Efficacy of recombinant human erythropoietin in critically ill patients admitted to a long-term acute care facility: a randomized, double-blind, placebo-controlled trial

Jehovah's Witness Needing Critical Care: A Narrative Review on the Expanding Arsenal

Present day Jehovah's Witness (JW) religion accounts for 8.5 million followers. A tenant feature of the JW faith is religious objection to transfusions of blood and blood products. Interpatient variability, as it pertains to blood and blood products may occur; hence, a confidential interview will determine which products individual may consent to (Marsh and Bevan, 2002). This belief and practice place great restrictions on treating medical professionals in scenarios of life-threatening anaemia and active haemorrhage. The review to follow explores the physiological and pathophysiological consequences of severe anaemia. Non-blood transfusion practices are explored, many of which are potentially lifesaving. Particular attention is drawn to the evolving science involving artificial oxygen carriers and their use in emergency situations. A greater safety profile ensures its future use amongst religious objectors to be greatly beneficial. Intravenous iron supplementation has enjoyed a lively debate within the critical care community. A review of recent systematic and meta-analysis supports its use in the ICU; however, more investigation is needed into the complementary use of hepcidin.

Pharmacotherapy for Reducing RBC Transfusion for Patients in the ICU: A Systematic Review and Network Meta-Analysis

OBJECTIVES

To determine optional therapeutic strategies by comparing monotherapies and combination therapies to reduce RBC transfusion requirement for patients in the ICU.

DATA SOURCES

MEDLINE, CENTRAL, and Embase were searched for studies published from database inception until July 2023.

DATA EXTRACTION

We included randomized controlled trials comparing erythropoiesis-stimulating agents (Epo), iron, combination therapy with iron and Epo, hypoxia-inducible factor prolyl hydroxylase inhibitor (HIF-PHI), vitamin D 3 (VD3), and placebo/no treatment. A frequentist network meta-analysis (NMA) was performed using a random effects model, and the confidence in NMA was rated.

DATA SYNTHESIS

Of 117 eligible studies, 75 studies (15,091 patients) were included in the quantitative analysis. Compared with placebo/no treatment, the combination therapy reduces the requirement for RBC transfusion (risk ratio [RR]: 0.60; 95% CI, 0.49-0.74; confidence rating: moderate). The Epo or iron monotherapy may reduce the requirement for RBC transfusion (RR: 0.81; 95% CI, 0.63-1.04; confidence rating: low; RR: 0.83; 95% CI, 0.70-0.98; confidence rating: low, respectively). Combination therapy may not increase the prevalence of both venous thromboembolism (VTE) (RR: 0.73; 95% CI, 0.25-2.08; confidence rating: low) and infection. Epo monotherapy may not increase the prevalence of VTE but may increase that of infections (RR: 1.27; 95% CI, 0.94-1.73; confidence rating: low). Iron monotherapy may not increase the prevalence of both VTE and infection. Evidence for VD3 and HIF-PHI remains uncertain.

CONCLUSIONS

Combination therapy with iron and Epo likely reduces the requirement for RBC transfusion and may be less harmful than other therapies.

Lessons learned from patient outcomes when lowering hemoglobin transfusion thresholds during COVID-19 blood shortages

OBJECTIVES

This study examines whether patient outcomes were affected when the hemoglobin (Hb) transfusion threshold was lowered by 1 g/dL during COVID-19-related blood shortages.

METHODS

Outcomes of lowered Hb thresholds (from <7 to <6 g/dL) were defined by 14-month intervals in 2 patient groups (prepandemic [January 2019-February 2020] and pandemic [April 2020-May 2021]). We evaluated patient admissions, pretransfusion (if transfused) or nadir admission (if not transfused) Hb levels between 5.0 and 8.0 g/dL, and total red blood cell (RBC) transfusions during admission (if transfused). Baseline variables and outcomes were selected from electronic health records. Primary COVID-19-related admissions were excluded. Regression analysis was conducted to determine outcomes.

RESULTS

Those in the prepandemic group (1976) and pandemic group (1547) were transfused. Fewer RBCs (2186, vs 3337) were used in the prepandemic group than in the pandemic group, respectively. Those in the prepandemic group had significantly higher rates of hypertension and diabetes as well as more smokers. Significant differences were observed when comparing the number of procedures and incidence of sepsis between the patient groups. Similar patterns were observed for the not transfused and transfused subgroups.

