Effect of Perioperative Intravenous Iron Supplementation for Complex Cardiac Surgery on Transfusion Requirements

Abstract

Objectives: We investigated whether routine perioperative intravenous iron replenishment reduces the requirement for packed erythrocytes (pRBC) transfusion. Summary of Background Data: Patients undergoing complex cardiac surgery are at high risk of developing postoperative iron deficiency anemia, thus requiring transfusion, which is associated with adverse outcomes. Methods: Patients were randomized to receive either ferric derisomaltose 20 mg/kg (n ¼ 103) or placebo (n ¼ 101) twice during the perioperative period: 3 days before and after the surgery. The primary endpoint was the proportion of patients who received pRBC transfusion until postoperative day (POD) 10. Hemoglobin, reticulocyte count, serum iron profile, hepcidin, and erythropoietin were serially measured. Results: pRBC was transfused in 60.4% and 57.2% of patients in the control and iron group, respectively (P ¼ 0.651). Hemoglobin concentration at 3 weeks postoperatively was higher in the iron group than in the control group (11.6 AE 1.5 g/dL vs 10.9 AE 1.4 g/dL, P < 0.001). The iron group showed higher reticulocyte count [205 (150-267)Â10 3 /mL vs 164 (122-207)Â10 3 /mL, P ¼ 0.003] at POD 10. Transferrin saturation and serum ferritin were significantly increased in the iron group than in the control group (P < 0.001). Serum hepcidin was higher in the iron group than in the control group ) ng/mL vs 39.3 (33.3-43.6) ng/mL, P < 0.001]. Erythropoietin concentration increased postoperatively in both groups (P ¼ 0.003), with no between-group difference. Conclusions: Intravenous iron supplementation during index hospitalization for complex cardiac surgery did not minimize pRBC transfusion despite replenished iron store and augmented erythropoiesis, which may be attributed to enhanced hepcidin expression.

Systematic review and meta‐analysis of intravenous iron therapy for adults with non‐anaemic iron deficiency: An abridged Cochrane review

“…Following de‐duplication and primary screening, 102 articles were selected for full‐text screening, and 21 studies were included in the qualitative and quantitative analyses. 18 , 19 , 23 , 33 , 34 , 35 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 Exclusions are detailed in Figure 2 .…”

“…Of these studies, seven were in people with heart failure, 33 , 35 , 41 , 44 , 47 , 51 , 52 two in elite athletes, 19 , 23 two in otherwise well, pre‐menopausal women, 18 , 46 two in people with restless legs syndrome 42 , 50 and two in blood donors, 34 , 43 and the remaining six were a variety of specific cohorts (following cardiac surgery, fibromyalgia, kidney disease, complex vascular heart surgery, COPD and cardiac transplant recipients). 38 , 39 , 40 , 45 , 48 , 49 The commonest placebo comparator used was sodium chloride (0.9%), and two studies were open‐label interventions. 47 , 51 …”

“…Twelve studies used a single‐dose administration, 18 , 23 , 33 , 34 , 38 , 40 , 41 , 43 , 45 , 48 , 50 , 52 whereas nine used repeat dosing at various points throughout the study. 19 , 35 , 39 , 42 , 44 , 46 , 47 , 49 , 51 Ferric carboxymaltose was used in thirteen studies, 18 , 19 , 23 , 33 , 34 , 35 , 39 , 42 , 44 , 48 , 50 , 51 , 52 iron isomaltoside (ferric derisomaltose) was used in five studies, 40 , 41 , 43 , 45 , 49 both preparations (ferric carboxymaltose and ferric derisomaltose) were used together in one study, 38 and iron sucrose was used in two studies. 46 , 47 The total dose of intravenous iron administered, where calculation was possible, ranged from 300 19 up to 2500 mg. 51 …”

“…Following de-duplication and primary screening, 102 articles were selected for full-text screening, and 21 studies were included in the qualitative and quantitative analyses. 18,19,23,[33][34][35][38][39][40][41][42][43][44][45][46][47][48][49][50][51][52] Exclusions are detailed in Figure 2. Note: The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).…”

Intravenous Iron for All in Cardiac Surgery?

“…Serum ferritin and transferrin saturation were even higher in the iv iron group than in the control group. 5 Overall, there was a high percentage of transfused patients without any difference between groups (approximately 60% in each group). This may be explained by the type of high blood loss surgery included, the late iv iron treatment and the lack of a co-treatment with an erythropoiesis stimulation agent such as erythropoietin alpha.…”