Recombinant human erythropoietin and autologous blood donation

Risks of transfusion are minimized with autologous blood. However, autologous donation programs require 2 to 5 weeks to yield only 2.2 units per patient. Recombinant human erythropoietin (r-HuEPO) has been shown to increase erythropoiesis. This study evaluated the effects of r-HuEPO on an aggressive autologous donation program. Twelve adult male baboons were randomized into two groups of six. All animals were studied three times per week for 5 weeks. A unit of blood was donated when on any study day the hematocrit was greater than 30%. Animals received intravenously either 750 units/kg of r-HuEPO (n = 6) or placebo (n = 6) on each study day. Iron dextran was given intravenously to replace 150% of shed iron. The r-HuEPO group had an earlier onset of reticulocytosis (2.7 vs 5.5 days, p less than 0.01) and donated 35% more blood (13.5 vs 10.0 units, p = 0.01) than the control group. No adverse reactions to r-HuEPO were observed. The data show that an aggressive autologous donation program can yield 10 units of blood over a 5-week period. Further, r-HuEPO increases that yield by an additional 35%. This aggressive autologous donation program with r-HuEPO may significantly reduce the need for homologous transfusion and its attendant risks.     

Recombinant human erythropoietin in preoperative autologous blood donation did not influence the haemoglobin recovery after surgery

BACKGROUND: Recombinant human erythropoietin in combination with preoperative autologous blood donation is an established regime for avoiding allogenic blood transfusions. The aim of the study was to determine endogenous erythropoietin production and haemoglobin recovery after preoperative autologous blood donation and surgery, with or without recombinant human erythropoietin treatment. METHODS: Thirty-eight patients having total hip joint replacement surgery were randomised to receive either autologous blood transfusion (control group) or autologous transfusion plus preoperative recombinant human erythropoietin treatment (EPO group). Haemoglobin, haematocrit, erythropoietin and reticulocyte concentrations were repeatedly analysed, before, during, and after surgery. RESULTS: No significant differences were found between the groups regarding haemoglobin, haematocrit, and erythropoietin, but the reticulocyte count increased significantly more in the EPO group. There was no difference in the requirement for allogeneic blood transfusions between the groups. The baseline haemoglobin was >13 g dL-1 in all but four patients. CONCLUSIONS: In patients with normal preoperative haemoglobin levels, recombinant human erythropoietin treatment did not improve haemoglobin levels, or reduce the need for allogenic blood transfusion. There were no differences in serum erythropoietin concentrations between the groups. We question whether recombinant human erythropoietin treatment facilitates preoperative autologous blood donation in patients with normal haemoglobin levels.     

Recombinant human erythropoietin in pediatric patients: efficacy in facilitating autologous blood donation in spinal deformity surgery

Preoperative autologous blood donation (PABD) is a widely used practice in orthopaedic elective surgery, but many pediatric patients are unable to complete the program of pre-deposit. Twenty-three consecutive patients undergoing spinal surgery for scoliosis received 6 administrations of 10000U of recombinant human erythropoietin (rHuEpo). Preop hemoglobin (Hb) levels and the numbers of collected and of autologous and allogeneic blood transfused units were determined. These results were compared with a previously-operated group of 28 patients, who differed only by the absence of concomitant erythropoietin therapy. Significant higher numbers of collected blood units and Hb levels were measured, and all of the patients completed the PABD program. A significantly lower requirement for allogeneic blood in the group was observed: 1 vs 9 patients (4.3%-32.1%; p < 0.001). The study documents the efficacy of rHuEpo in facilitating the completion of a PABD program and in reducing exposure to allogeneic blood in pediatric patients undergoing corrective spinal surgery.     

Recombinant human erythropoietin therapy for autologous blood donation in rheumatoid arthritis patients undergoing total hip or knee arthroplasty

The effect of recombinant human erythropoietin on autologous blood donation was investigated in 73 rheumatoid arthritis patients who underwent hip or knee arthroplasty. Autologous blood donation of 400 mL was successful with recombinant human erythropoietin (12,000 U per week), and no homologous blood was required. The mean period of blood collection was 33.8 days. Mean hemoglobin levels were 9.7 g/dL before treatment, 10.7 g/dL before surgery, and 10.2 g/dL after surgery. This study confirmed recombinant human erythropoietin is effective for enabling preoperative blood donation in rheumatoid arthritis patients.     