CONCLUSIONS

Patient outcomes were not affected after implementing lower Hb pretransfusion thresholds. Although confounding factors were mitigated, some may have been associated with procedures or sepsis. Proactive patient blood management strategies during COVID-19-related blood shortages may include adopting lower Hb thresholds.

Preoperative Correction of Anemia to Allow a 3000 ml Blood Loss Without Transfusion in a Jehovah's Witness Presenting for Explantation of an Infected Hip Joint Prosthesis: A Case Report

A 70-year-old Jehovah's Witness was treated with iron carboxymaltose intravenously, recombinant human erythropoietin alpha subcutaneously, and vitamin B12 and folate orally for 9 weeks to raise hemoglobin (Hb) from 10.8 to 17.0 g/dL before explantation of an infected hip joint prosthesis. The target Hb was calculated from the following formula: Hbtarget = Hbfinal/(1 - ABL/EBV), where Hbtarget= Hb to achieve before surgery, Hbfinal = lowest Hb patient could tolerate taking into consideration his comorbidities (7 g/dL), ABL = volume of blood the surgeon estimated the patient would lose intra- and postoperatively (3000 mL), and EBV = estimated blood volume (75 mL/kg for an adult man). Spinal anesthesia was provided with a single shot hyperbaric bupivacaine and fentanyl. Acute hypervolemic hemodilution was achieved with lactated Ringer's solution and hydroxyethyl starch. To further minimize blood loss, controlled hypotension to a mean blood pressure of 55 mm Hg was achieved with a propofol infusion and tranexamic acid was administered. Surgical blood loss was estimated to be 2500 mL. Hb at the end of surgery was 13.3 g/dL; on postoperative day 5, 11.7 g/L. No blood products were utilized.

Management and prevention of anemia (acute bleeding excluded) in adult critical care patients

OBJECTIVE

Anemia is very common in critical care patients, on admission (affecting about two thirds of patients), but also during and after their stay, due to repeated blood loss, the effects of inflammation on erythropoiesis, a decreased red blood cell life span, and haemodilution. Anemia is associated with severity of illness and length of stay.

METHODS

A committee composed of 16 experts from four scientific societies, SFAR, SRLF, SFTS and SFVTT, evaluated three fields: (1) anaemia prevention, (2) transfusion strategies and (3) non-transfusion treatment of anaemia. Population, Intervention, Comparison, and Outcome (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. Analysis of the literature and formulation of recommendations were then conducted according to the GRADE® methodology.

RESULTS

The SFAR-SRLF guideline panel provided ten statements concerning the management of anemia in adult critical care patients. Acute haemorrhage and chronic anemia were excluded from the scope of these recommendations. After two rounds of discussion and various amendments, a strong consensus was reached for ten recommendations. Three of these recommendations had a high level of evidence (GRADE 1±) and four had a low level of evidence (GRADE 2±). No GRADE recommendation could be provided for two questions in the absence of strong consensus.

CONCLUSIONS

The experts reached a substantial consensus for several strong recommendations for optimal patient management. The experts recommended phlebotomy reduction strategies, restrictive red blood cell transfusion and a single-unit transfusion policy, the use of red blood cells regardless of storage time, treatment of anemic patients with erythropoietin, especially after trauma, in the absence of contraindications and avoidance of iron therapy (except in the context of erythropoietin therapy).

Management and prevention of anemia (acute bleeding excluded) in adult critical care patients

Objective

Anemia is very common in critical care patients, on admission (affecting about two-thirds of patients), but also during and after their stay, due to repeated blood loss, the effects of inflammation on erythropoiesis, a decreased red blood cell life span, and haemodilution. Anemia is associated with severity of illness and length of stay.

Methods

A committee composed of 16 experts from four scientific societies, SFAR, SRLF, SFTS and SFVTT, evaluated three fields: (1) anemia prevention, (2) transfusion strategies and (3) non-transfusion treatment of anemia. Population, Intervention, Comparison, and Outcome (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. Analysis of the literature and formulation of recommendations were then conducted according to the GRADE^® methodology.

Results

The SFAR–SRLF guideline panel provided ten statements concerning the management of anemia in adult critical care patients. Acute haemorrhage and chronic anemia were excluded from the scope of these recommendations. After two rounds of discussion and various amendments, a strong consensus was reached for ten recommendations. Three of these recommendations had a high level of evidence (GRADE 1±) and four had a low level of evidence (GRADE 2±). No GRADE recommendation could be provided for two questions in the absence of strong consensus.

