From liberal to restrictive and beyond: a narrative review of red blood cell transfusion strategies in the modern era.

Authors

Athena Koutoulogeni, Stavros Tsalas, Elias Kyriakou, Styliani I Kokoris, Aimilia Tsante, Electra Loukopoulou, Emmanuel A Tsantes, Eleni Petrou, Georgios K Nikolopoulos, Stefanos Bonovas, Argirios E Tsantes

Published in

Blood transfusion = Trasfusione del sangue. Oct 14, 2026. Epub Oct 14, 2026.

Abstract

Red blood cell (RBC) transfusion remains a cornerstone of modern medicine, yet optimal transfusion thresholds continue to be debated. Historically, liberal strategies -maintaining hemoglobin (Hb) concentration above 10 g/dL- predominated, but evidence from the 1990s onward has favored restrictive approaches (Hb threshold 7-8 g/dL). This narrative review synthesizes contemporary evidence on restrictive versus liberal transfusion strategies published between 2021 and 2026, evaluates population-specific considerations, and explores emerging ultra-restrictive thresholds.
A structured narrative literature search was conducted in PubMed and Google Scholar with particular emphasis on evidence published between 2021 and 2026. Evidence from randomized controlled trials, systematic reviews, meta-analyses, and clinical practice guidelines is critically discussed.
The 2025 Cochrane update (48 trials, >20,000 participants) provided high-certainty evidence that restrictive strategies induce a reduction in the risk or proportion of patients receiving at least one RBC transfusion by 41% without increasing 30-day mortality or major morbidity. Restrictive thresholds are safe in stable critically ill patients, in those undergoing non-cardiac surgery, and in patients with acute gastrointestinal bleeding. However, important exceptions include: acute myocardial infarction (in which liberal strategies may reduce cardiac events), neurocritical care (conflicting evidence on neurological outcomes), chronic transfusion-dependent conditions such as thalassemia (liberal strategies are disease-modifying), and hematologic malignancies (individualized approach required). Ultra-restrictive thresholds (Hb <6-7 g/dL) have emerged as a potential blood conservation tool during shortages but require further safety validation.
Restrictive transfusion strategies are safe and effective for many stable adult hospitalized patients, reducing blood product utilization without compromising outcomes. However, individualized approaches remain essential for specific high-risk populations. Ultra-restrictive strategies are promising, but these approaches should currently be considered only in selected contexts pending further safety validation.

PMID:
42970330
Bibliographic data and abstract were imported from PubMed on 03 Nov 2026.

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