Preoperative treatment with recombinant human erythropoietin or predeposit of autologous blood in women undergoing primary hip replacement

A meta-analysis and systematic review evaluating the use of erythropoietin in total hip and knee arthroplasty

Purpose

The debate is still ongoing on the effectiveness and safety of erythropoietin (EPO) treatment in orthopedic surgeries. Specifically, previous studies have not compared the dynamic change of hemoglobin (Hb) levels between different transfusion methods. Besides, complications or side effects of this alternative have not been quantitatively analyzed. We conducted a meta-analysis and systemic review to evaluate the efficacy of EPO on Hb levels observed during the whole perioperative period as well as the volume of allogeneic blood transfusion (ABT), the risk of venous thromboembolism, and application frequency of ABT in hip and knee surgery.

Materials and methods

PubMed, Embase, Web of Science, and the Cochrane library were systematically searched from inception to November 2017. The data from randomized controlled trials were extracted and the risk of bias assessed using Cochrane’s Collaboration’s tool.

Results

Twenty-five randomized controlled trials involving 4,159 patients were included in this meta-analysis. EPO could reduce exposure to allogeneic blood transfused (odds ratio [OR] =0.42, P=0.001) and reduce the average volume of allogeneic blood transfused (OR = −0.28, P=0.002). When EPO and preoperative autologous blood donation (PABD) were compared, the use of EPO was associated with lower exposure to ABT (OR =0.48, P=0.03), but no significant decrease in the average volume of allogeneic blood transfused (OR = −0.23, P=0.32). The use of EPO was associated with a higher level of Hb with or without use of PABD at all the 4 time points (preoperation, 24–48 hours postoperation, 3–5 days postoperation, discharge of last observation) (P<0.0001), which means EPO could increase the level of Hb significantly during the perioperative period. The results also indicated EPO does not increase the risk of a venous thromboembolism event.

Conclusion

Preoperative administration of EPO was shown to generally increase Hb levels during the whole perioperative period; however, the extent of the positive effects varies with time points. Additionally, EPO minimizes the need for transfusion significantly in patients undergoing hip or knee surgery without increasing the chance of developing thrombotic complications. Therefore, EPO offers an alternative blood management strategy in total hip arthroplasty and total knee arthroplasty.

Combination of erythropoietin and tranexamic acid in bilateral simultaneous total hip arthroplasty: a randomised, controlled trial

INTRODUCTION

This study aimed to evaluate whether the combination of erythropoietin (EPO) and tranexamic acid (TXA) exerted any additional benefits on the number of blood transfusions required and haematological parameters compared with TXA alone following primary bilateral simultaneous total hip arthroplasty.

MATERIALS AND METHODS

We conducted a single-centre, prospective, randomised, and controlled trial at our hospital. Group EPO + TXA (n = 30) received daily subcutaneous injections EPO (10,000 IU) on preoperative days 1-4 and postoperative days 1-3. Additionally, these patients were administered TXA (15 mg/kg) 10 min prior to the incision. Group TXA (n = 32) received only TXA (15 mg/kg) 10 min prior to the incision. The primary outcomes were the haematological parameters and number of blood transfusions required. The secondary outcomes were total blood loss, drainage volume, and postoperative complications.

RESULTS

The total amount of blood transfusion and mean blood transfusion per patient was lower in group EPO + TXA than in group TXA (p = 0.039, p = 0.023; respectively). In the postoperative period, patients in group EPO + TXA had higher haematological parameters (haemoglobin, haematocrit, and reticulocyte count) than patients in group TXA. No significant differences were found in total blood loss, drainage volume, and DVT or PE between the 2 groups.

CONCLUSIONS

This study showed that administrating EPO + TXA in combination can increase haematological parameters and reduce the need for blood transfusion without increasing the risk of DVT or PE compared with TXA alone.

The effectiveness and safety of preoperative use of erythropoietin in patients scheduled for total hip or knee arthroplasty: A systematic review and meta-analysis of randomized controlled trials

INTRODUCTION

Because allogeneic blood transfusion carries a risk of serious complications, erythropoietin (EPO) has been used in patients scheduled for total hip or knee arthroplasty in an effort to reduce the need for allogeneic blood transfusion; however, its efficacy, cost-effectiveness, and safety are still controversial. The purpose of this review was to determine the hematopoiesis-promoting effect and potential complications, as well as the cost-effectiveness, of preoperative use of EPO in patients scheduled for total hip or knee arthroplasty.

METHODS

We searched MEDLINE, EMBASE, Cochrane, and ClinicalTrials.gov databases for relevant literature from 2000 to 2015. Risk of bias was assessed for all included studies and data were extracted and analyzed.

