Case 6: Does this patient need a blood transfusion?

Preoperative Care of Patients with Kidney Disease
Author: V. Dimov, M.D., Department of General Internal Medicine, Cleveland Clinic

56 yo male with ESRD on hemodialysis (HD), HTN, DM2, and hyperlipidemia is here for preoperative evaluation for total knee replacement (TKR) in 1 week. His hemoglobin level is 7.8 mg/dL.

Does he need a blood transfusion?

Yes.

CKD and ESRD lead to decreased renal production of erythropoetin, and subsequently anemia. In addition, small amount of blood is lost during the HD procedure performed 3 times per week.

There is no standard for safe preoperative hemoglobin (Hgb) level in patients with kidney disease.

One study showed increased intraoperative complications in ESRD and preoperative hematocrit 20-26% (Hgb 6.6-8.6).

Downsides of blood transfusion:
- antibody formation, which decreases future chances of successful renal transplantation
- intraoperative transfusion may cause hyperkalemia in 44% of patients with ESRD

Medical treatment of perioperative anemia has been shown to decrease the need for transfusion and to improve perioperative outcomes such as post-operative infections, lenght of stay and mortality.

Synthetic erythropoetin was approved by the FDA and has been used for almost nine years in orthopedic surgeries as a method to improve hemoglobin in anemic patients undergoing surgery, and thus for decreasing blood transfusions. Several centers in the U.S. have adapted this novel therapy to reduce blood transfusions. The efficacy of preoperative erythropoietin therapy for increasing hemoglobin concentration and reducing exposure to allogeneic red blood cell transfusion has been demonstrated by several double-blinded randomized clinical trials in orthopedic surgery

In conlcusion, if the surgery is elective, synthetic erythropoetin can be started several weeks before the operation to raise hemoglobin level. Iron deficiency may occur during erythropoetin therapy. Normal ferritin but low transferrin saturation is observed due to inability to mobilize iron stores rapidly enough to keep pace with the increased erythropoiesis. Supplemental oral or intravenous iron supports erythropoiesis and prevents iron store depletion.

Summary

Hgb needs to be monitored and increased to a reasonable level (Hgb of 10 mg/dL) preferably through the use of erythropoetin. Blood transfusions may be needed.

Note: Avoid IV lines and blood draws in the nondominant arm of patients who will be starting HD in near future. Suitable vessels need to be protected for creation of AV fistula or graft.

Update 3/28/2007:

FDA added a black box warning to the labels of all currently available Erythropoiesis Stimulating Agents (ESAs). Source: ASN.

References

Preoperative Care of Patients with Kidney Disease. Mahesh Krishnan, M.D., M.P.H. Am Fam Physician 2002;66:1471-6.
Perioperative Management of the Patient With Chronic Renal Failure. Kenneth E Otah, MD, MSc, Moro O Salifu, MD, MPH, Eseroghene Otah, MD. eMedicine.com, last accessed 3/7/06
eMedicine.com/med/topic3166.htm.
De A, Jr., Jove M, Landon G et al. Baseline hemoglobin as a predictor of risk of transfusion and response to Epoetin alfa in orthopedic surgery patients. Am J Orthop 1996, August;25(8):533-42.
Goldberg MA, McCutchen JW, Jove M et al. A safety and efficacy comparison study of two dosing regimens of epoetin alfa in patients undergoing major orthopedic surgery. Am J Orthop 1996 August;25(8):544-52.
Faris PM, Ritter MA, Abels RI. The effects of recombinant human erythropoietin on perioperative transfusion requirements in patients having a major orthopaedic operation. The American Erythropoietin Study Group. J Bone Joint Surg Am 1996 January;78(1):62-72.

Image source: JHeuser, GNU Free Documentation License.

Created: 5/31/2006
Updated: 03/28/2007

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