Red blood cell transfusion thresholds in acute leukemia: Current practice and physician perspectives from a national survey

BACKGROUND: Red blood cell (RBC) transfusions are part of essential supportive therapy in patients with acute leukemia, where patients often present with anemia and thrombocytopenia. Together these cytopenias increase bleeding risk; however, optimal hemoglobin (Hb) thresholds for RBC transfusion remain undefined, and current recommendations for restrictive strategies (<7 g/dL) are based on low-certainty, indirect evidence. STUDY DESIGN AND METHODS: A national web-based survey was distributed to 43 physicians (24 centers, Canada) to assess current RBC transfusion practice in patients with acute leukemia, perceptions of a liberal threshold (11 g/dL) in the context of a clinical trial, and feasibility considerations. The survey included categorical responses and open-text fields. RESULTS: Of 38 eligible physicians, 34 responded (89%). For stable, non-bleeding patients receiving induction chemotherapy, 27/34 (79%) used a Hb threshold of 7 g/dL, 6/34 (18%) used 8 g/dL, and 1/34 (3%) used 9 g/dL. Fourteen (14/34, 41%) respondents indicated that a Hb threshold of 11 g/dL was reasonable for the liberal arm of a clinical trial, while 20/34 (59%) did not. For such a trial, 32/34 (94%) would consider enrolling patients in the trial and 2/34 (6%) would not. DISCUSSION: A Hb threshold of 7 g/dL was most reported as standard-of-care. Most respondents supported enrolling their patients in a clinical trial comparing a liberal RBC transfusion strategy of 11 g/dL with standard-of-care. The feasibility of 11 g/dL should be tested with clear justification, appropriate study outcomes, and attention to safety risks and resource demands.