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PLASTIC RECONSTRUCTIVE AND REGENERATIVE SURGERY

Review

Ahead-of-Print

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

Authors

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

Key words: Restrictive transfusion strategy, liberal transfusion strategy, hemoglobin threshold, patient blood management, red blood cell transfusion
Doi: 10.2450/BloodTransfus.1409
Transfusion medicine
Publication Date: 2026-10-14

Abstract

Background - 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.

Materials and methods - 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.

Results - 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.

Discussion - 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.

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Authors

Athena Koutoulogeni Laboratory of Hematology and Blood Bank Unit, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece ORCID

Stavros Tsalas Laboratory of Hematology and Blood Bank Unit, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece ORCID

Elias Kyriakou Laboratory of Hematology and Blood Bank Unit, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece ORCID

Styliani I. Kokoris Laboratory of Hematology and Blood Bank Unit, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece

Aimilia Tsante Laboratory of Hematology and Blood Bank Unit, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece

Electra Loukopoulou Laboratory of Hematology and Blood Bank Unit, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece

Emmanuel A. Tsantes Laboratory of Hematology and Blood Bank Unit, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece

Eleni Petrou Laboratory of Hematology and Blood Bank Unit, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece ORCID

Georgios K. Nikolopoulos Medical School, University of Cyprus, Nicosia, Cyprus ORCID

Stefanos Bonovas Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy ORCID

Argirios E. Tsantes Laboratory of Hematology and Blood Bank Unit, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece ORCID

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