Conclusions

The experts reached a substantial consensus for several strong recommendations for optimal patient management. The experts recommended phlebotomy reduction strategies, restrictive red blood cell transfusion and a single-unit transfusion policy, the use of red blood cells regardless of storage time, treatment of anaemic patients with erythropoietin, especially after trauma, in the absence of contraindications and avoidance of iron therapy (except in the context of erythropoietin therapy).

Erythropoietin as candidate for supportive treatment of severe COVID-19

In light of the present therapeutic situation in COVID-19, any measure to improve course and outcome of seriously affected individuals is of utmost importance. We recap here evidence that supports the use of human recombinant erythropoietin (EPO) for ameliorating course and outcome of seriously ill COVID-19 patients. This brief expert review grounds on available subject-relevant literature searched until May 14, 2020, including Medline, Google Scholar, and preprint servers. We delineate in brief sections, each introduced by a summary of respective COVID-19 references, how EPO may target a number of the gravest sequelae of these patients. EPO is expected to: (1) improve respiration at several levels including lung, brainstem, spinal cord and respiratory muscles; (2) counteract overshooting inflammation caused by cytokine storm/ inflammasome; (3) act neuroprotective and neuroregenerative in brain and peripheral nervous system. Based on this accumulating experimental and clinical evidence, we finally provide the research design for a double-blind placebo-controlled randomized clinical trial including severely affected patients, which is planned to start shortly.

Transfusion strategies in non-bleeding critically ill adults: a clinical practice guideline from the European Society of Intensive Care Medicine

OBJECTIVE

To develop evidence-based clinical practice recommendations regarding transfusion practices in non-bleeding, critically ill adults.

DESIGN

A task force involving 13 international experts and three methodologists used the GRADE approach for guideline development.

METHODS

The task force identified four main topics: red blood cell transfusion thresholds, red blood cell transfusion avoidance strategies, platelet transfusion, and plasma transfusion. The panel developed structured guideline questions using population, intervention, comparison, and outcomes (PICO) format.

RESULTS

The task force generated 16 clinical practice recommendations (3 strong recommendations, 13 conditional recommendations), and identified five PICOs with insufficient evidence to make any recommendation.

CONCLUSIONS

This clinical practice guideline provides evidence-based recommendations and identifies areas where further research is needed regarding transfusion practices and transfusion avoidance in non-bleeding, critically ill adults.

Pharmacotherapy in Acutely Anemic Jehovah’s Witnesses: An Evidence-Based Review

Objective: To determine the pharmacological treatment methods available to anemic Jehovah’s Witnesses (JW). Data Sources: MEDLINE and PubMed were searched from inception through February 2018 using the search terms Jehovah’s Witnesses, treatment, erythropoietin, hemoglobin-based oxygen carrier, Sanguinate, Hemopure, bleeding, and anemia. Study Selection and Data Extraction: All clinical trials, cohort studies, case-control studies, and observational trials involving pharmacotherapy in anemic JW patients were evaluated. Case reports and bibliographies were also analyzed for inclusion. Data Synthesis: Two studies involving the use of erythropoietin (EPO) and one study involving recombinant factor VIIa were included. Information was also included from other pharmacotherapeutic modalities that had case report data only. Current published evidence is limited with regard to evidence-based management of JW patients. High-dose EPO, intravenous iron supplementation, and hemostatic agents have demonstrated good clinical outcomes in case reports. EPO doses as high as 40 000 units daily have been advocated by some experts; however, pharmacokinetic studies do not support dose-dependent effects. Hemoglobin-based oxygen carriers (HBOCs) are currently not Food and Drug Administration approved. They are available through expanded access programs and may represent a lifesaving modality in the setting of severe anemia. Conclusions: There are currently not enough data to make definitive recommendations on the use of pharmacological agents to treat severe anemia in the JW population. Further evidence utilizing EPO and HBOCs will be beneficial to guide therapy.

Blood Product Administration in the Critical Care and Perioperative Settings

The critical care and perioperative settings are high consumers of blood products, with multiple units and different products often given to an individual patient. The recommendation of this review is always to consider the risks and benefits for a specific blood product for a specific patient in a specific clinical setting. Optimize patient status by treating anemia and preventing the need for red blood cell transfusion. Consider other options for correction of anemia and coagulation disorders and use an imperative non-overtransfusion policy for all blood products.

