A further update on mortality and morbidity in patients with very low hemoglobin levels who decline blood transfusion

Transfusion. 2024 Jul;64(7):1198-1206. doi: 10.1111/trf.17867. Epub 2024 May 8.


Background: In the past two decades, researchers have published mortality and morbidity rates in patients with very low hemoglobin levels declining blood transfusion. The clinical knowledge and tools available for the management of patients who decline transfusions have grown since these publications. The aim of our study was to provide a further update on outcomes associated with severe anemia in these patients.

Study design and methods: A retrospective observational study of patients declining allogeneic blood transfusions with nadir hemoglobin levels ≤8 g/dL treated at The Institute for Blood Management, HELIOS Klinikum Gotha, Germany. Outcomes were in-hospital mortality within 30 days and composite morbidity or mortality, with morbidity events defined as acute myocardial infarction, cardiac failure, wound infection, arrhythmia, and pneumonia.

Results: Between June 2008 and June 2021, The Institute for Blood Management treated 2841 admissions of which 159 (5.6%) recorded nadir hemoglobin levels ≤8 g/dL. Of these, five (3.1%) patients died in hospital within 30 days, including four (4.8%) patients admitted for surgical procedures and one (1.4%) medical admission. There was a significant increase in the unadjusted proportion of composite morbidity or mortality events with severity of nadir hemoglobin, with each gram decrease in hemoglobin associated with a 1.48 (95% confidence interval = 1.05-2.09; p = .025) times increase.

Conclusion: Our comparatively lower proportion of patients reaching hemoglobin levels ≤8 g/dL and lower mortality rates suggest outcomes in patients with severe anemia is modifiable with the application of current patient blood management and bloodless medicine and surgery strategies.

Keywords: anemia; bloodless medicine; patient blood management.

Publication types

  • Observational Study

MeSH terms

  • Aged
  • Anemia* / blood
  • Anemia* / mortality
  • Anemia* / therapy
  • Blood Transfusion*
  • Female
  • Hemoglobins* / analysis
  • Hospital Mortality*
  • Humans
  • Male
  • Middle Aged
  • Morbidity
  • Retrospective Studies


  • Hemoglobins