This is a randomized control trial of patients undergoing bilateral total knee arthroplasty and presenting with iron deficiency, either absolute (ferritin < 100 g/L) or functional (ferritin 100-300 g/L, transferrin saturation < 20 %). The intraoperative administration of intravenous (IV) iron sucrose (200 mg) plus recombinant human erythropoietin (rHuEPO) (3000 IU), with repeated doses in the postoperative period whenever Hb < 8 g/dL (maximum twice), and a restrictive transfusion trigger (Hb < 7 g/dL) reduced transfusion rates (20.4% vs. 53.7%, p = 0.011) and hastened the recovery from low postoperative Hb levels, with respect to a control group. Interestingly, preoperative Hb levels in transfused patients from the treatment group were almost 1 g/dL lower than those from the control group. No increase in thromboembolic events was observed. These results are in agreement with those previously reported for unilateral total knee arthroplasty, starting 48 h before operation and using a larger dose of rHuEPO (40000 IU) (Cuenca J et al, Transfusion 2006;46:1112-9; Garca-Erce JA et al, Transfus Med 2006;16:335-41), and reinforce the concept that patients scheduled for orthopedic surgery with moderate-high blood loss and presenting with ferritin levels <100 ng/mL may benefit from perioperative IV iron supplementation (Beris P et al, Br J Anaesth 2008;100:599-604). In addition, the beneficial effect of IV iron may be enhanced by adjuvant treatment with rHuEPO (to overcome inflammation-induced reduction of EPO production and action in response to anemia) (Garca-Erce JA et al, Transfus Med 2006;16:335-41; Garca-Erce JA et al, Vox Sang 2009; 97:260-7. Altogether, these data suggest that, although preoperative anemia management should be preferred, it can be effectively started upon the patients admission to the hospital. – Manuel Muoz