Dataset Information

Role of preoperative intravenous iron therapy to correct anemia before major surgery: a systematic review and meta-analysis.

ABSTRACT:

Background

Preoperative anemia is a common comorbidity that often necessitates allogeneic blood transfusion (ABT). As there is a risk associated with blood transfusions, preoperative intravenous iron (IV) has been proposed to increase the hemoglobin to reduce perioperative transfusion; however, randomized controlled trials (RCT) investigating this efficacy for IV iron are small, limited, and inconclusive. Consequently, a meta-analysis that pools these studies may provide new and clinically useful information.

Methods/design

Databases of MEDLINE, EMBASE, EBM Reviews; Cochrane-controlled trial registry; Scopus; registries of health technology assessment and clinical trials; Web of Science; ProQuest Dissertations and Theses; Clinicaltrials.gov; and Conference Proceedings Citation Index-Science (CPCI-S) were searched. Also, we screened all the retrieved reference lists.

Selection criteria

Titles and abstracts were screened for relevance (i.e., relevant, irrelevant, or potentially relevant). Then, we screened full texts of those citations identified as potentially applicable.

Results

Our search found 3195 citations and ten RCTs (1039 participants) that met our inclusion criteria. Preoperative IV iron supplementation significantly decreases ABT by 16% (risk ratio (RR): 0.84, 95% confidence interval [CI]: 0.71, 0.99, p = 0.04). In addition, preoperatively, hemoglobin levels increased after receiving IV iron (mean difference [MD] between the study groups: 7.15?g/L, 95% CI: 2.26, 12.04?g/L, p = 0.004) and at follow-up >??4?weeks postoperatively (MD: 6.46?g/L, 95% CI: 3.10, 9.81, p = 0.0002). Iron injection was not associated with increased incidence of non-serious or serious adverse effects across groups (RR: 1.13, 95% CI: 0.78, 1.65, p = 0.52) and (RR: 0.96, 95% CI: 0.44, 2.10, p = 0.92) respectively.

Conclusions

With moderate certainty, due to the high risk of bias in some studies in one or two domains, we found intravenous iron supplementation is associated with a significant decrease in the blood transfusions rate, and modest hemoglobin concentrations rise when injected pre-surgery compared with placebo or oral iron supplementation. However, further full-scale randomized controlled trials with robust methodology are required. In particular, the safety, quality of life, and cost-effectiveness of different intravenous iron preparations require further evaluation.

SUBMITTER: Elhenawy AM

PROVIDER: S-EPMC7824930 | biostudies-literature | 2021 Jan

REPOSITORIES: biostudies-literature

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Publications

Role of preoperative intravenous iron therapy to correct anemia before major surgery: a systematic review and meta-analysis.

Elhenawy Abdelsalam M AM Meyer Steven R SR Bagshaw Sean M SM MacArthur Roderick G RG Carroll Linda J LJ

Systematic reviews 20210123 1

<h4>Background</h4>Preoperative anemia is a common comorbidity that often necessitates allogeneic blood transfusion (ABT). As there is a risk associated with blood transfusions, preoperative intravenous iron (IV) has been proposed to increase the hemoglobin to reduce perioperative transfusion; however, randomized controlled trials (RCT) investigating this efficacy for IV iron are small, limited, and inconclusive. Consequently, a meta-analysis that pools these studies may provide new and clinical ...[more]

