Effects of intravenous iron monotherapy for patients with iron deficient anemia undergoing total knee arthroplasty

Abstract

Background Unnecessary costs and complications can be reduced by increasing hemoglobin (Hb) levels and minimizing blood transfusions in patients who underwent total knee arthroplasty (TKA). This study aimed to determine the effects of intravenous iron monotherapy before TKA on preoperative iron deficient anemia and postoperative transfusion rates. Methods This prospective cohort study included 45 patients scheduled for TKA in the experimental group (Group I) and 221 patients who underwent TKA in 2015 and 2018 in the control group (Group C). One thousand milligrams of ferric carboxymaltose was administrated 1 month before TKA in group I. Intergroup comparison of the rate and total volume of transfusion, perioperative changes in Hb and analysis of iron metabolism variables in group I were performed. Subgroup analysis of Group I was conducted according to the response to iron monotherapy. Results Although Hb levels increased after intravenous iron monotherapy in Group I, postoperative transfusion rates in Groups I and C were 17.8% and 18.6%, respectively, without significant intergroup differences in the rate and total units of transfusion. Ferritin level and transferrin saturation were corrected in both subgroups of Group I. Only 17 patients (37.78%) showed response to iron monotherapy, with an Hb increase of 1.0 g/dL or more. Subgroup analysis showed lower proportions of coexisting chronic diseases, including chronic kidney disease in responders. Conclusion IV iron monotherapy was shown to be insufficient in successfully treating preoperative iron-deficient anemia to reduce postoperative allogenic blood transfusion in patients who underwent TKA. As preoperative anemia should be managed due to the high rates of postoperative transfusion for this surgery, clinicians should consider the complex interplay among the causal factors of anemia, apart from ID, in patients with preoperative anemia who are scheduled for TKA.

Postoperative Intravenous Iron Supplementation Increases Hemoglobin Level in Total Knee Arthroplasty

“…15 This is a concept that has been widely used in other departments and has recently been used in the field of orthopaedics after major surgeries, such as arthroplasty. 8,16,17 Our results concurred with the findings of other Postoperative IV Iron Supplementation Increases Hemoglobin Level in TKA Nam et al…”

“…15 This is a concept that has been widely used in other departments and has recently been used in the field of orthopaedics after major surgeries, such as arthroplasty. 8,16,17 Our results concurred with the findings of other studies wherein iron supplementation decreased hemoglobin drops at 2 to 6 weeks after TKA surgery. 8,13,18,19 Our study showed that the hemoglobin drop of the I group during hospitalization was lower than the NI group after administration of iron supplementation, even though the difference did not reach statistical significance.…”

Reported outcomes in patients with iron deficiency or iron deficiency anemia undergoing major surgery: a systematic review of outcomes

“…In total, 13 studies met our inclusion criteria. The eligible 13 studies comprised five RCTs [ 21 – 25 ] and eight observational studies: two prospective [ 26 , 27 ], five retrospective cohort studies [ 28 – 32 ], and one observational study [ 33 ] comparing a prospective intervention group to a historic cohort. Table 2 gives an overview of the study characteristics.…”

“…of studies, n (%) No. of studies reporting as primary outcome Variation in reported outcome Death Mortality/survival Mortality 5 (38) [ 21 , 25 – 27 , 30 ] 0/5 - Reported as number or percentage of patients deceased - Time points: from up to 30 days to 6 months after intervention Physiological/clinical outcomes Blood and lymphatic system outcomes Hemoglobin (Hb) levels 12 (92) [ 21 – 27 , 29 – 33 ] 6/12 - Continuous variable: reported as mean ± SD concentrations or differences in concentrations - Categorical variable: success versus failure in reaching target Hb (10g/dL); number/percentage of patients reaching Hb >10g/dL - Time points: at baseline, 28-35 days prior to surgery, at day of surgery, 1 day to 6 months postoperatively, at discharge - 2 studies reported number of patients reaching a Hb level of 10 g/dL before surgery and time needed for it Change in iron metabolism parameters 6 (46) [ 21 , 22 , 24 , 25 , 30 ] 1/6 - Reported as mean ± SD concentrations or differences in concentrations of iron parameters: ferritin, transferrin, transferrin saturation, iron, iron-binding capacity - Time points: up to 4 preoperatively and up to 4 postoperatively or not specified Blood loss 2 (15) [ 24 , 33 ] 0/2 - Reported as estimated mean blood loss ± SD and blood loss in drainage - Time points: 5 and 7 days postoperatively Other outcomes regarding hematopoiesis 2 (15) [ 22 , 29 ] 0/2 - Reported as mean ± SD or differences in number of white and red blood cells, and mean cell volume - Time points: preoperatively up to 4 weeks and up to 4 weeks postoperatively Adverse events Adverse events (AE) See variation in reported outcome 10 (77) [ 21 – ...…”

“…of studies reporting as the primary outcome Variation in reported outcome Life impact Delivery of care Outcomes related to the feasibility of study/intervention 3 (23) [ 25 – 27 ] 3/3 - Feasibility of the study reported as the number of participants recruited/enrolled, consenting, receiving study drug, and completing the study. - Time points: within 4 to 12 months, or not specified Global quality of life Quality of life 6 (46) [ 21 , 23 , 25 – 27 , 30 ] 0/6 - Reported as median with IQR or mean ± SD scores on various quality of life questionnaires, such as Short-Form (SF-12, SF-36), Single Question Outcome Measure (SQOM), European Quality of Life (EQ-5D-3L, EQ-5D-5L) - Time points: from baseline to 2 weeks, 30 days, 3 months, 6 months after intervention or surgery or not specified Physical functioning See variation in reported outcome 2 (15) [ 26 , 27 ] 0/2 - Reported as median with IQR or mean ± SD days and scores on various physical functioning scales, such as Days-alive-and-out-of-hospital (DAH/DAOH; 6-minute walk test (6MWT); cardiopulmonary exercise testing (CPET) Multidimensional Fatigue Inventory-20 (MFI-20) - Time points: from baseline to 2 weeks, 30 days, 3 months, 6 months after intervention or surgery or not specified Resource use Need for further intervention Need for blood transfusion 10 (77) [ 21 , 24 – 29 , 31 – 33 ] 3/10 - Reported as number or percentage of patients receiving blood transfusion; number of blood units transfused or amount of transfused blood in total or per patient in mean ± SD or median with IQR; reduction in risk or odds ratio for (with 95% CI) blood transfusion; categories of units transfused used: 1–2 and 3–4 - Time points: preoperatively without further specification or at up to 30 days before surgery; during surgery; postoperatively at 5 days, 7 days, 30 days until discharge or not further specified; other time points: during hospital stay; from overall from recruitment to discharge or not specified Iron treatment 1 (8) [ 21 ] 0/1 - Reported as number of patients requiring continued iron treat...…”