Predeposit autologous blood donation

Predeposit autologous donation for elective surgical procedures during which there is a potential requirement for transfusion is medically proven as safe and efficacious but significantly underutilized. The primary advantages are avoidance of transfusion-transmitted disease and alloimmunization. Appropriate donor selection is essential. In general, there are no age or weight limits for donors. The incidence of adverse reactions is no greater in properly selected autologous donors than in homologous donors. Administration of oral ferrous sulfate allows many patients to meet all of their perioperative transfusion requirements. The blood is usually stored in the liquid state, but can be frozen.
The mere availability of autologous blood is not an indication for its reinfusion. The criteria for transfusion are similar to those for homologous blood. However, a more liberal interpretation may be appropriate in some clinical situations. The issue of disposition of predonated blood which is not transfused to donor-patients remains unresolved. In some areas all units are discarded. In others, the blood can be administered to other patients if the donor met all the criteria for homologous donors and the blood tested negative for infectious disease markers.     

The effect of recombinant human erythropoietin therapy on red cell expansion during autologous blood donation

As the result of the institution of coordinated programs involving regional blood centers, hospital blood banks, information services, and physicians, preoperative autologous blood donation, a previously underutilized practice, has become a standard of care in a number of elective surgical procedures. In addition, the administration of recombinant human erythropoietin has been shown to facilitate the collection of autologous blood from patients scheduled for elective orthopaedic surgery. An analysis of the findings in a study of 263 orthopaedic surgical patients in which the relationship between autologous blood ordering, collection and storage, and subsequent blood transfusion was studied indicates that both blood ordering and blood procurement practices are significant factors with regard to allogeneic blood exposure.     

Preoperative autologous blood donation with cardiac surgery

BACKGROUND: Preoperative autologous blood donation is commonly used to reduce exposure to homologous blood transfusions among patients undergoing elective cardiac surgery. The purpose of this study was to ascertain how much volume of predonated autologous blood need to avoid of homologous blood transfusion in cardiac procedure. METHODS: One hundred twenty-eight patients underwent scheduled cardiac procedure between January 1998 and December 1999. Group 1: 400 ml predonated, operation without cardiopulmonary bypass (CPB) [n = 33], group 2: 800 ml predonated, operation without CPB (n = 23), group 3: 800 ml predonated, operation with CPB (n = 36), group 4: 1,200 ml predonated, operation with CPB (n = 36). Surgical procedures underwent only off-pump coronary artery bypass grafting (OPCAB) in groups 1 and 2. In groups 3 and 4 included coronary artery bypass grafting (CABG), valve replacement, CABG + valve replacement and atrial septal defect repair. RESULTS: There were no significant differences in mean body weight, mean preoperative hematocrit values or mean volume of intraoperative blood loss between groups 1 and 2. There were no significant differences in mean age, mean body weight, mean preoperative and postoperative day-7 hematocrit values, mean volume of intraoperative blood loss or mean CPB time between groups 3 and 4. The mean postoperative day-7 hematocrit value was significantly lower in group 1 than in group 2. Homologous blood transfusion was avoided in 63.6% of those with predonation of group 1 versus 100% at group 2 (p < 0.05), 86.1% at group 3 versus 94.4% at group 4 (p < 0.05). In group 3, all patients who underwent redo operation or CABG + valve replacement needed homologous blood transfusion. CONCLUSIONS: Autologous blood transfusion is effective for reducing the homologous blood requirement. It also seems that predonation of 800 ml may be sufficient to avoid homologous blood transfusion in cardiac surgery, however predonation of 1,200 ml is desirable in cases of redo operation or CABG + valve replacement.     

Two different dosing regimens of human recombinant erythropoietin beta during preoperative autologous blood donation in patients having hip arthroplasty

Purpose  

Our aim was to evaluate the effectiveness of two different dosing regimens of human recombinant erythropoietin (rHu-EPO) for preoperative autologous blood collection in patients undergoing total hip arthroplasty (THA).     

