Iron and erythropoietin measurement in autologous blood donors with anemia: implications for management

Iron depletion induced by bloodletting and followed by rhEPO administration as a therapeutic strategy in progressive multiple sclerosis: a pilot, open-label study with neurophysiological measurements

OBJECTIVES

To evaluate the concept that iron depletion (ID) induced by bloodletting and followed by recombinant human erythropoietin (rhEPO) administration could be a therapeutic strategy in progressive multiple sclerosis (PMS) and that it could be assessed by neurophysiological measurements.

PATIENTS AND METHODS

In four patients with PMS, bloodletting was performed until ID was induced, and then rhEPO was administered (300 UI/kg/week). The changes induced by the treatment were assessed by clinical scores, biological tests, and neurophysiological study of cortical excitability using transcranial magnetic stimulation techniques.

RESULTS

The treatment was well tolerated except for muscle cramps and one popliteal vein thrombosis in a patient confined to chair. ID was obtained within 28 weeks and was associated with endogenous production of EPO. No bloodletting was further required during a six-month period after introduction of rhEPO. At the end of the follow-up (up to one year), fatigue and walking capacities tended to improve in two patients. Neurophysiological changes were characterized by an increased cortical excitability, including a decrease of motor thresholds and an enhancement of intracortical facilitation and cerebellothalamocortical inhibition.

CONCLUSIONS

The combined ID-rhEPO therapy could authorize a prolonged administration of rhEPO in PMS patients, able to modify cortical excitability of the glutamatergic and gabaergic circuits. These preliminary data are encouraging to design a larger, controlled therapeutical trial to assess the value of such a strategy to improve functional symptoms in PMS patients, and maybe to prevent axonal degeneration. Neurophysiological measurements based on cortical excitability studies could provide sensitive parameters to evaluate treatment-induced changes in this context.

Nineteen years of experience with autotransfusion for elective surgery in children: more troublesome than we expected

BACKGROUND

Under the rationale that children undergoing elective surgery are the best candidates for autologous blood donors because of their long life expectancy, aggressive donations of autologous blood, even from infants, have been reported. A number of problems are associated with the procedure, however, whereas the risks of homologous blood are very low.

STUDY DESIGN AND METHODS

From 1987 through 2005, of 5792 patients referred to blood transfusion services at two Japanese university hospitals for autologous blood donations, 314 children younger than 16 years old served as subjects for assessment.

RESULTS

Of 314 children, 7 were not suitable as autologous donors. In most cases this was due to uncooperative behavior. Over a follow-up period of 19 years, the authors encountered 53 cases (17.3%) of donation-related problems, and this rate was higher than the 6 percent rate recorded for adult cases (316/5305). Nine children suffered crucial complications such as vasovagal reactions, and one 14-year-old boy required a vasopressor drug. Important findings were that 6 of these were first-time donors, and the amount of blood drawn was under 10 percent of their estimated blood volume.

CONCLUSION

Of 53 donation-related problems, 9 (17.0%) were accompanied by marked hypotension. Drawing autologous blood from children has become easier with advanced devices; however, lessening of anxiety and tension are essential for the safety of children's autologous blood donation programs. Aggressive donation should be avoided.

Increased iron absorption during autologous blood donation supported by recombinant human erythropoietin therapy

BACKGROUND

Recombinant human erythropoietin (rHuEPO) therapy improves the success of autologous blood (AB) donation programs before elective surgery. The aim of this study was to evaluate iron absorption during an AB donation program with or without rHuEPO.

STUDY DESIGN AND METHODS

Thirty-two patients were randomly assigned among placebo (Group 1) or 300 (Group 2) or 600 UI per kg rHuEPO (Group 3) on the first, second, and third donation visits. All patients also received daily oral iron (200 mg Fe(+)).

