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Review:
Alan T. Tinmouth, MD MSc, Lauralynn A. McIntyre, MD MSc, and Robert A. Fowler, MDCM MS
Blood conservation strategies to reduce the need for red blood cell transfusion in critically ill patients
CMAJ 2008; 178: 49-57 [Abstract] [Full text] [PDF]
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[Read eLetter] May efficacy and safety of erythropoietin be improved by IV iron in ICU patients?.
Manuel Muñoz   (8 February 2008)

May efficacy and safety of erythropoietin be improved by IV iron in ICU patients?. 8 February 2008
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Manuel Muñoz
Transfusion Medicine

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Re: May efficacy and safety of erythropoietin be improved by IV iron in ICU patients?.

mmunoz{at}uma.es Manuel Muñoz

Manuel Muñoz1, José Antonio García-Erce2, Alice Maniatis3, Philippe van der Linden4

1Transfusion Medicine, School of Medicine, Malaga, Spain; 2Department of Hematology, Miguel Servet University Hospital, Zaragoza, Spain; 3Hematology Division, Henry Dunant Hospital, Athens, Greece; 4Department of Anaesthesiology, CHU Brugmann–HUDERF Brussels, Belgium.

We read with interest the review on blood conservation strategies to reduce the need for red blood cell transfusion in critically ill patients recently published in CMAJ by Tinmouth et al (1), and we would like to comment regarding the possible role of recombinant human erythropoietin and intravenous iron.

Functional iron deficiency (FID) due to inflammation is a common condition in ICU patients and it may blunt the erythropoietic response to rHuEPO (2). As oral iron is unlikely to correct FID, IV iron preparations, which are able to directly release iron to transferrin in the plasma, might be an alternative (3). In this regard, a study reported a significant reduction in the transfusion requirements in ICU patients receiving IV iron sucrose (100 mg three times per week) and subcutaneous rHuEPO (40,000 units once per week or three times per week) compared to those receiving iron sucrose alone (4).

When this study was compared with those by Corwin et al (5,6) there were no differences among the 3 control groups transfusion requirements, variation of Hb levels, or mortality rates (14.5&, 12.4%, and 11.4%, respectively) (suggesting that IV iron administration to ICU patients seems to be safe). In addition, after discounting the effects of ABT (1 ABT unit increasing hemoglobin concentration by 1 g/dL), a net increase in hemoglobin (ΔHbnet, g/dL = ΔHbosb – ABT) was only observed in patients receiving rHuEPO and IV iron (+0.8 g/dL, -1.1 g/dL, and -0.5 g/dL, respectively). This net increase in Hb may have led to a reduction in transfusion requirements which was not abrogated by the use of a restrictive transfusion protocol. Therefore, it seems that administration of IV iron might allow for the correction of FID, thereby improving the erythropoietic response to HuEPO, and probably for a reduction of rHuEPO dose and dose-dependent rHuEPO side effects.

References

1. Tinmouth AT, McIntyre AL, Fowler RA. Blood conservation strategies to reduce the need for red blood cell transfusion in critically ill patients. CMAJ 2008; 178: 49-57.

2. Walsh TS, Saleh E-E-D. Anaemia during critical illness. Br J Anaesth 2006; 97 :278-91.

3. Muñoz M, Breymann C, García-Erce JA, Gómez-Ramírez S, Comin J, Bisbe E. Efficacy and safety of intravenous iron therapy as an alternative/adjunct to allogeneic blood transfusion. Vox Sang 2008 (DOI: 10.1111/j.1423-0410.2007.01014.x).

4. Georgopoulos D, Matamis D, Routsi C, Michalopoulos A, Margina N, Dimopoulos G, et al. Recombinant human erythropoietin therapy in critically ill patients: a dose-response study. Crit Care 2005; 9: R508- R515.

5. Corwin HL, Gettinger A, Pearl RG, Fink MP, Levy MM, Shapiro MJ, et al. Efficacy of recombinant human erythropoietin in critically ill patients: a randomized, controlled trial. JAMA 2002; 288: 2827-35.

6. Corwin HL, Gettinger A, Fabian TC, May A, Pearl RG, Heard S, et al. Efficacy and safety of epoetin alfa in critically ill patients. New Engl J Med 2007; 357: 965-76.

Conflict of Interest:

None declared