Effects of red blood cell storage time on transfused patients in the ICU-protocol for a systematic review

BACKGROUND

Patients in the intensive care unit (ICU) are often anaemic due to blood loss, impaired red blood cell (RBC) production and increased RBC destruction. In some studies, more than half of the patients were treated with RBC transfusion. During storage, the RBC and the storage medium undergo changes, which lead to impaired transportation and delivery of oxygen and may also promote an inflammatory response. Divergent results on the clinical consequences of storage have been reported in both observational studies and randomised trials. Therefore, we aim to gather and review the present evidence to assess the effects of shorter vs. longer storage time of transfused RBCs for ICU patients.

METHODS

We will conduct a systematic review with meta-analyses and trial sequential analyses of randomised clinical trials, and also include results of severe adverse events from large observational studies. Participants will be adult patients admitted to an ICU and treated with shorter vs. longer stored RBC units. We will systematically search the Cochrane Library, MEDLINE, Embase, BIOSIS, CINAHL and Science Citation Index for relevant literature, and we will follow the recommendation by the Cochrane Collaboration and the Preferred Reporting Items for Systemtic Review and Meta-Analysis (PRISMA)-statement. We will assess the risk of bias and random errors, and we will use the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach to evaluate the overall quality of evidence.

CONCLUSION

We need a high-quality systematic review to summarise the clinical consequences of RBC storage time among ICU patients.

Anemia and Red Blood Cell Transfusion: Advances in Critical Care

Anemia is common in the intensive care unit (ICU), resulting in frequent administration of red blood cell (RBC) transfusions. Significant advances have been made in understanding the pathophysiology of anemia in the ICU, which is anemia of inflammation. This anemia is related to high hepcidin concentrations resulting in iron-restricted erythropoiesis, and decreased erythropoietin concentrations. A new hormone (erythroferrone) has been identified, which mediates hepcidin suppression to allow increased iron absorption and mobilization from iron stores. RBC transfusions are most commonly administered to ICU patients for treatment of anemia. All strategies to reduce anemia in the ICU should be implemented.

Harms of off-label erythropoiesis-stimulating agents for critically ill people

BACKGROUND

Anaemia is a common problem experienced by critically-ill people. Treatment with erythropoiesis-stimulating agents (ESAs) has been used as a pharmacologic strategy when the blunted response of endogenous erythropoietin has been reported in critically-ill people. The use of ESAs becomes more important where adverse clinical outcomes of transfusing blood products is a limitation. However, this indication for ESAs is not licensed by regulatory authorities and is called off-label use. Recent studies concern the harm of ESAs in a critical care setting.

OBJECTIVES

To focus on harms in assessing the effects of erythropoiesis-stimulating agents (ESAs), alone or in combination, compared with placebo, no treatment or a different active treatment regimen when administered off-label to critically-ill people.

SEARCH METHODS

We conducted a systematic search of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, PsycINFO via OvidSP, CINAHL, all evidence-based medicine (EBM) reviews including IPA and SCI-Expanded, Conference Proceedings Citation Index- Science, BIOSIS Previews and TOXLINE up to February 2017. We also searched trials registries, checked reference lists of relevant studies and tracked their citations by using SciVerse Scopus.

SELECTION CRITERIA

We considered randomized controlled trials (RCTs) and controlled observational studies, which compared scheduled systemic administration of ESAs versus other effective interventions, placebo or no treatment in critically-ill people.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened and evaluated the eligibility of retrieved records, extracted data and assessed the risks of bias and quality of the included studies. We resolved differences in opinion by consensus or by involving a third review author. We assessed the evidence using GRADE and created a 'Summary of findings' table. We used fixed-effect or random-effects models, depending on the heterogeneity between studies. We fitted three-level hierarchical Bayesian models to calculate overall treatment effect estimates.

MAIN RESULTS

Of the 27,865 records identified, 39 clinical trials and 14 observational studies, including a total of 945,240 participants, were eligible for inclusion. Five studies are awaiting classification. Overall, we found 114 adverse events in 33 studies (30 RCTs and three observational studies), and mortality was reported in 41 studies (32 RCTs and nine observational studies). Most studies were at low to moderate risk of bias for harms outcomes. However, overall harm assessment and reporting were of moderate to low quality in the RCTs, and of low quality in the observational studies. We downgraded the GRADE quality of evidence for venous thromboembolism and mortality to very low and low, respectively, because of risk of bias, high inconsistency, imprecision and limitations of study design.It is unclear whether there is an increase in the risk of any adverse events (Bayesian risk ratio (RR) 1.05, 95% confidence interval (CI) 0.93 to 1.21; 3099 participants; 9 studies; low-quality evidence) or venous thromboembolism (Bayesian RR 1.04, 95% CI 0.70 to 1.41; 18,917 participants; 18 studies; very low-quality evidence).There was a decreased risk of mortality with off-label use of ESAs in critically-ill people (Bayesian RR 0.76, 95% CI 0.61 to 0.92; 930,470 participants; 34 studies; low-quality evidence).