RESULTS

Preoperative use of EPO was associated with lower exposure to allogeneic blood transfusion (odds ratio = 0.41) and higher hemoglobin concentration after surgery (standardized mean difference = 0.86, P < 0.001). Complications were not generally reported, but there was no significant difference between the group with and without EPO based on given data. Cost-effectiveness was also summarized but was not conclusive.

CONCLUSION

Preoperative administration of EPO reduces the requirement for allogeneic blood transfusion and increases hemoglobin level after surgery. The studies of cost-effectiveness were not conclusive. Further studies and guidelines specific to blood management in the perioperative stage of total knee and hip arthroplasty are expected.

The use of preoperative erythropoiesis-stimulating agents (ESAs) in patients who underwent knee or hip arthroplasty: a meta-analysis of randomized clinical trials

Erythropoiesis-stimulating agents (ESAs) have been used in orthopedic patients to reduce allogeneic blood transfusion (ABT). The purpose of this systematic review of randomized clinical trials is to evaluate the efficacy of preoperative administration of ESAs on hemoglobin level at discharge and frequency of ABT in patients undergoing hip or knee surgery. Pooled results of 26 trials with 3560 participants showed that the use of preoperative ESAs reduced ABT in patients undergoing hip or knee surgery [RR: 0.48, 95% CI: 0.38 to 0.60, P<0.00001]. Hemoglobin mean difference between ESA and control groups was 7.16 (g/L) [95% CI of 4.73 to 9.59, P=0.00001]. There was no difference in the risk of developing thromboembolism between ESA and control groups [RD: 0, 95 % CI: -1%-2%, P=0.95]. ESAs offer an alternative blood conservation method to avoid ABT in patients undergoing hip or knee surgery.

[Preoperative anemia in orthopedic surgery: clinical impact, diagnostics and treatment]

In a national audit of elective orthopedic surgery conducted in the US, 30% of patients were found to have hemoglobin (Hgb) levels < 13 g/dl at preadmission testing. Preoperative anemia has been associated with increased mortality and morbidity after surgery, increased allogeneic blood transfusion therapy and increased rates of postoperative infection leading to a longer length of hospital stay. Because of the risks associated with allogeneic blood transfusions according to German law patients have to be offered the option of autologous transfusion if the risk associated with allogeneic blood transfusion is > 10%. However, one of these measures, the autologous blood donation, can exaggerate anemia and can increase the overall transfusion rates (allogeneic and autologous). As autologous procedures (autologous blood donation and cell salvage) are not always appropriate for anemic patients together with an expected shortage of blood and because preoperative anemia is associated with perioperative risks of blood transfusion, a standardized approach for the detection, evaluation and management of anemia in this setting was identified as an unmet medical need. A panel of multidisciplinary physicians was convened by the Society for Blood Management to develop a clinical care pathway for anemia management in elective surgery patients for whom blood transfusion is an option. In these guidelines elective surgery patients should have Hgb level determination at the latest 28 days before the scheduled surgical procedure. The patient target Hgb before elective surgery should be within the normal range (normal female ≥ 120 g/l, normal male ≥ 130 g/l). Laboratory testing should take place to further determine nutritional deficiencies, chronic renal insufficiency and/or chronic inflammatory diseases. Nutritional deficiencies should be treated and erythropoiesis-stimulating agent (ESA) therapy should be used for anemic patients in whom nutritional deficiencies have been ruled out and/or corrected.

Detection, evaluation, and management of preoperative anaemia in the elective orthopaedic surgical patient: NATA guidelines

Previously undiagnosed anaemia is common in elective orthopaedic surgical patients and is associated with increased likelihood of blood transfusion and increased perioperative morbidity and mortality. A standardized approach for the detection, evaluation, and management of anaemia in this setting has been identified as an unmet medical need. A multidisciplinary panel of physicians was convened by the Network for Advancement of Transfusion Alternatives (NATA) with the aim of developing practice guidelines for the detection, evaluation, and management of preoperative anaemia in elective orthopaedic surgery. A systematic literature review and critical evaluation of the evidence was performed, and recommendations were formulated according to the method proposed by the Grades of Recommendation Assessment, Development and Evaluation (GRADE) Working Group. We recommend that elective orthopaedic surgical patients have a haemoglobin (Hb) level determination 28 days before the scheduled surgical procedure if possible (Grade 1C). We suggest that the patient's target Hb before elective surgery be within the normal range, according to the World Health Organization criteria (Grade 2C). We recommend further laboratory testing to evaluate anaemia for nutritional deficiencies, chronic renal insufficiency, and/or chronic inflammatory disease (Grade 1C). We recommend that nutritional deficiencies be treated (Grade 1C). We suggest that erythropoiesis-stimulating agents be used for anaemic patients in whom nutritional deficiencies have been ruled out, corrected, or both (Grade 2A). Anaemia should be viewed as a serious and treatable medical condition, rather than simply an abnormal laboratory value. Implementation of anaemia management in the elective orthopaedic surgery setting will improve patient outcomes.

