Intended for healthcare professionals


Can we be certain that storage duration of transfused red blood cells does not affect patient outcomes?

BMJ 2019; 365 doi: (Published 11 June 2019) Cite this as: BMJ 2019;365:l2320
  1. Marialena Trivella, senior medical statistician1,
  2. Simon J Stanworth, consultant haematologist2,
  3. Susan Brunskill, systematic reviewer3,
  4. Peter Dutton, medical statistician1,
  5. Douglas G Altman, professor of statistics1
  1. 1Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
  2. 2Department of Haematology, NHS Blood and Transplant/Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital; Radcliffe Department of Medicine, University of Oxford, and Oxford BRC Haematology Theme, Oxford, UK
  3. 3Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
  1. Correspondence to: M Trivella marialena.trivella{at}

Large pragmatic randomised trials have found no evidence that the age of red blood cells affects patient survival, but Trivella and colleagues say that problems with their design and analysis leave unanswered questions about safety

Red cell transfusion is one of the most common forms of medical intervention in hospitals. Optimal practice continues to be defined through randomised trials, with evidence then pooled in meta-analyses. Prolonged storage of red blood cells is associated with cellular and biochemical changes,12 and this has led to numerous studies exploring whether the age of red blood cells might influence clinical outcomes. Establishing clinical consequences of storage effects on red blood cells would be of major importance for blood transfusion services. The four most recent randomised trials (ABLE,3 RECESS,4 INFORM,5 and TRANSFUSE6; box 1) analysed nearly 30 000 patients who received transfusions, reporting neither benefit nor harm from cells with different storage durations. These results should provide adequate reassurance that storage duration has no clinical impact. Several older and smaller trials,789101112131415161718192021 as well as recent meta-analyses,222324 have reported similar conclusions. However, clinical, methodological, and statistical problems may have affected the analysis and interpretation of trial results. Here, we discuss the difficulties in analysing the trials and suggest some solutions.

Box 1

Four large trials of red blood cell storage

ABLE3(a pragmatic superiority trial)—Recruited 2510 patients (of whom 2430 completed the trial in the primary outcome) admitted to critical care to test whether mortality was reduced by using red blood cells stored for shorter periods. No benefit was reported in mortality or a range of secondary outcomes for patients receiving cells stored for less than eight days compared with those receiving standard issue cells (mean (SD) storage 6.1 (4.9) …

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