with one degree of freedom).</p>a<p>Risk group determined according to model published in <a href=\"http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001664#pmed.1001664-Perel1\" target=\"_blank\">[10]</a>.</p>b<p>OR adjusted for country as well as use of platelets (<i>n = </i>806), fresh frozen plasma (<i>n = </i>2,633), and cryoprecipitate (<i>n = </i>392). In total, 2,726 (13.5%) patients received one of these blood products.</p>", "links"=>[], "tags"=>["Critical care and emergency medicine", "transfusion"], "article_id"=>1059446, "categories"=>["Biological Sciences"], "users"=>["Pablo Perel", "Tim Clayton", "Doug G. Altman", "Peter Croft", "Ian Douglas", "Harry Hemingway", "Aroon Hingorani", "Katherine I. Morley", "Richard Riley", "Adam Timmis", "Danielle Van der Windt", "Ian Roberts"], "doi"=>"https://dx.doi.org/10.1371/journal.pmed.1001664.t006", "stats"=>{"downloads"=>0, "page_views"=>2, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Mortality_by_category_of_predicted_risk_of_death_and_red_blood_cell_transfusion_adjusted_analysis_/1059446", "title"=>"Mortality by category of predicted risk of death and red blood cell transfusion (adjusted analysis).", "pos_in_sequence"=>0, "defined_type"=>3, "published_date"=>"2014-06-17 02:49:19"}
  • {"files"=>["https://ndownloader.figshare.com/files/1537268"], "description"=>"<p>Interaction between RBC transfusion and predicted risk of death on the OR, <i>p<</i>0.0001 (chi-square <i> = </i>227 with one degree of freedom).</p>a<p>Risk group determined according to model published in <a href=\"http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001664#pmed.1001664-Perel1\" target=\"_blank\">[10]</a>.</p>", "links"=>[], "tags"=>["Critical care and emergency medicine"], "article_id"=>1059443, "categories"=>["Biological Sciences"], "users"=>["Pablo Perel", "Tim Clayton", "Doug G. Altman", "Peter Croft", "Ian Douglas", "Harry Hemingway", "Aroon Hingorani", "Katherine I. Morley", "Richard Riley", "Adam Timmis", "Danielle Van der Windt", "Ian Roberts"], "doi"=>"https://dx.doi.org/10.1371/journal.pmed.1001664.t003", "stats"=>{"downloads"=>1, "page_views"=>3, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Mortality_by_category_of_predicted_risk_of_death_and_red_blood_cell_transfusion_/1059443", "title"=>"Mortality by category of predicted risk of death and red blood cell transfusion.", "pos_in_sequence"=>0, "defined_type"=>3, "published_date"=>"2014-06-17 02:49:19"}
  • {"files"=>["https://ndownloader.figshare.com/files/1537267"], "description"=>"<p>Data are presented as number (percent) of patients.</p>a<p>Myocardial infarction, stroke, pulmonary embolism, or deep vein thrombosis.</p>", "links"=>[], "tags"=>["Critical care and emergency medicine", "outcomes"], "article_id"=>1059442, "categories"=>["Biological Sciences"], "users"=>["Pablo Perel", "Tim Clayton", "Doug G. Altman", "Peter Croft", "Ian Douglas", "Harry Hemingway", "Aroon Hingorani", "Katherine I. Morley", "Richard Riley", "Adam Timmis", "Danielle Van der Windt", "Ian Roberts"], "doi"=>"https://dx.doi.org/10.1371/journal.pmed.1001664.t002", "stats"=>{"downloads"=>1, "page_views"=>4, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Clinical_outcomes_by_red_blood_cell_transfusion_/1059442", "title"=>"Clinical outcomes by red blood cell transfusion.", "pos_in_sequence"=>0, "defined_type"=>3, "published_date"=>"2014-06-17 02:49:19"}

PMC Usage Stats | Further Information

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