Tiffanie Kei1, Nikhil Mistry1, Gerard Curley2, Katerina Pavenski3,4, Nadine Shehata5, Rosa Maria Tanzini6, Marie-France Gauthier7, Kevin Thorpe8, Tom A Schweizer9, Sarah Ward10, C David Mazer1,9,11, Gregory M T Hare12,13,14,15. 1. Department of Anesthesia, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada. 2. Department of Anesthesia and Critical Care Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland. 3. Department of Laboratory Medicine and Pathobiology, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada. 4. St. Michael's Hospital, Centre of Excellence in Patient Blood Management, Toronto, ON, Canada. 5. Departments of Medicine and Laboratory Medicine and Pathobiology, Institute of Health Policy Management and Evaluation, Mount Sinai Hospital, Toronto, ON, Canada. 6. Department of Pharmacy, St. Michael's Hospital, Toronto, ON, Canada. 7. Department of Pharmacy, Montfort Hospital, Ottawa, ON, Canada. 8. Applied Health Research Centre, St. Michael's Hospital, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada. 9. Keenan Research Centre for Biomedical Science in the Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada. 10. Division of Orthopedic surgery, Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada. 11. Department of Physiology, University of Toronto, Toronto, ON, Canada. 12. Department of Anesthesia, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada. hareg@smh.ca. 13. Keenan Research Centre for Biomedical Science in the Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada. hareg@smh.ca. 14. St. Michael's Hospital, Centre of Excellence in Patient Blood Management, Toronto, ON, Canada. hareg@smh.ca. 15. Department of Physiology, University of Toronto, Toronto, ON, Canada. hareg@smh.ca.
Abstract
PURPOSE: Iron restricted anemia is prevalent in surgical patients and is associated with an increased risk of allogeneic red blood cell (RBC) transfusion and adverse events. Treatment of anemia includes oral and intravenous iron and erythropoiesis stimulating agents (ESAs). More recent studies have focused on the use of intravenous iron as the primary approach to treating anemia. Nevertheless, the optimal treatment strategy for anemia remains to be established. Our primary objective was to evaluate the efficacy and safety of ESA and iron therapy relative to iron therapy alone in reducing RBC transfusion in surgical patients. SOURCE: We searched the Cochrane Library, MEDLINE, EMBASE, and ClinicalTrials.gov from inception to May 2018. We included randomized-controlled trials in which adult surgical patients received an ESA and iron, vs iron alone, prior to cardiac and non-cardiac surgery. Our primary outcome was RBC transfusion rate. Secondary outcomes included hemoglobin concentration (post-treatment and postoperatively), number of RBC units transfused, mortality, stroke, myocardial infarction (MI), renal dysfunction, pulmonary embolism (PE), and deep vein thrombosis (DVT). PRINCIPAL FINDINGS: In total, 25 studies (4,719 participants) were included. Erythropoiesis stimulating agents and iron therapy reduced RBC transfusion relative to iron therapy (relative risk [RR] 0.57; 95% confidence interval [CI], 0.46 to 0.71) without any change in mortality (RR 1.31; 95% CI, 0.80 to 2.16), stroke (RR 1.91; 95% CI, 0.63 to 5.76), MI (RR 1.12; 95% CI, 0.50 to 2.50), renal dysfunction (RR 0.96; 95% CI, 0.72 to 1.26), PE (RR 0.92; 95% CI, 0.15 to 5.83), or DVT (RR 1.48; 95% CI, 0.95 to 2.31). CONCLUSION: Administration of ESA and iron therapy reduced the risk for RBC transfusion compared with iron therapy alone in patients undergoing cardiac and non-cardiac surgery. Nevertheless, publication bias and heterogeneity reduces the confidence of the finding. Although the analysis was probably under-powered for some outcomes, no difference in the incidence of serious adverse events was observed with ESA and iron compared with iron alone. Further large prospective trials are required to confirm these findings.
