Finding the optimal regimen for short-term daily recombinant human erythropoietin treatment for blood-saving purpose in patients undergoing unilateral primary total hip arthroplasty: a double-blinded randomized placebo-controlled trial

Abstract

Purpose To find the best short-term daily recombinant human erythropoietin (rhEPO)-based treatment protocols for blood-saving purpose in THA. Method The patients were randomized to 1 of 3 interventions: Patients in group A received 10,000 IU (150 IU/kg) of subcutaneous rhEPO (1 ml) daily from 5 days preoperatively to 3 days postoperatively (9 doses in total); Patients in group B received 1 ml of subcutaneous normal saline daily from 5 days preoperatively to 3 days preoperatively and then 10,000 IU (150 IU/kg) of subcutaneous rhEPO daily until 3 days postoperatively (6 doses in total). Patients in group C received 1 ml of subcutaneous normal saline daily from 5 days preoperatively to one day preoperatively and then 10,000 IU (150 IU/kg) of subcutaneous rhEPO daily from the day of surgery to 3 days postoperatively (4 doses in total). Results One hundred eighty patients were included. On postoperative day one, patients in the group A showed significantly higher Hb level (108.4 ± 11.4 g/L) than group C (103.9 ± 8.8 g/L). Group B (107.8 ± 8.4 g/L) also showed significantly higher Hb level than group C (103.9 ± 8.8 g/L) (p < 0.05). On postoperative day 3, no significant difference was found between group B and group C in Hb level (98.7 ± 10.5 and 94.9 ± 8.7 g/L, respectively) (p = 0.094), but the Hb level in group A (103.6 ± 11.0 g/L) was still markedly higher than in group B and the Hb level in group A was also markedly higher than in group C. In terms of blood loss, no markedly difference was found in intraoperative blood loss among group A, B and C (78.3 ± 22.4, 84.6 ± 29.1, and 80.3 ± 23.9 ml, respectively) (p = 0.381), but on postoperative day one, the mean blood loss in group C (522.4 ± 189.4 ml) was significantly more than group B (371.2 ± 124.6 ml), and group B was also significantly more than group A (284.8 ± 112.9 ml) with 95% confidence interval, and group B had significantly less blood loss than group C (p < 0.001). With respect to the total blood loss, the total blood loss in group C (881.6 ± 314.9 ml) was significantly more than group B (642.6 ± 232.9 ml), and group B was also significantly more than group A (514.5 ± 204.6 ml) with 95% confidence interval (Table 2). Only 2 patients in each group received allogeneic blood transfusion and each patient received 2 units of red blood cells, so, the transfusion requirements among the three groups were comparable. Conclusions Daily small-dose of subcutaneous rhEPO administered from 5 days before THA could significantly decrease perioperative blood loss and improve postoperative Hb levels, without increasing risks of complications, when compared with the application of rhEPO from 3 days before THA or from the day of surgery. However, surgeons should choose the regimen individually according to different patients’ personal circumstances.

Correlation of the severity of anemia in patients undergoing total joint arthroplasty with preoperative deep vein thrombosis: a retrospective cohort study

“…In contrast, patients with fractures are subject to a deadline operation. A low dose of EPO taken daily for 5 days before THA significantly reduced perioperative blood loss, improved postoperative Hb level, and did not increase the risk of complications compared to EPO taken 3 days before THA or the day of surgery [ 42 ]. It was suggested that starting EPO (150 IU/kg) three days before TJA is preferable to begin on the day of surgery because it is more effective in increasing Hb levels and reducing blood loss without additional complications [ 43 ].…”

Identification and management of preoperative anaemia in adults: A British Society for Haematology Guideline update

“…62 A further study found no additional benefit of an increased number of doses of preoperative ESA when compared with the standard of care of four doses. 63 Spahn investigated the impact of a combination of intravenous iron, ESA, B12 and folate given the day before surgery to anaemic patients undergoing cardiac surgery and demonstrated a reduction in transfusions and higher haemoglobin levels in the treatment group. 64 This immediately preoperative therapy may be attractive if anaemia has not been detected and managed in a preoperative clinic; however, again there were no differences seen between treatment and placebo groups when considering secondary outcomes such as length of hospital stay, and higher costs were incurred in the treatment group.…”

“…Several recent, small studies have examined alternative ESA‐dosing regimens, including the use of a smaller number of larger doses immediately preoperatively, which appeared to be safe and resulted in reduced transfusion rates 62 . A further study found no additional benefit of an increased number of doses of preoperative ESA when compared with the standard of care of four doses 63 . Spahn investigated the impact of a combination of intravenous iron, ESA, B12 and folate given the day before surgery to anaemic patients undergoing cardiac surgery and demonstrated a reduction in transfusions and higher haemoglobin levels in the treatment group 64 .…”

Minimally Invasive versus Conventional Approaches in Total Hip Arthroplasty: A Systematic Review and Meta-Analysis of 47 Randomized Controlled Trials

“…The cell saver device offers the possibility of autotransfusion. The use of iron supplements and erythropoietin is considered a postoperative option to avoid transfusions [77].…”