Liberal transfusion in cancer patients with septic shock: no benefit, more thrombosis

Design

Multicentre randomised superiority trial, stopped early

Population

187 adults with cancer, septic shock and haemoglobin <9 g/dL, France

Primary outcome

Lactate reduction at 12 hours

Effect

52% vs 50%, OR 1.07 (95% CI 0.60–1.90); thrombotic events 13% vs 1%; 28-day mortality 46% vs 53%

TRANSPORT randomised adults with solid or haematological cancer, septic shock, lactate above 2 mmol/L and haemoglobin below 9 g/dL at 18 French centres. Patients were transfused to a threshold of 9 g/dL or 7 g/dL for the first 48 hours. The trial planned 260 patients but stopped at 187 for safety concerns.

Lactate clearance at 12 hours was the same, 52% against 50%. Arterial or venous thrombotic events occurred in 13% with the liberal strategy and 1% with the restrictive one. Mortality at 28 days was 46% and 53%, a difference that was not significant.

There had been a plausible argument that anaemic, immunocompromised patients in shock might need a higher haemoglobin to restore oxygen delivery. This trial does not support it. The restrictive threshold of 7 g/dL used for other septic patients remains reasonable for patients with cancer, and liberal transfusion may cause harm.

• Use a haemoglobin threshold of 7 g/dL in septic shock, including patients with cancer
• Do not transfuse to clear lactate; it did not work faster at a higher haemoglobin
• Watch for venous and arterial thrombosis in cancer patients who are transfused
• Individualise for active bleeding or acute coronary ischaemia

Why it matters

It removes the case for higher transfusion thresholds in a group many clinicians treat as an exception.

Don't overread it

Stopped early at 187 patients, the trial is underpowered for mortality, and the thrombosis signal needs confirmation.

The statistics, in plain English

Lactate clearance OR 1.07 (95% CI 0.60–1.90) is compatible with no effect. The thrombotic imbalance (13% vs 1%) is large, but the trial stopped early and the authors call it uncertain. The mortality difference was not significant and the trial could not have detected a modest effect.

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