Current issues of ACP Journal Club are published in Annals of Internal Medicine


Therapeutics

Erythropoietin reduced the need for homologous blood transfusion in patients having total hip replacement

ACP J Club. 1995 Mar-April;122:36. doi:10.7326/ACPJC-1995-122-2-036


Source Citation

Biesma DH, Marx JJ, Kraaijenhagen RJ, et al. Lower homologous blood requirement in autologous blood donors after treatment with recombinant human erythropoietin. Lancet. 1994 Aug 6;344:367-70.


Abstract

Objective

To evaluate the effectiveness of recombinant human erythropoietin (rhEPO) in reducing the need for homologous blood transfusion in patients having total hip replacement.

Design

Randomized controlled trial with 31-day follow-up.

Setting

Hospital in the Netherlands.

Patients

105 patients (mean age 67 y; 78% women) having unilateral total hip replacement. Exclusion criteria were a packed-cell volume < 34% or > 52%; uncontrolled hypertension; history of seizures; current or previous treatment with cytostatic drugs, hormone preparations, or immunosuppressants; thrombocytosis; infection or malignant disease; vitamin B12 or folic acid deficiency; iron depletion; pregnancy or lactation. 10 patients withdrew from the study.

Intervention

50 patients were allocated to rhEPO, 500 U/kg body weight subcutaneously twice weekly for 3 weeks, and 45 patients received no treatment. All patients donated 2 units of blood before surgery and all patients received 3 doses of elemental iron, 66 mg/d, orally from a week before the first phlebotomy.

Main Outcome Measures

Need for homologous blood transfusion, blood loss, packed-cell volume, reticulocyte counts, renal function, platelet count, and blood pressure (BP).

Main Results

5 patients (10%) receiving rhEPO required homologous blood transfusions compared with 16 patients (36%) in the control group {95% CI for the 26% abolute risk reduction, 9% to 42%; P = 0.003) (Table).; relative risk reduction, 71.9%; number neded to treat, 4; CI, 2 to 11}*. rhEPO had the greatest effect in patients with a calculated blood volume of < 4 L and an expected blood loss of < 2 L or in patients with a blood volume of 4 to 5 L and an expected blood loss of 1 to 2 L. rhEPO therapy had no effect on renal function, platelet count, or BP. Reticulocyte counts increased up to the fourth injection of rhEPO.

Conclusion

Subcutaneous recombinant human erythropoietin reduced the need for homologous blood transfusions in patients having unilateral total hip replacement.

Source of funding: Boehringer Mannheim GmbH, Mannheim, Germany.

For article reprint: Dr. D.H. Biesma., Department of Internal Medicine, University Hospital Utrecht, Room F 02.126, P.O. Box 85500, 3508 GA Utrecht, the Netherlands. FAX 31-30-544-397.

*Numbers calculated from data in article.


Commentary

Since the successful perioperative use of rhEPO more than 5 years ago in an animal model, many reports (1) have detailed its use in clinical medicine. The investigation by Biesma and colleagues joins a growing list of studies that support the preoperative clinical use of rhEPO as an adjunct to decrease allogeneic (homologous) red blood cell use (1, 2). Their study is also unique in that it helps to define specific groups of patients who may most benefit from preoperative rhEPO, namely, those autologous blood donors with blood volumes < 5 L.

Autologous blood collection services currently allow many patients who are having elective surgery to bank their own blood. As much as 60% of the autologous blood collected in the United States, however, does not get transfused. In the study by Biesma and colleagues, 54% (27 of 50) of the patients in the rhEPO-treated group were not transfused with any red blood cells. The cost to the hospital pharmacy for rhEPO is approximately $10 per 1000 units, which translates into a bare minimum cost of approximately $2100 per patient by the protocol used in this study.

Given the high cost of rhEPO therapy, the potential for side effects, the need for concomitant iron therapy (oral or parenteral), and the overcollection of autologous blood in general, studies further defining patients most likely to benefit are important. These issues need to be addressed before the routine preoperative use of rhEPO can be advocated outside of the research setting.

Ronald E. Domen, MD
The Cleveland Clinic FoundationCleveland, Ohio


References

1. Tabbara IA. Erythropoietin: biology and clinical applications. Arch Intern Med. 1993;153:298-304.

2. Canadian Orthopedic Perioperative Erythropoietin Study Group. Effectiveness of perioperative recombinant human erythropoietin in elective hip replacement. Lancet. 1993;341:1227-32.