PURPOSE:Iron restricted anemia is prevalent in surgical patients and is associated with an increased risk of allogeneic red blood cell (RBC) transfusion and adverse events. Treatment of anemia includes oral and intravenous iron and erythropoiesis stimulating agents (ESAs). More recent studies have focused on the use of intravenous iron as the primary approach to treating anemia. Nevertheless, the optimal treatment strategy for anemia remains to be established. Our primary objective was to evaluate the efficacy and safety of ESA and iron therapy relative to iron therapy alone in reducing RBC transfusion in surgical patients. SOURCE: We searched the Cochrane Library, MEDLINE, EMBASE, and ClinicalTrials.gov from inception to May 2018. We included randomized-controlled trials in which adult surgical patients received an ESA and iron, vs iron alone, prior to cardiac and non-cardiac surgery. Our primary outcome was RBC transfusion rate. Secondary outcomes included hemoglobin concentration (post-treatment and postoperatively), number of RBC units transfused, mortality, stroke, myocardial infarction (MI), renal dysfunction, pulmonary embolism (PE), and deep vein thrombosis (DVT). PRINCIPAL FINDINGS: In total, 25 studies (4,719 participants) were included. Erythropoiesis stimulating agents and iron therapy reduced RBC transfusion relative to iron therapy (relative risk [RR] 0.57; 95% confidence interval [CI], 0.46 to 0.71) without any change in mortality (RR 1.31; 95% CI, 0.80 to 2.16), stroke (RR 1.91; 95% CI, 0.63 to 5.76), MI (RR 1.12; 95% CI, 0.50 to 2.50), renal dysfunction (RR 0.96; 95% CI, 0.72 to 1.26), PE (RR 0.92; 95% CI, 0.15 to 5.83), or DVT (RR 1.48; 95% CI, 0.95 to 2.31). CONCLUSION: Administration of ESA and iron therapy reduced the risk for RBC transfusion compared with iron therapy alone in patients undergoing cardiac and non-cardiac surgery. Nevertheless, publication bias and heterogeneity reduces the confidence of the finding. Although the analysis was probably under-powered for some outcomes, no difference in the incidence of serious adverse events was observed with ESA and iron compared with iron alone. Further large prospective trials are required to confirm these findings.
Authors: Hélène Charbonneau; Marie Pasquié; Pierre Berthoumieu; Nicolas Savy; Gérard Autones; Olivier Anglès; Anne Laure Berthelot; Madeleine Croute-Bayle; Isabelle Decramer; David Duterque; Yannick Gabiache; Valérie Julien; Laurent Mallet; Mimoun M'rini; Jean François Quedreux; Benoit Richard; Laurent Sidobre; Laurence Taillefer; Philippe Soula; Olivier Garcia; Issam Abouliatim; Olivier Vahdat; Marc Bousquet; Jean Marc Ferradou; Yves Jansou; Pierre Brunel; Claude Breil; Nicolas Mayeur Journal: Contemp Clin Trials Commun Date: 2020-07-15
Authors: Pierre Tibi; R Scott McClure; Jiapeng Huang; Robert A Baker; David Fitzgerald; C David Mazer; Marc Stone; Danny Chu; Alfred H Stammers; Tim Dickinson; Linda Shore-Lesserson; Victor Ferraris; Scott Firestone; Kalie Kissoon; Susan Moffatt-Bruce Journal: J Extra Corpor Technol Date: 2021-06
Authors: Lutz Kaufner; Christian von Heymann; Anne Henkelmann; Nathan L Pace; Stephanie Weibel; Peter Kranke; Joerg J Meerpohl; Ravi Gill Journal: Cochrane Database Syst Rev Date: 2020-08-13
Authors: Gregory M T Hare; Melina P Cazorla-Bak; S F Michelle Ku; Kyle Chin; Nikhil Mistry; Michael C Sklar; Katerina Pavenski; Ahmad Alli; Adriaan Van Rensburg; Jan O Friedrich; Andrew J Baker; C David Mazer Journal: Can J Anaesth Date: 2020-08-07 Impact factor: 6.713