AUTHORS' CONCLUSIONS

Low quality of evidence suggests that off-label use of ESAs may reduce mortality in a critical care setting. There was a lack of high-quality evidence about the harm of ESAs in critically-ill people. The information for biosimilar ESAs is less conclusive. Most studies neither evaluated ESAs' harm as a primary outcome nor predefined adverse events. Any further studies of ESA should address the quality of evaluating, recording and reporting of adverse events.

Impact of intravascular volume replacement and transfusion on outcome: where are we now?

Intravenous fluid administration is often required to counteract haemodynamic instability during emergency and elective surgeries, as well as in the intensive care unit. However, the best type and the amount of fluid required are controversial. A recent meta-analysis suggested that there is no difference among different types of colloids on outcome. Furthermore, colloids and crystalloids seem to be comparable in terms of efficiency in reverting haemodynamic instability, as well as morbidity and mortality. The interpretation of the results of different randomised controlled trials is somewhat difficult - the context must be always kept in mind. For example, results may differ in septic as compared to non-septic patient populations. Another important aspect concerns the effects on the macro- versus microcirculation. More recent studies emphasise that the microcirculation has to be taken into account when studying and interpreting the interaction between fluid therapy and the underlying disease. Nevertheless, the macrocirculation and clinical parameters have to be considered as well. Given that red blood cells remain the most important oxygen carriers, recent evidence regarding blood age may stimulate new studies according to the actual range for blood storage. Artificial oxygen carriers may play a role in specific situations, where the transfusion is indicated but the access to blood is problematic, but there is doubt that they may replace blood transfusion.

Impact of erythropoietin on intensive care unit patients

Anemia is common in intensive care unit (ICU) patients. Red blood cell (RBC) transfusions are mainstays of their treatment and can be life-saving. Allogeneic blood components inherently bear risks of infection and immune reactions. Although these risks are rare in developed countries, recombinant human erythropoietin (rhEpo) and other erythropoiesis-stimulating agents (ESAs) have been considered alternative anti-anemia treatment options. As summarized herein, however, most of the clinical studies suggest that ESAs are not usually advisable in ICU patients unless approved indications exist (e.g., renal disease). First, ESAs act in a delayed way, inducing an increase in reticulocytes only after a lag of 3-4 days. Second, many critically ill patients present with ESA resistance as inflammatory mediators impair erythropoietic cell proliferation and iron availability. Third, the ESA doses used for treatment of ICU patients are very high. Fourth, ESAs are not legally approved for general use in ICU patients. Solely in distinct cases, such as Jehovah's Witnesses who refuse allogeneic blood transfusions due to religious beliefs, ESAs may be considered an exceptional therapy.

Safety of off-label erythropoiesis stimulating agents in critically ill patients: a meta-analysis

PURPOSE

Erythropoiesis stimulating agents (ESAs) are used to treat anemia in critically ill patients. This indication is off-label, because it is not licensed by regulatory authorities. Recently ESAs were suspected to harm critically ill patients. Our objective was to assess the safety of ESAs in off-label indications in critically ill patients.

METHODS

Eleven databases were searched up to April 2012. We considered randomized controlled trials (RCTs) and controlled observational studies in any language that compared off-label ESAs treatment with other effective interventions, placebo or no treatment in critically ill patients. Two authors independently screened and evaluated retrieved records, extracted data and assessed risk of bias and quality of reporting.

RESULTS

We used frequentist and Bayesian models to combine studies, and performed sensitivity and subgroup analyses. From 12,888 citations, we included 48 studies (34 RCTs; 14 observational), involving 944,856 participants. Harm reporting was of medium to low quality. There was no statistically significant increased risk of adverse events in general, serious adverse events, the most frequently reported adverse events, and death in critically ill patients treated with ESAs. These results were robust against risk of bias and analysis methods. There is evidence that ESAs increase the risk of clinically relevant thrombotic vascular events, and there is some less certain evidence that ESAs might increase the risk for venous thromboembolism.