Utilization of preoperative autologous blood donation in elective surgery

Background: The aim of the present paper was to review the pattern of collection and transfusion of autologous red cells for elective surgical procedures Methods: Data on requests for preoperative autologous donation of blood were obtained from the Australian Red Cross Blood Service, Victoria and the Royal Melbourne Hospital for the calendar year 1998. The following information was collected: patient age, sex, surgery type, number of autologous units requested and collected and, if relevant, reasons for not achieving the requested collection. Transfusion of autologous units and any additional homologous units was confirmed from records at the blood banks of the Royal Melbourne Hospital and Melbourne Pathology (the pathology provider performing cross‐matching for the majority of autologous units collected by Australian Red Cross Blood Service, Victoria). Results: Over 12 months, 2803 units of autologous blood were requested and 2282 units collected from 1301 patients. The most common reason for failure to collect the number of units requested was insufficient time between referral and surgery. Of the autologous units collected, 73% were transfused giving a collection to transfusion ratio of 1.4. Sixty‐eight per cent of patients received their autologous units only, 10% received both autologous and homologous units, while 22% were not transfused. For the majority of procedures, patients using preoperative autologous donation of blood had higher transfusion rates than those who did not use this. Conclusions: Ninety per cent of patients undergoing preoperative autologous donation of blood successfully avoided homologous blood exposure. However, preoperative autologous donation of blood is both wasteful and increases the incidence of transfusion in surgical procedures.     

Autologous blood donation with recombinant human erythropoietin in anemic patients

BACKGROUND: Various blood management strategies can be used to reduce the need for allogeneic blood in cardiac surgery. In anemic patients, however, avoidance of allogeneic blood transfusion is difficult to achieve. This study was performed to assess the safety and effectiveness of preoperative blood collection using recombinant human erythropoietin (rHuEPO) for reducing the exposure to allogeneic blood in anemic patients. METHODS: Thirty-two anemic patients undergoing cardiac surgery at our hospital between January 1994 and October 1997 were divided into two groups according to preoperative strategies: 3-week treatment with rHuEPO and blood donation (group 1, n = 16) or iron supplementation alone (group 2, n = 16). RESULTS: There were no statistically significant differences between the two groups in patients' characteristics and surgical data. The number of reticulocytes was increased at just before surgery in group 1, whereas group 2 showed no significant increase. The estimated hemoglobin increases in group 1 were higher at 7 days and just before surgery. The mean number of required allogeneic blood for patients during surgery was 0.59 +/- 1.12 U in group 1 and 5.01 +/- 2.63 U in group 2. In 75% of group 1 patients, allogeneic blood transfusion was successfully avoided, whereas all patients in group 2 received allogeneic blood. CONCLUSIONS: This study suggests that the combination of rHuEPO administration and autologous blood donation can reduce the need for allogeneic blood in anemic patients.     

Mannheim concept of preoperative autologous blood donation and perioperative autologous blood transfusion in hip endoprosthesis surgery

PURPOSE: To investigate the efficiency of preoperative autologous deposit and intra- and postoperative cell salvage (CS) to reduce homologous transfusion in hip arthroplasty and revision hip arthroplasty. METHODS: In a retrospective study, the data of 1402 patients scheduled for hip arthroplasty and for revision hip arthroplasty were analysed. RESULTS: 767 women and 635 men, age 62.9 +/- 9.8 years (x +/- s) were included in the study. 1270 were scheduled for hip arthroplasty, 132 for revision hip arthroplasty. Of the autologous donors, 51 patients predeposited four units, 1020 patients three, 204 patients two, 39 patients one unit. 88 patients who had not enrolled in the autologous donation program but received CS served as a control group. Blood loss in autologous donors amounted to 1620 (220-5620) ml in hip arthroplasty and 2830 (950-7910) ml in revision arthroplasty. CS was employed in part of the cases in arthroplasty and in all revision operations. 470 (0-2200) ml and 705 (0-2200) were retransfused. In hip arthroplasty 227 of 1182 patients (19.2%) received homologous blood. Homologous transfusion in patients with coxarthrosis due to acetabular protrusio, avascular necrosis of the femoral head and hip dysplasia showed a trend to higher values. Patients who had donated 3 units and received CS required homologous transfusion in 12.4% of the cases. CS reduced the homolgous transfusion rate significantly if the preoperative hemoglobin concentration was < or = 12 g/dl. A group of autologous donors receiving CS was matched with patients receiving CS only. 12 of 76 (15.8%) vs. 45 of 76 (59.2%) required homologous transfusion. In revision hip arthroplasty 58 of 132 patients (43.9%) required homologous blood. CONCLUSIONS: Preoperative deposit reduces homologous transfusion requirements considerably in hip surgery. Under the conditions studied CS should be employed in hip arthroplasty in addition to preoperative deposit if the preoperative hemoglobin concentration falls below 12 g/dl. In revision arthroplasty, 4 or more autologous units should be predeposited and CS should be used regularly.     