The effect of patient position on blood loss in primary cemented total hip arthroplasty

INTRODUCTION

The total blood loss of 101 cemented primary total hip arthroplasties was studied in a prospective randomised study.

MATERIALS AND METHOD

Fifty of them were implanted in the supine position and 51 in the lateral position. The patients were matched for sex, height, weight and ASA grade. Only one surgeon carried out the operations using the same operative technique and identical prosthesis in both groups.

RESULTS

The intraoperative blood loss associated with the supine position was 1,156 ml (954-1,265 ml) and 1,129 ml (989-1,310 ml) in the lateral position. There was no difference when comparing the two groups (P = 0.41).

CONCLUSION

Patient positioning in supine or lateral during total hip arthroplasty surgery has no bearing on the total amount of blood loss.

Blood use in elective surgery: the Austrian benchmark study

BACKGROUND

Benchmarking transfusion activity may help to eliminate inappropriate use of blood products. The goal of this study was to measure and to compare the current transfusion practice and to identify predictors of transfusion in public hospitals to develop strategies to optimize transfusion practices.

STUDY DESIGN AND METHODS

This was a prospective observational study in 18 randomly selected public hospitals from April 2004 to February 2005. Primary outcome measures were the amount of intra- and postoperative blood components transfused and intercenter variability of transfusion rate. Secondary outcome measures were prevalence of preoperative anemia, calculated perioperative blood loss, and lowest measured perioperative hemoglobin (Hb) level.

RESULTS

Adult patients undergoing primary unilateral total hip replacement (THR, n = 1401), primary unilateral knee replacement (TKR, n = 1296), hemicolectomy (HECOC, n = 148), and coronary artery bypass graft (CABG) surgery (n = 777) were enrolled. Due to the small number, data of HECOC patients were not fully analyzed. In the remaining procedures, there was a large intercenter variability in the percentage of patients who received transfusions: THR 16 to 85 percent, TKR 12 to 87 percent, and CABG 37 to 63 percent. In the patients who received transfusions, the number of red blood cells (RBC) units transfused varied significantly. There was also a considerable intercenter variability in RBC loss. The prevalence of preoperative anemia was 19 percent and identical in both sexes. The incidence of preoperative anemia was three times higher in patients who received transfusions compared to those who did not.

CONCLUSION

This study demonstrates a high intercenter variability in RBC transfusions and RBC loss in standard surgical procedures. Whereas the variability in blood loss remains largely unexplained, the main predictors for allogeneic RBC transfusions are preoperative and nadir Hb and surgical RBC loss.

A randomized, parallel-group, open-label trial of recombinant human erythropoietin vs preoperative autologous donation in primary total joint arthroplasty: effect on postoperative vigor and handgrip strength

This randomized trial assessed the effect of recombinant human erythropoietin (EPO) vs preoperative autologous donation (PAD) on postoperative vigor and handgrip strength in patients undergoing primary total joint arthroplasty. Adults with baseline hemoglobin level of 11 to 14 g/dL received EPO (600 IU/kg once weekly for 4 doses, n = 130) or PAD (n = 121) before primary, unilateral hip or knee arthroplasty. Mean changes in vigor score and handgrip strength from baseline were not significantly different between treatment groups. Multivariate analyses found a significant treatment effect favoring EPO over PAD for vigor, but not for handgrip strength. Patients in the EPO group had higher hemoglobin levels and required fewer transfusions. Both treatments were well tolerated. Additional study is needed to elucidate the influence of blood management strategies on postoperative vigor.

Influence of hemoglobin levels on inpatient rehabilitation outcomes after total knee arthroplasty

This retrospective study examined the influence of hemoglobin (Hb) on the outcomes of 184 acute inpatient rehabilitation patients admitted to a single university-based inpatient rehabilitation facility after primary total knee arthroplasty between 2001 and 2003. Patient function was measured using the Functional Independence Measure (FIM) instrument. Average length of stay was 9.4 days. Total FIM score increased from 81.5 to 110.8. Mean baseline Hb was 10.5 g/dL. Multivariate analyses demonstrated that a higher Hb at baseline was associated with significantly shorter length of stay (P = .004) and greater FIM efficiency (change in total FIM score/length of stay) (P = .04). Hemoglobin is associated with rehabilitation outcomes after total knee arthroplasty; additional research into the influence of blood management strategies on rehabilitation outcomes is warranted.

