Patient blood management in elective total hip- and knee-replacement surgery (Part 1): a randomized controlled trial on erythropoietin and blood salvage as transfusion alternatives using a restrictive transfusion policy in erythropoietin-eligible patients

This is an interesting randomised controlled study evaluating the efficacy and the cost-effectiveness of using erythropoietin (EPO) and/or autotransfusion in patients with preoperative haemoglobin (Hb) from 10-13 g/dL, within a PBM programme for hip and knee arthroplasties in The Netherlands. According to the authors’ results, the efficacy of EPO on the reduction of transfusion is clear (from 26% to 16%) but at an “unacceptable cost”.

These results could be expected, as they are in agreement with those reported in the literature. In my opinion, they may not apply to other institutions, as all patients with a Hb <13 g/dL received 4 doses of EPO 40,000 IU (weekly dose), regardless of the patient's starting Hb level, weight, gender, and cause of anemia. This practice is clinically inefficient, hazardous and not cost-effective, as demonstrated by the study results. Several observational and randomised studies reported that 1-2 doses of EPO are enough to reach the targeted Hb level in most patients, especially if intravenous iron supplements are co-administered. It is well known that almost 50% of elderly patients presenting with preoperative anaemia have absolute or functional iron deficiency; thus, iron supplementation should be the treatment of choice in many cases. Deficiencies of other essential haematinic nutrients may also be present (vitamin B12 or folic acid) and must be ruled out or corrected. It is also important to stress that oral iron absorption is often compromised by inflammation and pharmacological interactions in these patients, leading to iron-restricted erythropoiesis. This may impair the response to EPO treatment and lead to thrombocytosis, which in turn could increase the thromboembolic risk. – Elvira Bisbe