Preoperative anaemia in surgical patients: Intravenous iron and erythropoiesis-stimulating agents (ESAs) to the rescue

Abstract

Despite the propensity for allogeneic blood transfusion by clinicians, the space for this therapy is steadily being contracted by limited evidence of benefit from its use in most situations, adverse effects of its use, high cost, limited supply and rejection by some religious faithfuls. Available literature concedes to the high prevalence of preoperative anaemia in diverse surgical settings irrespective of geography and reflects the global burden of anaemia. Beyond the poorer surgical outcome directly attributed to preoperative anaemia, it has also been recognized as the major predictor of allogeneic blood transfusion with attendant morbidity and mortality. The concept of Patient Blood Management (PBM) seeks to minimize exposure of patients to allogeneic blood and is based on three pillars of maximizing total red cell mass, minimizing iatrogenic blood loss and harnessing patient’s physiological tolerance of anemia. Consequently, PBM places great premium on correcting preoperative anaemia in surgical patients. With the limited success of leucodepletion and other measures at addressing the complications of allogeneic blood transfusions new interest is expanding in PBM. Several of these have been evaluated and among them the use of newer formulations of intravenous iron with or without erythropoiesis– stimulating agents has been most studied and credited with substantial success and good safety profile. Insight is also offered on the oversubscribed misconception of iron overload in HbSS patients while elucidating on the basis for iron supplementation in proven cases of iron deficiency. Some prevailing barriers, however, threaten the full realization of the potentials of these therapies.