Ann Thorac Surg 2001;71:1734-1735
© 2001 The Society of Thoracic Surgeons
Update
Update 2001: Preoperative use of erythropoietin for cardiovascular operations in anemia
Toshio Konishi, MDa,*,
Mutsumu Fukata, MDa,
Makoto Takeda, MDa,
Kanji Matsuzaki, MDa
a Department of Cardiovascular Surgery, Yokohama Rosai Hospital, Yokohama, Japan
* Address reprint requests to Dr Konishi, Department of Cardiovascular Surgery, Yokohama Rosai Hospital, 3211, Kozukue-cho, Kohoku-ku, Yokohama, 222-0036 Japan (Email: konix{at}muf.biglobe.ne.jp).
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Abstract
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As Originally Published in 1993:
Erythropoietin (EPO) may be of use in cardiovascular surgery without homologous blood transfusion, even in the chronically anemic population. In Japan, a multicenter study has been organized to evaluate the effectiveness of recombinant human EPO (Epoetin alfa; Kirin Brewery Co, Ltd, Tokyo, Japan) for surgery in anemic patients, in which we have participated since 1995. Although the final results of the study are still in the publishing process, there is a preliminary summary from the cardiovascular surgery section [1].
According to the guidelines of the Japanese Association of Transfusion, the minimum blood hemoglobin level for blood donation should be over 11 g/dL. Thirty patients who were scheduled to undergo coronary artery bypass graft or valvular surgery at 14 institutions, whose hemoglobin level was 10.3 (±0.9) g/dL, received subcutaneous administration of 24,000 units of EPO per week, along with daily oral administration of iron. On average, a period of 14.2 (±7.5) days and 1.8 (±1.0) times of EPO administration were necessary to raise the patients’ hemoglobin levels above 11.7 (±0.8) g/dL before their first autologous blood deposit. Within 28.2 (±8.9) days following the first EPO injection, 786.7 (±169.2) ml of their blood had been stored. All of the patients’ hemoglobin levels remained around 11.0 (±0.8) g/dL just before surgery; 65.2% of the patients did not require homologous blood transfusion after the surgery.
Although the above prescription was based on a minimum loading dose and duration, the results suggest that longer periods of EPO treatment would result in fewer homologous blood transfusions. As long as the preoperative process remains around 1 month, it might be performed while the patient is on the waiting list for the operation. Patients with moderate anemia may be the best candidates for the use of preoperative EPO. It is time-consuming, however, which can be an obstacle in patients with profound anemia because of the longer period of time needed to boost erythropoiesis before autologous blood procurement. At present, for the purpose of time efficiency, we have compromised by using EPO mainly in subanemic cohorts. If patients and surgeons could accept the treatment, many more nonemergency cases would be covered without homologous blood transfusion, but this is a policy issue rather than a scientific issue. However, there can be technical difficulties with comorbidity, such as with rheumatic disease or blood diseases, in which EPO tends to have less influence. These complications remain problematic in the EPO regimen.
EPO has made a great impact on the treatment of anemic patients who require surgery. Further studies about how EPO triggers the erythropoietic cascade are expected to eliminate negative factors [2, 3] or identify adjunctive measures [4–6] in order to increase the effectiveness of EPO. We believe that there should be wider preoperative use of EPO in the anemic population.
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References
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- Tanemoto K, Kawashima Y, Eguchi S, Fuse K. Investigation of autologous blood donation with erythropoietin for open heart surgery in anemia J Jpn Soc Autologous Blood Transfus 1997;10:177-181.
- Goicoechea M, Martin J, Sequera P, et al. Role of cytokines in the response to erythropoietin in hemodialysis patients Kidney Int 1998;54:1337-1343.[Medline]
- Tzioufas AG, Kokori SI, Petrovas CI, Moutsopoulos HM. Autoantibodies to human recombinant erythropoietin in patients with systemic lupus erythematosus Arthritis Rheum 1997;40:2212-2216.[Medline]
- Nordström D, Lindroth Y, Marsal L, et al. Availability of iron and degree of inflammation modifies the response to recombinant human erythropoietin when treating anemia of chronic disease in patients with rheumatoid arthritis Rheumatol Int 1997;17:67-73.[Medline]
- Matsumura M, Hatakeyama S, Koni I, Mabuti H. Effect of L-carnitine and palmitoyl-L-carnitine on erythroid colony formation in fetal mouse liver cell culture Am J Nephrol 1998;18:355-358.[Medline]
- Freudenthaler SM, Schenck T, Gleiter LCH. Fenoterol stimulates human erythropoietin production via renin angiotensin system Br J Clin Pharmacol 1999;48:631-634.[Medline]
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