Red blood cell transfusion in elderly patients: Hemoglobin thresholds and clinical outcomes

BACKGROUND: The optimal hemoglobin (Hb) threshold for red blood cell (RBC) transfusion in elderly patients is controversial. Guidelines favor restrictive strategies, but older adults may benefit from higher triggers. OBJECTIVE: To compare clinical outcomes between restrictive and liberal RBC transfusion strategies in elderly patients. METHODS: This single-center retrospective cohort study enrolled 106 patients aged ≥ 65 years who received RBC transfusions between January 2022 and June 2025. Patients were categorized into restrictive (Hb <7.0 g/dL; n = 53) and liberal (Hb <9.0 g/dL; n = 53) groups. The primary outcome was 30-day all-cause mortality; secondary outcomes included 90-day mortality, length of stay (LOS), ICU admission, acute kidney injury, major adverse cardiovascular events, and infection rates. Kaplan-Meier, Cox regression, and multivariate logistic regression were performed. RESULTS: Baseline characteristics were comparable between groups. The restrictive group had numerically higher 30-day mortality than the liberal group, 22.6% versus 7.5%, P = .055, and 90-day mortality, 26.4% versus 11.3%, P = .082. Kaplan-Meier analysis showed better 90-day survival in the liberal group, log-rank P = .048. The restrictive group had longer hospitalization, 14.09 versus 10.38 days, P < .001, and more ICU admissions, 34.0% versus 13.2%, P = .022. Adjusted mortality associations favored the liberal strategy but were not statistically significant and were attenuated in sensitivity analyses. CONCLUSIONS: In this small retrospective cohort, liberal transfusion was associated with shorter hospitalization and fewer ICU admissions, but mortality benefits were not statistically robust. Prospective studies are needed.