Alsaleh and co-workers present a meta-analysis of 26 randomized controlled trials (RCTs) comparing the preoperative use of erythropoiesis-stimulating agents (ESAs) alone (17 trials) or combined with preoperative autologous donation PAD (9 trials) on the perioperative allogeneic transfusion rate and the postoperative hemoglobin concentration (Hb) after hip or knee arthroplasty (uni- or bilateral, primary or revision).

Preoperative administration of ESAs (alone or combined with PAD) was associated with a statistically significant reduction in the number of patients requiring allogeneic blood transfusion (RR 0.48; 95% CI 0.38-0.60, p<0.00001). There was no evidence of increased efficacy if PAD was combined with preoperative ESAs. Postoperative Hb was significantly higher (7.16 g/dL) in patients having received preoperative ESAs as compared to control patients (95% CI 4.73-7.59, p=0.00001). There was no difference in the risk of developing venous thromboembolism between ESA and control groups. Cost-effectiveness of preoperative ESAs was not evaluated due to a lack of data. While keeping in mind the general weaknesses of meta-analyses (e.g. heterogeneity of patients, of protocols and of dosages in the different studies), the present analysis clearly shows that ESAs alone improve postoperative Hb and reduce the need for allogeneic transfusion in patients undergoing hip and knee replacement without increasing their risk of venous thromboembolism. – Oliver Habler