CONCLUSIONS

In critically ill patients, administration of ESAs is associated with a significant increase in clinically relevant thrombotic vascular events but not with other frequently reported adverse events and death.

The use of erythropoiesis-stimulating agents in the intensive care unit

Anemia is common in critically ill patients, but treatment with red blood cell transfusions can have unwanted effects. Limiting the occurrence and severity of anemia by using erythropoietic agents (iron and/or recombinant erythropoietin), therefore, remains an attractive option during the intensive care unit stay but also after hospital discharge. Moreover, these agents may have additional beneficial properties. In this article the authors review the rationale for the administration of iron and/or erythropoietin in critically ill patients.

Erythropoietin in the critically ill: do we ask the right questions?

There is a plethora of experimental data on the potential therapeutic benefits of recombinant human erythropoietin (rhEPO) and its synthetic derivatives in critical care medicine, in particular in ischemia/reperfusion injury. Most of the recent clinical trials have not shown clear benefits, and, in some patients, EPO-aggravated morbidity and mortality was even reported. Treatment with rhEPO has been successfully used in patients with anemia resulting from chronic kidney disease, but even a subset of this patient population does not adequately respond to rhEPO therapy. The following viewpoint uses rhEPO as an example to highlight the possible pitfalls in current practice using young healthy animals for the evaluation of therapies to treat patients of variable age and underlying chronic co-morbidity.

Polysaccharide hemostatic system reduces blood loss in high-body-mass-index patients undergoing simultaneous bilateral total knee arthroplasty

BACKGROUND

To investigate the efficacy of a topically applied hemostatic agent used to reduce blood loss in patients undergoing simultaneous bilateral total knee arthroplasty (TKA).

METHODS

Thirty-two patients (5 male, 27 female) mean age 65 ± 9.3 (46-80) undergoing single-stage bilateral TKA were enrolled in the study and divided in two groups. Groups 1 and 2 consisted of patients with body mass index (BMI) <30 and >30, respectively. Polysaccharide hemostatic agent (PHA; 3 g) was applied topically to the right knees of each patient intraoperatively. The left knees were used as controls. A negative suction drain was used and the effect of PHA and BMI on postoperative bleeding was evaluated.

RESULTS

Blood loss was significantly higher (p = 0.027, r = 0.397) for patients with higher BMI. Treatment by local application of PHA to potential bleeding sites significantly reduced blood loss-314 ± 151 ml (50-600) for the right knees versus 468 ± 140 ml (150-700) for the left knees (p = 0.007) in group 1; 420 ± 251 ml (100-900) for the right knees versus 620 ± 229 ml (350-1125) for the left knees (p = 0.036) in group 2. Blood loss reduction between the right and left knees was no different between the two groups (p = 0.173).

CONCLUSIONS

By reducing blood loss and the need for postoperative blood transfusion in patients with high BMI, PHA can be of value as adjuvant therapy in new blood-management procedures in major joint-replacement surgery.

Rupture of chronic type B aortic dissection in a Jehovah's Witness: successful surgical repair without blood transfusion

The patient, a 55-year-old female Jehovah's Witness who had suffered type B aortic dissection since the age of 53 years, presented with enlargement of the false lumen in the distal aortic arch and was subsequently admitted to our hospital. While hospitalized, her enlarged false lumen ruptured and she underwent replacement of the distal aortic arch and descending thoracic aorta without blood transfusion. Blood conservation strategies for this patient included the following: 1) meticulous hemostasis when incising muscle or soft tissue, 2) minimal use of gauze and discard suckers, 3) exclusive use of a cell salvage device "from skin to skin," 4) low-prime cardiopulmonary bypass, 5) minimal laboratory blood sampling, and 6) preoperative and postoperative erythropoietin treatment. Hemoglobin (Hb) values were 12.5, 15.5, 10.0, and 9.7 g/dL on admission, before rupture, after rupture, and just after the operation, respectively. The patient had an uneventful postoperative course, except for prolonged rehabilitation. The postoperative lowest Hb value was 5.2 g/dL on postoperative day 5, and the Hb value at hospital discharge (postoperative day 55) was 11.0 g/dL. Our experience with blood conservation surgery on this Jehovah's Witness patient suggests that ruptured chronic type B aortic dissection can be safely repaired on bypass through a left thoracotomy with no blood transfusion if the preoperative Hb value is >10.0 g/dL.