Preoperative epoetin alfa vs autologous blood donation in primary total knee arthroplasty

This prospective randomized trial compared preoperative autologous blood donation (PAD) with epoetin alfa in patients undergoing primary total knee reconstruction. Fifty adult patients with pretreatment hemoglobin level of 100 to 130 g/L were randomized to either epoetin alfa 40,000 U at preoperative days 14 and 7 or to a standard PAD protocol. Patient characteristics and operative blood loss were similar between groups. Baseline hematological parameters for epoetin alfa vs PAD were not significantly different; however, by the day of surgery the epoetin alfa group had significantly higher hemoglobin (130 vs 114 g/L; P < .001), hematocrit (0.408 vs 0.352; P < .001), and reticulocyte count (3.4 vs 2.1 x 10(9) cells per liter; P < .001). These differences remained significant for 1 to 2 days postoperatively. There was no significant difference in the incidence of allogeneic transfusions between groups (28% for epoetin alfa vs 8% for PAD; P = .1383). Both treatments were generally well tolerated. Epoetin alfa appears to be a safe alternative to PAD in patients who are at risk for transfusion in the perioperative period following total knee arthroplasty.

Erythropoietin as adjuvant to pre-operative autologous blood donation in total hip arthroplasty: new algorithm for use

Erythropoietin (rhEPO) has been used in different surgical procedures as a method for saving allogeneic blood, with variable efficacy. Forty consecutive patients entered the pre-operative autologous blood donation (PABD) program, and during donations hemoglobin fell below 115 g/l; they received rhEPO 40,000 U every week for three or four weeks (group 1). As control group, 35 consecutive patients who entered the PABD program were studied; during donations, hemoglobin levels in these patients fell below 115 g/l, but rhEPO was not administered (group 2). Pre-surgery hemoglobin levels were higher in patients who received rhEPO (134 g/l vs. 121 g/l; p<0.0002), and an average of 3.47 doses were administered. The number of transfused autologous units was 1.6 in group 1 and 2.1 in group 2 (p<0.05), while the number of allogeneic units was 0.9 and 0.1, respectively (p<0.0005), so that only 5% of patients treated with rhEPO required some allogeneic unit, as compared to 40% of those who did not receive rhEPO (p<0.0005). There were no relevant adverse effects, but in two patients from group 1, rhEPO treatment had to be discontinued because the level of hemoglobin exceeded 150 g/l. The mean duration of hospital admission was shorter in the patients who received rhEPO than in those who only underwent PABD (8 days vs. 11.8 days; NS). When adequately used, rhEPO is an effective and safe alternative to the use of allogeneic blood.

Two-dose epoetin alfa reduces blood transfusions compared with autologous donation

This study evaluated whether patients receiving a two-dose regime of epoetin alfa received less allogeneic blood than patients donating autologous blood before primary hip arthroplasty. Consenting patients with a hemoglobin level between 12 and 15 g/dL were randomly assigned to a two-dose administration of epoetin alfa (19 patients) or autologous donation (21 patients). Sixteen percent of the patients in the epoetin alfa group and 52% of the patients in the autologous donation group received transfusions, with a mean volume of 90 cc per patient in the epoetin alfa group and 340 cc in the autologous donation group. Hemoglobin was similar at screening; however, the epoetin alfa group achieved a higher hemoglobin (14.6 g/dL) than the autologous donation group (12.6 g/dL) before surgery. Hemoglobin remained significantly higher in the epoetin alfa group for 3 days after surgery. Administration of two doses of epoetin alfa provided patients with effective and safe reduction of allogeneic blood transfusions and decreased the necessity and difficulty of autologous donation before total hip arthroplasty.

Preoperative acute normovolemic hemodilution: a meta-analysis

BACKGROUND

Acute normovolemic hemodilution (ANH) involves withdrawal of whole blood with concurrent infusion of fluids to maintain normovolemia. The aim of this study was to quantify the efficacy and safety of preoperative ANH with a systematic review and meta-analysis.

STUDY DESIGN AND METHODS

Randomized controlled trials were identified through MEDLINE (1966-2002) and the Cochrane Controlled Trials Database and with hand searching of journals. All trials of preoperative ANH reporting on allogeneic transfusion, bleeding, or adverse outcomes were included. Paired reviewers independently abstracted data. Outcomes were pooled using random-effects models.

RESULTS

A total of 42 trials compared hemodilution to usual care or to another blood conservation method. The risk of allogeneic transfusion was similar among patients receiving ANH and those receiving usual care (relative risk [RR], 0.96; 95% CI, 0.90-1.01), or another blood conservation method (RR, 1.11; 95% CI, 0.96-1.28). Hemodiluted patients, however, were transfused from 1 to 2 fewer units of allogeneic blood. They had less total bleeding than patients receiving usual care (91 mL; 95% CI, 25-158 mL), although more intraoperative bleeding. Only one-third of studies reported on adverse events.

CONCLUSIONS

The literature supports only modest benefits from preoperative ANH. The safety of the procedure is unproven. Widespread adoption of ANH cannot be encouraged.