Cirrhosis Clinical Trial
Official title:
Randomized and Controlled Clinical Trial of Transfusional Requirements in Patients With Acute Gastrointestinal Bleeding.
Recently it has been suggested that a restrictive transfusion of units of Red Cells (URC)
may improve the outcome of ICU patients with anemia. Furthermore, it has been suggested that
the transfusion of URC may be deleterious for the hemostatic process of bleeding lesions,
which suggest that a restrictive transfusion may be valuable in patients which
gastrointestinal bleeding. Transfusion of URC may also increase portal pressure which may be
detrimental to control acute portal hypertensive bleeding.
The aim of the present study is to assess whether a restrictive transfusions may improve the
outcome of patients with acute nonvariceal gastrointestinal bleeding, and also whether such
a restrictive strategy may improve the outcome of bleeding episodes related with portal
hypertension.
The study will be carried out with a prospective, randomized and controlled design comparing
the restrictive transfusion strategy with the usual nonrestrictive transfusional strategy.
Overall 860 patients will be included; 430 in each group.
The main outcome measure will be survival. All deaths occurred within the 30 days after
admission, will be considered. Secondary outcomes will include rebleeding and complications
related to treatment, and related to the bleeding episode itself. Portal pressure will be
measured to assess the influence of the transfusions strategy on fluctuations of this
parameter, and the relationship with the clinical course of bleeding episode.
The study will be performed at the Bleeding Unit of our hospital during a period of 3 years.
HYPOTHESIS
At the present time there does not exist established criteria to decide when it is necessary
a blood transfusion in a patient with digestive hemorrhage, neither which should be the red
cells concentrates (RBC) amount that the most of the patients will need.
In clinical studies made in critical patients undergoing a by-pass coronary surgery, the
strategy of restrictive transfusion showed results similar to the one obtained with more
liberal strategies, even with an improvement of the survival and a smaller rate of
complications related to transfusion.
In animal models of GI bleeding (and also in human studies in the traumatic hemorrhage),
precocious or vigorous transfusion made hemostasia more difficult. Also an increase in the
rate of rebleeding has been observed, suggesting that arterial hypotension combined with
hypovolemia aid hemostasia, stabilize the clot. It leads to diminish by itself the
rebleeding rate.
In the same way, in patients with portal hypertension associated hemorrhage, aggressive
replacement of volemia causes increases on the portal pressure, and that could lead in a
condition of bigger difficulty for the control of the hemorrhage and greater rate of
recidiva.
On the other hand, potential complications associated with the transfusion would be seen
potentially reduced.
Our randomized prospective study tries to demonstrate that the use of a restrictive strategy
in the sanguineous transfusion in patients with acute GI upper bleeding can be at least as
beneficial than the habitually used.
Moreover, restricted transfusion in these patients could improve short term survival, as
well as a smaller rate transfusion-related or rebleeding.
In portal hypertension related hemorrhage, restricted transfusion could avoid fluctuations
of portal pressure caused by transfusion during the acute phase of hemorrhage, which could
favor hemostasia in these patients.
OBJECTIVES
The main objective is to evaluate if restrictive transfusion criterion in patients with
acute upper GI hemorrhage can maintain the rates of survival obtained using habitual
transfusion criteria, or to even improve them.
The more important secondary targets consist in evaluating if these restrictive
transfusional parameters are also accompanied by a better control of the hemorrhage, and
also to evaluate if this is accompanied by a smaller rate of complications.
Other additional objectives would be:
- Effect on changes in portal pressure and its correlation with the clinical evolution.
- Hospital stay and estimation of economic cost.
STUDY DESIGN
Ours is a prospective, randomized and controlled study, in which patients with acute upper
GI bleeding will be randomized into two groups of transfusional RBC treatment with:
Group 1 (of restricted transfusion), that constitutes the training group: they will receive
UCH transfusion when the hemoglobin descends below 70 G/L, to maintain values of hemoglobin
of 70 to 90 G/L.
Group 2 (of habitual transfusion), that constitutes the group control: they will receive
transfusion according to habitual practice, when the hemoglobin descends below 90 G/L, to
maintain values of hemoglobin of 90 to 110 G/L.
Randomization will be made by means of a closed opaque envelope that will contain the
treatment option that will have been obtained by means of a listing of random numbers
generated by computer.
The patients will be randomized as soon as the inclusion criteria/exclusion has been
verified.
Randomization will be stratified according to the origin of the hemorrhage (related to
portal hypertension or not).
NUMBER OF PREDICTED SUBJECTS AND JUSTIFICATION:
430 patients in every group will be required (860 altogether), to objective a mortality
reduction of 5%, with a global expected mortality secondary to GI bleeding at the control
group of 10%, with a type I error of 5% and a type II error of 20%.
280 patients in each group will be required (560 altogether) to objective a difference of
6%, with the detailed parameters.
An expected period of 3 years to include this
;
Allocation: Randomized, Endpoint Classification: Safety/Efficacy Study, Intervention Model: Parallel Assignment, Masking: Open Label, Primary Purpose: Treatment
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