Pre-operative autologous blood donation versus no blood donation in total knee arthroplasty: a prospective randomised trial

Purpose

During total knee arthroplasty (TKA) blood loss can be significant and in spite of all techniques for reducing blood loss there is still a significant possibility for blood transfusions. For blood loss management during TKA, pre-operative autologous blood donation (PABD) is still a standard of care. In this prospective randomised study we have evaluated the efficacy of PABD in patients undergoing TKA to answer the question whether there is any need for autologous blood donations during TKA and, if yes, for which group of patients.

Methods

Patients were randomised to three groups. In group 1 patients did not donate autologous blood, in group 2 patients donated 1 dose 72 hours prior to TKA and in group 3 patients donated autologous blood 14 days prior to TKA. In all patients haemoglobin, haematocrit, thrombocyte and reticulocyte values, iron concentrations (Fe, unsaturated iron binding capacity, total iron binding capacity), activated partial thromboplastin time, prothrombin time, and intra-operative and post-operative blood loss were measured and compared.

Results

With PABD there was no reduction in allogeneic blood transfusions and a large number of taken doses of autologous blood was discarded, which significantly increased the cost of treatment for these patients. For patients undergoing TKA, PABD can provoke iatrogenic anaemia and thereby increase the likelihood of the need for allogeneic blood transfusion.

Conclusions

Results of our study showed that PABD in non-anaemic patients is not justified and is not economically feasible.     

Preoperative autologous blood donation in elderly patients with cardiovascular surgery

BACKGROUND: During the cardiovascular surgeries in elderly people, only a few cases can avoid the homologous blood transfusion, because of their preoperative anemic tendency and low hemopoietic abilities. We examined the capability to avoid the homologous blood transfusion in over 75 year old patients by the preoperative autologous blood collection. Sixty-six patients underwent scheduled cardiovascular surgery between January 1996 and December 1999. The groups were divided into three categories of preoperatively collected autologous blood amounts: high-amount (800-1,200 ml), medium-amount (200-800 ml), and low-amount (0 ml). Each group was divided into two subgroups in according to the use of cardiopulmonary bypass (CPB). There were no differences among the each group in age, body weight, or preoperative and postoperative day-7 hematocrit values. RESULTS: Only 21.2% of patients could donate the expected blood amounts preoperatively. Mean volume was 641 ml. In groups used CPB, no patient was transfused homologous blood in high-amount group. On the contrary, 100% patients were donated in medium and low amount groups. In groups operated without CPB, homologous blood transfusion was required 14.3% in high-amount group, 25.0% in medium-amount group, and 83.3% in low-amount group. CONCLUSION: It seems that predonation of more than 800 ml may be sufficient to avoid the homologous blood transfusion in using CPB operation and more than 400 ml in non using CPB operation.     

Preoperative autologous blood donation in patients undergoing open heart surgery

We examined the possibility to avoid the homologous blood transfusion in patients undergoing open heart surgery by predonation of 200 ml or 400 ml on the day before operation. Between March 1999 and December 2001, 117 patients underwent scheduled open heart surgery. In these patients, preoperatively collected autologous blood on the day before operation amounted 200 ml or 400 ml. We divided these patients into 3 groups according to the necessity of homologous blood, no transfusion (group A, n = 77), intraoperative transfusion (group B 1, n-29) and postoperative transfusion (group B 2, n = 11). In 65.8% of patients the homologous blood transfusion could be avoided. Preoperative, intraoperative and postoperative factors were compared in the 3 groups. Especially, old age, female, body weight and preoperative hemoglobin value were significantly different between 3 groups. Postoperative Svo2 and postoperative hemoglobin value were significantly different between 3 groups. The purpose of this study was to evaluate that the predonation of 200 ml or 400 ml on the day before operation may be to avoid the homologous blood transfusion and that preoperative, intraoperative and postoperative factors in regard to homologous blood transfusion.     