PMID: 33485392

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Project description:BackgroundPreoperative anaemia affects a high proportion of patients undergoing major elective surgery and is associated with poor outcomes. We aimed to test the hypothesis that intravenous iron given to anaemic patients before major open elective abdominal surgery would correct anaemia, reduce the need for blood transfusions, and improve patient outcomes.MethodsIn a double-blind, parallel-group randomised trial, we recruited adult participants identified with anaemia at preoperative hospital visits before elective major open abdominal surgery at 46 UK tertiary care centres. Anaemia was defined as haemoglobin less than 130 g/L for men and 120 g/L for women. We randomly allocated participants (1:1) via a secure web-based service to receive intravenous iron or placebo 10-42 days before surgery. Intravenous iron was administered as a single 1000 mg dose of ferric carboxymaltose in 100 mL normal saline, and placebo was 100 mL normal saline, both given as an infusion over 15 min. Unblinded study personnel prepared and administered the study drug; participants and other clinical and research staff were blinded to treatment allocation. Coprimary endpoints were risk of the composite outcome of blood transfusion or death, and number of blood transfusions from randomisation to 30 days postoperatively. The primary analysis included all randomly assigned patients with data available for the primary endpoints; safety analysis included all randomly assigned patients according to the treatment received. This study is registered, ISRCTN67322816, and is closed to new participants.FindingsOf 487 participants randomly assigned to placebo (n=243) or intravenous iron (n=244) between Jan 6, 2014, and Sept 28, 2018, complete data for the primary endpoints were available for 474 (97%) individuals. Death or blood transfusion occurred in 67 (28%) of the 237 patients in the placebo group and 69 (29%) of the 237 patients in the intravenous iron group (risk ratio 1·03, 95% CI 0·78-1·37; p=0·84). There were 111 blood transfusions in the placebo group and 105 in the intravenous iron group (rate ratio 0·98, 95% CI 0·68-1·43; p=0·93). There were no significant differences between the two groups for any of the prespecified safety endpoints.InterpretationPreoperative intravenous iron was not superior to placebo to reduce need for blood transfusion when administered to patients with anaemia 10-42 days before elective major abdominal surgery.FundingUK National Institute of Health Research Health Technology Assessment Program.

Project description:BackgroundPreoperative anemia is common in patients undergoing cardiac surgery with various etiologies, among which iron deficiency is the leading cause. However, the benefit of intravenous (IV) iron for the treatment of anemia before cardiac surgery is uncertain. This updated meta-analysis aimed to evaluate the efficacy of IV iron in adult cardiac surgery patients with preoperative anemia.MethodsThis review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We searched Embase, PubMed and the Cochrane Central Register of Controlled Trials to identify eligible randomized controlled trials (RCTs) and observational studies. Quality was assessed using the Cochrane Collaboration risk of bias tool and Newcastle-Ottawa scale, and the strength of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) criteria. Trial sequential analysis was performed on the primary outcome (transfusion rate) to confirm whether firm evidence was reached.ResultsSix RCTs (936 patients) and 5 observational studies (1350 patients) were included in this meta-analysis. The IV iron group and the control group were comparable in terms of transfusion rate [55.1% vs 60.9%, risk ratio (RR) = 0.91, 95% confidence interval (CI) 0.81-1.03, P = 0.13, low quality]. There were no significant differences in units transfused per patient, ICU stay and hospital length of stay between the two groups. And pooled data showed a benefit of IV iron compared to the control group on mortality (2.76% vs 3.75%, RR = 0.58, 95% CI 0.36-0.95, P = 0.03, moderate quality) and no mortality reduction existed when including only RCTs.ConclusionsThis meta-analysis suggested that IV iron treatment for patients with anemia before cardiac surgery did not reduce the transfusion requirement (low quality), but it was associated with decreased mortality (moderate quality). More large-scale, high-quality randomized clinical trials are warranted to confirm or refute our findings. PROSPERO registry reference: CRD42022331875.