RESULTS

The number of units collected in Group 3 was higher than in Group 1 (4.6 +/- 0.5 vs. 3.6 +/- 0.8 units; p < 0.01). Red blood cell (RBC) production increased in a rHuEPO dose-dependent manner. With rHuEPO, the RBC volume collected per unit presented a lower decrease with number of donated units than with placebo and was similar to that of homologous blood units. Storage iron did not influence the number of units collected, whereas circulating mobilizable iron was the limiting factor. Oral iron absorption increased in a rHuEPO dose-dependent manner (12-fold with 600 UI/kg rHuEPO) and was proportional to erythropoietic activity.

CONCLUSION

rHuEPO does not only improve the number of AB units collected but also their quality. Storage iron cannot meet marrow iron requirements, but rHuEPO strongly increased oral iron absorption in a dose-dependent fashion through stimulation of erythropoietic activity.

Hematopoietic growth factors in the older cancer patient

Aging is associated with a progressive decline in the functional reserve of multiple organ systems, which may lead to enhanced susceptibility to stress such as that caused by cancer chemotherapy. Myelodepression is the most common and the most commonly fatal complication of antineoplastic drug therapy and may represent a serious hindrance to the management of cancer in older individuals. This is already a common and pervasive problem and promises to become more so. Currently 60% of all neoplasms occur in persons aged 65 years and older, and this percentage is expected to increase as the population ages. This well-known phenomenon, sometimes referred to as squaring or the age pyramid, is caused by the combination of an increasing life expectancy and a decreasing birth rate. This article explores the use of hematopoietic growth factors in the older cancer patient after reviewing the influence of age on hemopoiesis and chemotherapy-related complications. The issue is examined in terms of effectiveness and cost. An outline of the assessment of the older cancer patient is provided at the end of the chapter as a frame of reference for clinical decisions.

Red cell apheresis in autologous preoperative blood donation

Preoperative autologous blood donation (PAD) is a commonly used technique for elective surgical procedures with a predictable blood loss. The conventional method is to collect one unit whole blood weekly several times within the shelf-life of red cell concentrates. Erythrapheresis with the Haemonetics cell separator MCS-3p or plus makes it possible to collect two units of red cells in one single session and with this option the time interval and operation can be prolonged to three weeks to improve erythropoiesis. 295 patients, who were scheduled for hip replacement or knee endoprothesis were evaluated retrospectively calculating the net profit of red cells after donating two units of red cells by erythrapheresis. The median net profit of red cells was 140 ml red cells but with a wide range. The patients who profit most of PAD were those with a predonation hct below 42% who had net profits up to 300 ml red cells due to an increased erythropoiesis, which compensate for the withdrawal of the red cells. Thus erythrapheresis with the Haemonetics MCS-3p or Haemonetics MCS plus is recommended for patients with a predonation hct lower than 42% and who can be scheduled for PAD at least 3 weeks before operation when two units of red cells are the target for PAD.

Low ferritin levels indicate the need for iron supplementation: strategy to minimize iron-depletion in regular blood donors

Iron deficiency is a common problem in regular blood donors which can be prevented by timely iron supplementation. Consequently, these donors should be supplied with oral iron in good time. We evaluated the need to use ferritin rather than or in addition to haemoglobin to screen iron deficiency in blood donors. To this end, serum ferritin was measured routinely every 10th donation in 632 long-term and 171 first-time donors. Furthermore, donors with ferritin < 15 microg L-1 were supplemented with iron. The supplementation efficiency was assessed by follow-up haemoglobin levels over the course of five donations in blood donors with high donation frequency. Our results showed that ferritin decreases after 10 donations and with the increase of donation frequency. In 26% of regular donors, ferritin levels were < 15 microg L-1 and 12% of them were anaemic due to low haemoglobin. After iron supplementation, haemoglobin was raised rapidly in donors with initially low haemoglobin, and thus donor deferment was never indicated. In conclusion, regular ferritin measurement is a useful indicator for iron depletion in blood donors. Our data suggested the usefulness of ferritin screening in first-time donors and regular donors with low haemoglobin levels within the normal range.

Anemia of Aging: A Model of Erythropoiesis in Cancer Patients

Anemia produces deleterious effects in the older patient with cancer and corresponds with an increasing prevalence of comorbid conditions. Erythropoietin can improve anemia of chronic disease, the most common form of anemia in the elderly.