Erythropoietin prevents sepsis-related acute kidney injury in rats by inhibiting NF-κB and upregulating endothelial nitric oxide synthase

The pathophysiology of sepsis involves complex cytokine and inflammatory mediator networks, a mechanism to which NF-κB activation is central. Downregulation of endothelial nitric oxide synthase (eNOS) contributes to sepsis-induced endothelial dysfunction. Erythropoietin (EPO) has emerged as a major tissue-protective cytokine in the setting of stress. We investigated the role of EPO in sepsis-related acute kidney injury using a cecal ligation and puncture (CLP) model. Wistar rats were divided into three primary groups: control (sham-operated); CLP; and CLP+EPO. EPO (4,000 IU/kg body wt ip) was administered 24 and 1 h before CLP. Another group of rats received N-nitro-l-arginine methyl ester (l-NAME) simultaneously with EPO administration (CLP+EPO+l-NAME). A fifth group (CLP+EPOtreat) received EPO at 1 and 4 h after CLP. At 48 h postprocedure, CLP+EPO rats presented significantly higher inulin clearance than did CLP and CLP+EPO+l-NAME rats; hematocrit levels, mean arterial pressure, and metabolic balance remained unchanged in the CLP+EPO rats; and inulin clearance was significantly higher in CLP+EPOtreat rats than in CLP rats. At 48 h after CLP, creatinine clearance was significantly higher in the CLP+EPO rats than in the CLP rats. In renal tissue, pre-CLP EPO administration prevented the sepsis-induced increase in macrophage infiltration, as well as preserving eNOS expression, EPO receptor (EpoR) expression, IKK-α activation, NF-κB activation, and inflammatory cytokine levels, thereby increasing survival. We conclude that this protection, which appears to be dependent on EpoR activation and on eNOS expression, is attributable, in part, to inhibition of the inflammatory response via NF-κB downregulation.

When a patient refuses life-saving care: issues raised when treating a Jehovah's Witness

Patients who are Jehovah's Witnesses frequently cross the path of nephrologists when they are acutely ill in the intensive care unit and stable in the long-term setting. It is important that we as a group have a rudimentary understanding of their philosophy about blood transfusion so that we can be proactive in their management. We use a case as a launching point to discuss the origins of the faith and the decision to refuse blood, as well as potential therapeutic strategies that can be used to improve the care of these patients. Improvement in our understanding as physicians will facilitate a more productive conversation with our patients about a complex and emotional issue.

Is there a relationship between bone and critical illness?

Critical illness is a result of a series of severe diseases of complicated causes. Although accumulating therapeutic strategies have been carried out for the prevention and treatment of critical illness, mortality remains high. Inflammations, electrolyte disturbances, hyperglycemia, and depressed immune function are factors that may be responsible. Recent studies have suggested that the bone influences hematopoiesis, immunity, and metabolism. Published data and our own work have led us to hypothesize that the bone plays an important role in the pathogenesis and outcome of critical illness.

Anemia and transfusion therapy: an update

Anemia is one of the most prevalent diseases in the general population and is a very frequently found condition in medical and surgical patients in all medical specialties. A good evaluation of its clinical impact and its therapeutic possibilities is essential. Allogenic blood transfusion is a useful procedure in anemia management, although it has important adverse effects. It is the responsibility of the clinician to know and to take into account all the available alternatives for the treatment of anemia. Blood transfusions, erythropoiesis-stimulating agents, iron therapy (oral and endovenous) and other therapeutic alternatives must be rationally used, in accordance with the currently available clinical evidence. This review article summarizes some epidemiological characteristics of anemia, its clinical evaluation and the main therapeutic possibilities based on the present knowledge, placing special emphasis on the critically ill patient.

Erythropoetin as a novel agent with pleiotropic effects against acute lung injury

Current pharmacotherapy for acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) is not optimal, and the biological and physiological complexity of these severe lung injury syndromes requires consideration of combined-agent treatments or agents with pleiotropic action. In this regard, exogenous erythropoietin (EPO) represents a possible candidate since a number of preclinical studies have revealed beneficial effects of EPO administration in various experimental models of ALI. Taken together, this treatment strategy is not a single mediator approach, but it rather provides protection by modulating multiple levels of early signaling pathways involved in apoptosis, inflammation, and peroxidation, potentially restoring overall homeostasis. Furthermore, EPO appears to confer vascular protection by promoting angiogenesis. However, only preliminary studies exist and more experimental and clinical studies are necessary to clarify the efficacy and potentially cytoprotective mechanisms of EPO action. In addition to the attempts to optimize the dose and timing of EPO administration, it would be of great value to minimize any potential toxicity, which is essential for EPO to fulfill its role as a potential candidate for the treatment of ALI in routine clinical practice. The present article reviews recent advances that have elucidated biological and biochemical activities of EPO that may be potentially applicable for ALI/ARDS management.