Project description:ObjectiveTo perform a systematic review of randomized trials comparing oral vs intravenous (IV) iron therapy to treat postpartum anemia.Data sourcesData sources were as follows: PubMed (1972-2017); Cochrane Central Register of Controlled Trials, CENTRAL (1972-2017); CINAHL (1972-2017); Web of Science; Excerpta Medica Database, and EMBASE (1972-2017).Study eligibility criteriaWe included randomized trials comparing oral vs IV iron monotherapy to treat postpartum anemia (classified as a hemoglobin <12 g/dL).Study appraisal and synthesis methodsStudy quality was assessed with the Cochrane risk of bias assessment tool. The primary outcome was hemoglobin concentration at 6 weeks postpartum. Secondary outcomes included hemoglobin concentration at 1-5 weeks postpartum, ferritin concentration at 1-6 weeks postpartum, and maternal adverse outcomes. For meta-analysis, mean differences and odds ratios using a random effects model were calculated. Risk of heterogeneity was reported as I2.ResultsA total of 15 randomized trials met our inclusion criteria (n = 1001 and 1 181 women receiving oral iron and IV iron, respectively); 4 studies reported data for our primary outcome. We observed higher postpartum week 6 hemoglobin concentrations in the IV iron group compared to the oral iron group (mean difference, 0.9 g/dL; 95% confidence interval (CI), 0.4-1.3; P = .0003). Compared to oral iron, women receiving IV iron had higher hemoglobin concentrations at postpartum weeks 1, 2, and 3; higher ferritin concentrations at postpartum weeks 1, 2, 4, and 6; an increased likelihood of skin flushing (odds ratio [OR], 6.95; 95% CI, 1.56-31.03; P = .01; I2 = 0%); and a decreased likelihood of constipation (OR, 0.08; 95% CI, 0.03-0.21; P < .00001, I2 = 27%) and dyspepsia (OR, 0.07; 95% confidence interval, 0.01-0.42; P = .004; I2 = 0%). The reported event rate for anaphylaxis among women receiving IV iron was 0.6%.ConclusionIn this systematic review, among women with postpartum anemia, hemoglobin concentrations at 6 weeks postpartum were almost 1 g/dL higher in women who received IV iron compared to oral iron. The safety profile of IV iron was also reassuring. Given the weaker hemoglobin response and higher risk of gastrointestinal side effects with oral iron use, our findings suggest that IV iron be considered as a viable treatment option for postpartum iron deficiency anemia.

Project description:Preoperative anemia occurs in about one third of patients who undergo elective surgery and is associated with an impaired outcome. Therefore, screening of preoperative anemia was established in the context of a multidisciplinary Patient Blood Management (PBM) program at the University Hospital of Muenster, Germany. Anemic patients without contraindications were treated with intravenous (IV) iron (ferric carboxymaltose) to increase their hemoglobin (Hgb) levels and hence to treat anemia prior to surgery. Interestingly, we detected a large variability in the response of Hgb levels after IV iron administration. Systemic iron homeostasis is mainly regulated by the hepatic hormone hepcidin, which regulates the cell surface expression of the sole known iron exporter ferroportin. The objective of this retrospective pilot study was to analyze the potential of hepcidin to predict the response of anemic patients to preoperative IV iron treatment measured as increase in Hgb. Serum samples of non-anemic (n = 48), untreated anemic (n = 64) and anemic patients treated with IV iron (n = 79), in total 191 patients, were collected between October 2014 until June 2016. Serum hepcidin levels were determined and data were analyzed retrospectively. The analysis revealed at first a correlation between serum hepcidin levels and the parameters of the iron status. Second, patients treated with IV iron showed a noticeably higher increase in their delta Hgb level between PBM consultation and surgery (0.45g/dl [0.05, 1.05] compared to patients without IV iron (0.1g/dl [-0.48, 0.73], *p = 0.03). Patients were then grouped into 'non-responders', defined as delta Hgb <0.6g/dl and 'responders', with delta Hgb ?0.6g/dl between the day of IV iron treatment and the day of surgery. Within normal ranges and clinically unapparent, a statistically noticeable difference between responders and non-responders was found for CRP and leukocytes. Serum hepcidin levels were higher in the group of non-responders (10.6ng/ml [3.93, 34.77]) compared to responders (2.1ng/ml [0.25, 7.97], *p = 0.04). To conclude, the data of this retrospective pilot study indicate that hepcidin might be a promising biomarker to predict a patient`s responsiveness to IV iron in preoperative anemia treatment. Prospective studies have to investigate serum hepcidin levels as a biomarker to guide physician`s decision on IV iron substitution.

Dataset Information

Role of preoperative intravenous iron therapy to correct anemia before major surgery: a systematic review and meta-analysis.

Background

Methods/design

Selection criteria

Results

Conclusions

Publications

Role of preoperative intravenous iron therapy to correct anemia before major surgery: a systematic review and meta-analysis.

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