Methodologic quality assessment of red blood cell transfusion guidelines and the evidence base of more restrictive transfusion thresholds

Significance Statement

The World Health Organization indicates that every second someone in the world needs a blood transfusion. Blood transfusions therefore save many lives every year, and patients can die when they don’t receive a transfusion when necessary. However, transfusions also carry certain risks, and therefore should not be performed unless really necessary.

In recent years, a lot of emphasis has been put on this second consideration, which has been more broadly rebranded as “patient blood management” (PBM). PBM is a worthwhile effort, but should be evidence-based and not based on other considerations, be it religious (e.g., refusing of an allogenic blood transfusion as a Jehovah Witness) or commercial (e.g., receiving sponsorships by commercial companies who promote RBC replacing products).

It is therefore important that transfusion guidelines are of high quality, and based on the best scientific evidence. Our analysis of the quality of the most widely used transfusion guidelines, using an internationally used tool (AGREE II), indicates that guidelines recommending red blood cell transfusion as of Hb levels of 7 to 8 g/dL are based on high quality evidence, whereas the more recent guidelines recommending red blood cell transfusion only at Hb thresholds of ≤6 g/dL are not based on solid evidence.

The methodological robustness of the published transfusion guidelines is variable and has room for improvement. Furthermore, guideline developers and reviewers should always be transparent about conflicts of interest, whether religious or commercial, which was, based on other available information, not always the case in these guidelines.

About the author

Hans Van Remoortel, PT/PhD, physiotherapist, is staff member in the Centre for Evidence-Based Practice of the Belgian Red Cross-Flanders. After obtaining a Master in Rehabilitation Sciences and Physiotherapy in 2005, Hans worked for three years (2005-2008) as a clinical physiotherapist in cardiac rehabilitation programs in 2 Belgian hospitals (University Hospital of Leuven and Imelda Hospital Bonheiden). After working in a clinical setting, he obtained his PhD degree at the Faculty of Rehabilitation Sciences and Kinesiology at the University of Leuven (Belgium) with a project entitled ‘Physical activity and comorbidities in patients with chronic obstructive pulmonary disease’ (2009-2013).

He has published about 20 articles in peer reviewed journals, mainly in the field of exercise, physical activity, pulmonology and evidence-based medicine. In his current job, Hans is a methodologist working on the development of systematic reviews and guidelines within the relevant themes of the Belgian Red Cross, i.e. from humanitarian aid to blood supply. In his spare moments, Hans enjoys to spend time with his family, is a recreational sporter (squash, soccer, running, cycling) and enjoys to attend live music concerts.

About the author

Philippe Vandekerckhove, M.D./PhD, pathologist, is the CEO of the Belgian Red Cross-Flanders.

Prior to this position Philippe worked as Clinical Director of the University Hospital Leuven from where he also obtained his M.D./PhD and Pathology degree. His clinical and pathology training was further carried out in South Africa (Baragwanath – University of Johannesburg, and Groote Schuur Hospital – University of Cape Town), the US (Woods Hole Marine Biology Laboratory, University of Hawaii, New York University), and The Netherlands (Erasmus University, Rotterdam).

In addition, Philippe studied healthcare management at INSEAD (France) and general management at Harvard Business School. He has published about 60 articles in peer reviewed journals, and 5 chapters in textbooks, mainly in the field of immunology, hematology, blood banking and evidence-based medicine.

Philippe is associate professor at the Faculties of Medicine of the University of Leuven and the University of Ghen. He holds non-executive positions as president of the European Blood Alliance, president of GAP, member of the governing board of the International Federation of Red Cross and Red Crescent Societies, and of the investment committee of Flanders’ Care Invest (Flemish government). In his spare moments, he enjoys jogging, natural horsemanship and time and travel spent in natural surroundings.

Methodologic quality assessment of red blood cell transfusion guidelines and the evidence base of morerestrictive transfusion thresholds.

Journal Reference

Transfusion. 2016 Feb;56(2):472-80.

Van Remoortel H1, De Buck E1, Dieltjens T1, Pauwels NS1, Compernolle V1,2, Vandekerckhove P1,2,3.

[expand title=”Show Affiliations”]
  1. BelgianRed Cross-Flanders, Mechelen, Belgium.
  2. Faculty of Medicine, University of Ghent, Ghent, Belgium.
  3. Department of Public Health and Primary Care, Faculty of Medicine, Catholic University of Leuven, Leuven, Belgium.



Recent literature suggests that more restrictive red blood cell (RBC) transfusion practices are equivalent or better than more liberal transfusion practices. The methodologic quality of guidelines recommending more restrictive transfusion thresholds and their underlying scientific evidence is unclear. Therefore, we aimed to evaluate the quality of the development process of red blood cell transfusion guidelines and to investigate the underlying evidence of guidelines recommending a more restrictive hemoglobin (Hb) threshold.


Via systematic literature screening of relevant databases (NGC, GIN, Medline, and Embase), red blood cell transfusion guidelines recommending a more restrictive Hb level (<6, <7, or <8 g/dL) were included. Four assessors independently evaluated the methodologic quality by scoring the rigor of development domain (AGREE II checklist). The level of evidence served as a reference for the quality of the underlying evidence.


The methodologic quality of 13 red blood cell transfusion guidelines was variable (18%-72%) but highest for those developed by Advancing Transfusion and Cellular Therapies Worldwide (72%), the Task Force of Advanced Bleeding Care in Trauma (70%), and the Dutch Institute for Healthcare Improvement (61%). A Hb level of less than 7 g/dL (intensive care unit patients) or less than 8 g/dL (postoperative patients) were the only thresholds based on high-quality evidence. Only four of 32 recommendations had a high-quality evidence base.


Methodologic quality should be guaranteed in future RBC transfusion guideline development to ensure that the best available evidence is captured when recommending restrictive transfusion strategies. More high-quality trials are needed to provide a stronger scientific basis for RBC transfusion guidelines that recommend more restrictive transfusion thresholds.

© 2015 AABB.

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