Erythropoietin for autologous blood donation in total hip arthroplasty patients

Forty patients who were scheduled for a total hip arthroplasty were enrolled in a prospective study and were randomly divided into two groups. Group 1 received recombinant human erythropoietin (300 U/kg twice a week), and group 2 received placebo. The medication was started 2 weeks before the operation, and only one dose of medication was given after the operation. Autologous blood was administered at the same time as the medication until the hemoglobin level sank to 10 g/dl. Forty-eight and 49 units of autologous blood were collected in group 1 and group 2, respectively. Intraoperative homologous blood was transfused only to patients in group 2. Seven and 13 units of allogenic blood were transfused into group 1 and group 2 patients during the postoperative period, respectively. There were no any significant differences between the groups in terms of early postoperative hemoglobin level and amount of autologous blood collected. However, the increase of the reticulocyte count in patients who received erythropoietin was significantly higher than in the group 2 patients. The study showed that short-term and low-dose erythropoietin usage strongly stimulates the bone marrow. Erythropoietin administration and preoperative autologous blood donation diminished the total units of allogenic blood required during the intraoperative or postoperative pe-riod. Autologous blood administration without concurrent erythropoietin did not stimulate the bone marrow adequately. Received: 13 January 2000     

Autologous blood procurement--acute normovolemic hemodilution vs. preoperative autologous blood donation

Autologous blood procurement remains in evolution. Interest in preoperative autologous blood donation (PAD) increased substantially in the 1980's due to the recognition that HIV was transmissible by blood. Concomitant with increased blood safety, however, PAD activity has declined approximately 40% since 1992. Reasons for this decline are unclear; patients may feel more comfortable with issues regarding blood safety, but associated costs and discard rates of up to 50% of blood units are other important factors. An alternate strategy is acute normovolemic hemodilution (ANH), which has the advantages of lower costs along with no wastage of blood units. A further advantage is that since ANH units never leave the patient's bedside, there is no possibility of an administrative error that could lead to ABO-related hemolysis (as could occur with PAD units stored in the blood bank). Concerns regarding the adequacy of national blood inventories may restimulate interest in autologous blood procurement, independent of issues regarding blood risks or costs.     

Current situation and issues in preoperative autologous blood donation in Japan

Preoperative autologous blood donation (PABD) with no risk of blood-borne infection transmission has been considered the supreme blood transfusion therapy, and it has been reported to decrease incidence of postoperative deep-vein thrombosis. However, the need for PABD has decreased in the USA, because 1) risk of blood-borne infection transmission through allogeneic blood transfusion (ABT) has decreased after introduction of nucleic acid amplification test (NAT), and 2) blood collection-induced anemia has been found in many cases due to inapplicability of erythropoietin (rEPO). ABT risks are decreasing in Japan as in the USA, however, ABT has several issues proper to Japan, such as, outpacing of blood demand over supply in the near future and increase of HIV positive donors. Also, as rEPO can be used in Japan, PABD-induced anemia risks are low. Accordingly, necessity of PABD should increase in Japan. However, as those who usually perform PABD in Japan are surgeons, big issues arise such as bacterial contamination during blood collection and ABO incompatibility during transfusion. Underutilization of PABD in gastrointestinal cancer surgery should also be addressed. Appropriate technique and methodology must be established to increase the safety of PABD and to spread PABD in cancer surgery.     

Underutilization of autologous blood donation among eligible elective surgical patients

In January 1983, blood banks encouraged the use of autologous blood for transfusion in elective surgical patients due to the advent of transfusion-associated AIDS. Since autologous blood does not transmit hepatitis and other viruses and does not cause alloimmunization, it should be utilized whenever possible. To determine whether patients eligible to predeposit autologous blood before elective operation were actually doing so, we studied patients at three hospitals between January 1 and June 30, 1985. Patients considered eligible for autologous predeposit blood donation were adults with preoperative hemoglobin levels of 11 g/dl or more who underwent elective surgical procedures for which blood transfusion was anticipated. Excluded were patients undergoing cardiovascular, intracranial, or renal transplant procedures. Of eligible patients, only 11 percent (32 of 278) predeposited blood; of these, 81 percent (26 of 32) were transfused with only autologous blood. Among eligible patients who did not predeposit blood, all could have benefited from predepositing because transfusion was likely for the procedure. Of those who did not predeposit, 33 percent (83 of 246) received homologous blood and therefore would have benefited from autologous donation. We conclude that autologous donations are underutilized for medically eligible patients undergoing elective operation.