Transfusion thresholds for cancer patients Frédéric Pène Medical ICU, Hôpital Cochin, AP-HP, Paris University Paris Descartes Institut Cochin, Inserm U1016, CNRS UMR-8104

No conflict of interest

Does research about transfusion thresholds in critically ill OH patients remain relevant ? Blood products are limited and expensive resources Blood products are associated with side effects OH patients are high consumers of blood products Cytopenia are most often already present at ICU admission Translation from studies in general ICU population or stable OH patients to critically ill OH patients is questionable High risk of death and ICU-acquired complications Infections Bleeding Few but discrepant studies in the field

Hb > 7 g/dL Hb > 10 g/dL Number of packed RBC 2.6 ± 4.1 5.6 ± 5.3 Hb > 7 g/dL Hb > 10 g/dL

NEJM 2014

Mortality in septic pts Park, Crit Care Med 2012 Mortality in septic pts

RBC transfusions for early sepsis resuscitation in hemato patients No transfusion Mortality : - D7 : 13.3% vs. 20.5% p = 0,02 - ICU : 25.2% vs. 39% p < 0.001 - Hosp. : 36.6% vs. 49% p < 0.001 Cumulated survival Transfusion Days Mirouse A. for the Grrr-OH, Réanimation congress 2016

Holst, N Engl J Med 2014

RBC transfusion in OH patients with septic shock: the randomized studies Rygard, AAS 2016 Bergamin, CCM 2017 Number of patients 170 300 Setting Multicenter (Scandinavia) Single-center (Brazil) Inclusion criteria Septic shock & Hb<9 g/dL Septic shock Main exclusion criteria Prior transfusion in the ICU Hematological malignancies Underlying diseases 75 HM + 95 metastatic cancer 300 solid tumors SOFA HM 11 (9-14) vs. 11 (9-15) Cancer 10 (9-12) vs. 10 (8-12) 7 (5-9) vs. 6 (5-9) Transfusion strategies 7 vs. 9 g/dL (ICU stay) % transfused HM 69% vs. 100% Cancer 57 vs. 98% 41% and 61% Number of packed RBC HM 2 (0-7) vs. 5 (2-10) MC 1 (0-3) vs. 3 (2-5) 0 (0-2) vs. 1 (0-3) Mortality at day 90 HM 62% vs. 56% (ns) Cancer 60 vs. 55% (ns) 70% vs. 59%, p=0,03

Designing future studies in the field Still a relevant question? Restricting vs. promoting RBC transfusions? Chronic vs. ICU-acquired anemia Multicenter studies Should transfusion indications be hemoglobin-based only? Relevant endpoints? Mortality (short-term & long-term) Alternative endpoints Clinical deterioration/improvement ICU-acquired complications (infectious and non-infectious)