Scientific Article   |    
Preoperative Use of Recombinant Human Erythropoietin Before Total Joint Arthroplasty
Hari P. Bezwada, MD; David G. Nazarian, MD; David H. Henry, MD; Robert E. BoothJr., MD
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Investigation performed at the Pennsylvania Hospital, Philadelphia, Pennsylvania

Hari P. Bezwada, MD
David G. Nazarian, MD
David H. Henry, MD
Robert E. Booth Jr., MD
Booth, Bartolozzi, Balderston Orthopaedics, Pennsylvania Hospital, 800 Spruce Street, Philadelphia, PA 19107. E-mail address for H.P. Bezwada: hbezwada@yahoo.com

The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

A commentary is available with the electronic versions of this article, on our web site (www.jbjs.org) and on our quarterly CD-ROM (call our subscription department, at 781-449-9780, to order the CD-ROM).

J Bone Joint Surg Am, 2003 Sep 01;85(9):1795-1800
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Background: Previous reports have suggested that the use of recombinant human erythropoietin is effective for decreasing the need for perioperative allogeneic blood transfusion. The purpose of this study was to evaluate the efficacy of erythropoietin in combination with, and compared with, preoperative autologous donation for reducing allogeneic blood requirements for total joint arthroplasty.

Methods: Two hundred and forty patients undergoing primary and revision total hip or knee arthroplasty were enrolled into three groups with different treatment regimens: (1) erythropoietin and preoperative autologous donation (Group 1), (2) erythropoietin alone (Group 2), and (3) preoperative autologous donation alone (Group 3). Patients were evaluated with regard to requirements for allogeneic transfusion, change from the baseline to the lowest postoperative hemoglobin value, postoperative complications, and adverse reactions.

Results: The rate of allogeneic transfusion was 11% in Group 1 (erythropoietin and preoperative autologous donation) compared with 28% in Group 2 (erythropoietin alone) and 33% in Group 3 (preoperative autologous donation alone). Within Group 1, patients who had a unilateral primary arthroplasty had an allogeneic transfusion rate of 4% and those who had a bilateral or revision arthroplasty had an allogeneic transfusion rate of 17%. In Groups 2 and 3, the allogeneic transfusion rates were 14% and 15%, respectively, for the patients who had a unilateral primary arthroplasty and 35% and 47%, respectively, for those who had a bilateral or revision arthroplasty.

Conclusions: Preoperative use of erythropoietin in conjunction with preoperative autologous donation reduces the need for allogeneic blood transfusion associated with total joint arthroplasty more effectively than does either erythropoietin or preoperative autologous donation alone.

Level of Evidence: Therapeutic study, Level II-1 (prospective cohort study). See Instructions to Authors for a complete description of levels of evidence.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Hari P. Bezwada
    Posted on December 18, 2003
    Dr Bezwada and colleagues respond to Dr. Salot
    Pennsylvania Hospital

    We appreciate the comments from Dr. Salot. We will respond to his points individually.

    1) While it is true that the combination of recombinant human erythropoietin with preoperative autologous donation might not necessarily be in conformity with medicare regulations; Goodnough et al noted the ability to increase the amount of autologous donation with recombinant erythropoietin. Furthermore, peroperative autologous donation only leads to preoperative anemia, as noted by several authors. The combination of erythropoietin and preoperative autologous donation allows the patient to preoperatively donate without the development of a significant preoperative anemia.

    2) This particular study did not address the issue of cost. While it is true that the combination of autologous blood and recombinant erythropoietin remains costly, this study addresses the issue of efficacy not cost. The selection of a hemoglobin of 140 g/l as an inclusion criteria was at the suggestion of our hematologist (DHH). This was a hemoglobin level selected for other cases in which erythropoietin was utilized.

    3) While it is true that not many patients with a baseline hemoglobin of >130 g/l will require allogeneic transfusions. Previous studies have suggested that they have to be healthy patients, generally under 60 years of age, and be undergoing primary unilateral total joint arthroplasty. This study combined a large number of bilateral and revision arthroplasties. There should be no dispute that bilateral and revision arthroplasties have a greater allogeneic blood requirements than primary unilateral arthroplasty. A baseline hemoglobin of 140 g/l may not be sufficient to avoid allogeneic blood transfusions in bilateral and revision arthroplasties.

    William H. Salot, M.D.
    Posted on December 03, 2003
    Guidelines Regarding the Use of Erythropoietin Before Total Joint Arthroplasty
    Associated Orthopedists of Detroit, P.C.

    To the Editor;

    I was impressed by the efficacy of recombinant human erythropoietin when used with autologous blood donation to reduce the need for perioperative allogeneic blood transfusion in total joint arthroplasty. However, your readership should be aware that the protocol followed in this study was not in conformity with current Medicare guidelines.

    These guidelines restrict the surgical use of recombinant erythropoietin to patients whose preoperative hemoglobin range lies between 100 g/L and 130 g/L, and who are not candidates for autologous blood donation. The authors’ selection of 140 g/L as the upper limit of preoperative hemoglobin, as well as their addition of autologous blood donation to the treatment regimen, if adopted by others, could lead to challenges of reimbursement for these expensive programs.

    The use of 140 g/L as the upper limit of preop hemoglobin is puzzling, as a number of those patients between 130 g/l and 140 g/L probably need no preoperative treatment at all. Faris et al (1) demonstrated that patients whose hemoglobin was > 130g/L were only half as likely to require allogeneic blood in primary joint replacement as those with levels <130g/L.

    William H. Salot, M.D.

    Associated Orthopedists of Detroit,P.C.

    24715 Little Mack St.

    St. Clair Shores, Michigan 48080


    1) Faris,P.M., Spence, R.K., Larholt, K.M., Sampson, A.R., Frei, D. The predictive power of baseline hemoglobin for transfusion risk in surgery patients Orthopedics 1999 January:22 (1 suppl.) s 135-40

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