Biology Reference
In-Depth Information
75% autologous wastage noted. Billote et al. [28, 33] evaluated PAD in
patients receiving total hip arthroplasty and found no benefit in PAD for non-
anemic patients undergoing primary hip replacement. Each patient donated
two units of autologous blood with an additional cost of US$ 758 per patient.
Etchason et al. [34] evaluated the cost of a PAD program and concluded that
the increased protection afforded by donating autologous blood is limited and
may not justify the increased costs.
Use of erythropoietins
While the importance of pre-operative hemoglobin concentration has been dis-
cussed,the surgeon is often limited in his/her ability to return the patient to
pre-donation hemoglobin values. Unhappy with the anemia caused by a PAD
program, we have put our patients on another protocol. We obtain the hemo-
globin concentrations at the time of surgical booking and based on the hemo-
globin concentration, we identify those patients at high risk for a transfusion.
Patients with hemoglobin concentrations >10 and <13 g/dL receive 40,000 U
of recombinant human erythropoetin (rHuEPO) at three, two, and one week
before surgery; they also receive iron supplementation. Nearly 75% of our
patients avoid autologous donations and only 25% of those who are in need of
transfusions have them. We recently compared 50 patients who received
rHuEPO with 50 patients who were in an autologous program with automatic
transfusion. Patients receiving rHuEPO had higher blood parameters, pre-
operative, post-operative, and on discharge, compared with patients who par-
ticipated in the autologous program. In addition, our overall cost was reduced
because using a patient-specific approach only on the 25% of patients who
received rHuEPO had transfusions.
In Europe, one brand of epoetin alfa (Eprex, Janssen-Cilag) and the brand
epoetin beta (NeoRecormon, F Hoffmann-LaRoche) are licensed for use in
patients with mild anemia, including those undergoing PAD. Epoetin alfa is
licensed by most European countries for the treatment of patients with anemia
who are scheduled to undergo orthopedic surgery.
In the United States, one brand of epoetin alfa (Procrit, Ortho Biotech) is
licensed for use in PAD. Treatment with peri-operative epoetin alfa alone,
without concomitant PAD,has been shown to reduce the need for transfusion
in patients undergoing major orthopedic surgery by increasing the peri-opera-
tive hemoglobin concentration and the rate of erythropoietic recovery [19-21].
Two large, double-blind, placebo-controlled trials reported that the use of epo-
etin alfa significantly reduced the percentage of patients receiving allogeneic
red blood cell transfusions compared with the patients who received placebo
[19, 21]. A multicenter, double-blind,placebo-controlled, parallel-group study
determined that epoetin alfa 300 U/kg for 15 consecutive days starting 10 days
before surgery could reduce peri-operative transfusion requirements [20]. The
mean number of units transfused was lower for patients receiving epoetin alfa
