Written by Clark Strunk
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This trial found no significant difference in long-term neurologic outcomes in anemic patients with aneurysmal subarachnoid hemorrhage (aSAH) with a liberal versus restrictive transfusion strategy.
SAHARA – when less is more?
Anemia is common in patients with aSAH and has been associated with worse outcomes; however, the optimal transfusion target in this population is unknown. In most patient populations, there is minimal evidence to support a more liberal transfusion threshold compared to a more restrictive one. The recent TRAIN trial assessed transfusion targets in patients with a variety of different types of brain injury (TBI, SAH, and ICH) and demonstrated improved 180-day neurologic outcomes in patients who received a liberal transfusion strategy. The SAHARA trial was a pragmatic, open-label, multicenter RCT that included anemic patients (hemoglobin <10 g/dl) with aSAH randomized to a liberal (mandatory transfusion at hemoglobin <10g/dl) versus restrictive (permissible transfusion at hemoglobin <8 g/dl) strategy. The primary outcome was unfavorable neurologic function at 12 months, using the modified Rankin scale score, which occurred in 33.5% of patients in the liberal group and 37.7% of patients in the restrictive group and was not statistically significantly different between groups (RR 0.88, 95%CI 0.72-1.09; p = 0.22). A limitation to this trial is that the treatment team could not be blinded to the intervention, but outcome assessment was blinded.
How will this change my practice?
I will likely continue to transfuse patients with aSAH when their hemoglobin is less than 7 g/dl. However, given the recent TRAIN trial (TBI, SAH, ICH patients) demonstrated better neurologic outcomes with a more liberal transfusion strategy, and the point estimates in both HEMOTION (TBI patients) and SAHARA (aSAH patients) favored a liberal strategy. Although it did not reach statistical significance, a more liberal strategy in patients with brain injury could be reasonable. Perhaps additional trials or a meta-analysis might provide further clarity to me.
Source
Liberal or Restrictive Transfusion Strategy in Aneurysmal Subarachnoid Hemorrhage. N Engl J Med. 2024 Dec 9. doi: 10.1056/NEJMoa2410962. Epub ahead of print. PMID: 39655786
Works Cited
- Liberal or Restrictive Transfusion Strategy in Patients with Traumatic Brain Injury. N Engl J Med. 2024 Aug 22;391(8):722-735. doi: 10.1056/NEJMoa2404360. Epub 2024 Jun 13. PMID: 38869931.
- Restrictive vs Liberal Transfusion Strategy in Patients With Acute Brain Injury: The TRAIN Randomized Clinical Trial.JAMA. 2024 Nov 19;332(19):1623-1633. doi: 10.1001/jama.2024.20424. PMID: 39382241; PMCID: PMC11581574.
