Despite being a retrospective analysis of patients undergoing unilateral total knee arthroplasty, this modest study of clinical practice shows us, probably, the death throes of preoperative autologous blood donation (PABD). The results of the current study—economy and efficacy—support the use of autologous blood donation in anemic patients undergoing primary TKA. The data support the efficacy of only one unit PABD in anemic TKR patients. Why not? If recent guidelines recommend restrictive transfusion criteria, transfusing red cells unit by unit after clinical reevaluation, why not transfuse only one PABD unit? Nevertherless, this study has an important limitation: the decision to transfuse autologous blood was initiated at the discretion of the anesthesiologist and strict transfusion guidelines were not always enforced.

One interesting point of view of this study—in our current economical climate—lies in the analysis of the difference in costs between the two blood management protocols. If preoperative autologous blood donation is utilized only for anemic patients—cutoff hemoglobin of 12.5 g/dL—the overall cost per patient remains similar to a group without PABD: US $256.63/patient versus US $217.83/patient. So, while routine PABD is costly, limiting PABD to anemic patients only reduces the overall need for allogenic blood and only marginally increases costs. But this economical analysis has once again the limitations of the non-restrictive transfusion practice at the authors’ institution.

The authors claim that the best method to minimize allogenic blood exposure in anemic patients undergoing TKA remains uncertain. We will probably never have the correct answer: who is going to develop and implement a protocol, with a sufficient number of patients comparing nothing (standard care), treatment of anaemia (oral iron, intravenous iron, EPO, vitamin B), preoperative autodonation, intraoperative cell saver or postoperative recovery? Till this moment, anemia must be studied and safely treated, restricted transfusion criteria applied, blood loss reinfused, and PABD limited to special situations or selected population.

Autodonation is dead. Long live autodonation!

– José A. García-Erce