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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