Prolonged storage of packed red blood cells (storage of 21 days or more) in comparison with fresh cells on recipients of blood transfusion

Review question

We reviewed the clinical benefits and harms of prolonged storage of packed red blood cells (storage of 21 days or more) in comparison with the use of fresher packed red blood cells on recipients of blood transfusion.

Background

Blood transfusion is used to try to solve life- and health-threatening conditions on a short-term basis. Packed red blood cells are most often used for blood transfusion. Sometimes blood is transfused after prolonged storage of these cells but there is continuing debate as to whether transfusion of 'older' blood is as beneficial as transfusion of 'fresher' blood.

Study characteristics

We identified three studies, involving a total of 120 participants, comparing packed red blood cells stored for ≥ 21 days versus < 21 days.

Key results

The results of the studies for the outcome death from any cause were uncertain due to the small number of participants who contributed information. We could not exclude an effect on death with either longer or shorter storage. None of the trials considered the other outcomes of interest in this review, namely transfusion-related acute lung injury, postoperative infections, and adverse events. The safety profiles of the two approaches are unknown.

Quality of evidence

The level of confidence in the results of this review is very low. The studies have limitations in the way they were designed and executed. Moreover, the limited number of people included in the studies led to imprecise results. We are aware of four large ongoing trials in this area which will help us to better understand the effects of storage on red blood cells in relation to outcomes for patients.

Authors' conclusions: 

Recognising the limitations of the review, relating to the size and nature of the included trials, this Cochrane Review provides no evidence to support or reject the use of packed red blood cells for blood transfusion which have been stored for ≥ 21 days ('prolonged' or 'older') compared with those stored for < 21 days ('fresh'). These results are based on three small single centre trials with high risks of bias. There is insufficient evidence to determine the effects of fresh or older packed red blood cells for blood transfusion. Therefore, we urge readers to interpret the trial results with caution. The results from four large ongoing trials will help to inform future updates of this review.

Read the full abstract...
Background: 

A blood transfusion is an acute intervention, used to address life- and health-threatening conditions on a short-term basis. Packed red blood cells are most often used for blood transfusion. Sometimes blood is transfused after prolonged storage but there is continuing debate as to whether transfusion of 'older' blood is as beneficial as transfusion of 'fresher' blood.

Objectives: 

To assess the clinical benefits and harms of prolonged storage of packed red blood cells, in comparison with fresh, on recipients of blood transfusion.

Search strategy: 

We ran the search on 1st May 2014. We searched the Cochrane Injuries Group Specialized Register, Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), MEDLINE (OvidSP), Embase (OvidSP), CINAHL (EBSCO Host) and two other databases. We also searched clinical trials registers and screened reference lists of the retrieved publications and reviews. We updated this search in June 2015 but these results have not yet been incorporated.

Selection criteria: 

Randomised clinical trials including participants assessed as requiring red blood cell transfusion were eligible for inclusion. Prolonged storage was defined as red blood cells stored for ≥ 21 days in a blood bank. We did not apply limits regarding the duration of follow-up, or country where the study took place. We excluded trials where patients received a combination of short- and long-stored blood products, and also trials without a clear definition of prolonged storage.

Data collection and analysis: 

We independently performed study selection, risk of bias assessment and data extraction by at least two review authors. The major outcomes were death from any cause, transfusion-related acute lung injury, and adverse events. We estimated relative risk for dichotomous outcomes. We measured statistical heterogeneity using I2. We used a random-effects model to synthesise the findings.

Main results: 

We identified three randomised clinical trials, involving a total of 120 participants, comparing packed red blood cells with ≥ 21 days storage ('prolonged' or 'older') versus packed red blood cells with < 21 days storage ('fresh'). We pooled data to assess the effect of prolonged storage on death from any cause. The confidence in the results from these trials was very low, due to the bias in their design and their limited sample sizes.

The estimated effect of packed red blood cells with ≥ 21 days storage versus packed red blood cells with < 21 days storage for the outcome death from any cause was imprecise (5/45 [11.11%] versus 2/46 [4.34%]; RR 2.36; 95% CI 0.65 to 8.52; I2: 0%, P = 0.26, very low quality of evidence). Trial sequential analysis, with only two trials, shows that we do not yet have convincing evidence that older packed red blood cells induce a 20% relative risk reduction of death from any cause compared with fresher packed red blood cells. No trial included other outcomes of interest specified in this review, namely transfusion-related acute lung injury, postoperative infections, and adverse events. The safety profile is unknown.

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