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.
Early erythropoiesis-stimulating agents in preterm or low birth weight infants.Cochrane Database Syst Rev. 2017 Nov 16;11(11):CD004863. doi: 10.1002/14651858.CD004863.pub5. Cochrane Database Syst Rev. 2017. PMID: 29145693 Free PMC article. Updated. Review.
The role of iron in the management of chemotherapy-induced anemia in cancer patients receiving erythropoiesis-stimulating agents.Cochrane Database Syst Rev. 2016 Feb 4;2:CD009624. doi: 10.1002/14651858.CD009624.pub2. Cochrane Database Syst Rev. 2016. PMID: 26845108 Review.
Early erythropoiesis-stimulating agents in preterm or low birth weight infants.Cochrane Database Syst Rev. 2020 Feb 11;2(2):CD004863. doi: 10.1002/14651858.CD004863.pub6. Cochrane Database Syst Rev. 2020. PMID: 32048730 Review.
Late erythropoiesis-stimulating agents to prevent red blood cell transfusion in preterm or low birth weight infants.Cochrane Database Syst Rev. 2019 Feb 15;2(2):CD004868. doi: 10.1002/14651858.CD004868.pub5. Cochrane Database Syst Rev. 2019. PMID: 30776084 Free PMC article. Updated.
Transfusion of red blood cells stored for shorter versus longer duration for all conditions.Cochrane Database Syst Rev. 2018 Dec 22;12(12):CD010801. doi: 10.1002/14651858.CD010801.pub3. Cochrane Database Syst Rev. 2018. PMID: 30578732 Free PMC article.
Cited by 2 articles
Preoperative anemia-screening clinics.Hematology Am Soc Hematol Educ Program. 2019 Dec 6;2019(1):570-576. doi: 10.1182/hematology.2019000061. Hematology Am Soc Hematol Educ Program. 2019. PMID: 31808909
The Effect of Intraoperative Ferric Carboxymaltose in Joint Arthroplasty Patients: A Randomized Trial.J Clin Med. 2019 Oct 13;8(10):1674. doi: 10.3390/jcm8101674. J Clin Med. 2019. PMID: 31614940 Free PMC article.