Bench to bedside: A role for erythropoietin in sepsis

Sepsis is the systemic inflammatory response to infection and can result in multiple organ dysfunction syndrome with associated high mortality, morbidity and health costs. Erythropoietin is a well-established treatment for the anaemia of renal failure due to its anti-apoptotic effects on red blood cells and their precursors. The extra-haemopoietic actions of erythropoietin include vasopressor, anti-apoptotic, cytoprotective and immunomodulating actions, all of which could prove beneficial in sepsis. Attenuation of organ dysfunction has been shown in several animal models and its vasopressor effects have been well characterised in laboratory and clinical settings. Clinical trials of erythropoietin in single organ disorders have suggested promising cytoprotective effects, and while no randomised trials have been performed in patients with sepsis, good quality data exist from studies on anaemia in critically ill patients, giving useful information of its pharmacokinetics and potential for harm. An observational cohort study examining the microvascular effects of erythropoietin is underway and the evidence would support further phase II and III clinical trials examining this molecule as an adjunctive treatment in sepsis.

[Anemia and transfusion therapy: an update]

Anemia is one of the most prevalent diseases in the general population and is a very frequently found condition in medical and surgical patients in all medical specialties. A good evaluation of its clinical impact and its therapeutic possibilities is essential. Allogenic blood transfusion is a useful procedure in anemia management, although it has important adverse effects. It is the responsibility of the clinician to know and to take into account all the available alternatives for the treatment of anemia. Blood transfusions, erythropoiesis-stimulating agents, iron therapy (oral and endovenous) and other therapeutic alternatives must be rationally used, in accordance with the currently available clinical evidence. This review article summarizes some epidemiological characteristics of anemia, its clinical evaluation and the main therapeutic possibilities based on the present knowledge, placing special emphasis on the critically ill patient.

Lipopolysaccharide evokes resistance to erythropoiesis induced by the long-acting erythropoietin analogue darbepoetin alfa in rats

BACKGROUND

Anemia is common in patients with sepsis but its mechanism is unknown. We tested the hypothesis that effects on erythropoiesis evoked by darbepoetin alfa (DA), a long-acting erythropoietin analog, are diminished by lipopolysaccharide (LPS).

METHODS

We performed a prospective, controlled, randomized animal study (male Lewis rats n = 44). The interventions we used were intraperitoneal injection of Escherichia coli LPS (10 mg/kg) or vehicle followed by either DA (25 microg/kg) or vehicle (four experimental groups). Blood and reticulocyte counts and variables of iron metabolism were measured at baseline and 3 and 14 days after interventions.

RESULTS

Animals treated with DA alone showed an eightfold increase in reticulocyte count from baseline on Day 3, whereas no increase was seen in animals administered LPS or LPS/DA. On Day 14, the red blood cell count and hemoglobin concentration had increased by approximately 10% from baseline (P < 0.001) in the DA group but had decreased after LPS on Days 3 and 14 (P < 0.05) and in animals administered LPS/DA. Consumption of iron was seen on Day 3 in the DA group but not after LPS or LPS/DA combined. Values of ferritin and transferrin did not change between groups.

CONCLUSION

LPS abolishes erythropoiesis and iron use evoked by DA and this is accompanied by a decrease in hemoglobin concentration and red blood cell concentration. Accordingly, endotoxin suppresses DAs ability to increase erythropoiesis.

Therapeutic effects of erythropoietin in murine models of endotoxin shock

OBJECTIVE

Erythropoietin has recently emerged as a cytoprotective cytokine, which possesses the ability to protect many tissues, including the brain, heart, and kidneys, against ischemia or traumatic injury. We investigated the therapeutic effects of erythropoietin in a murine model of endotoxin shock.

DESIGN

Prospective, randomized study.

SETTING

University-based research laboratory.

SUBJECTS

Male BALB/c mice.

INTERVENTIONS

Mice intraperitoneally received either lipopolysaccharide (LPS) from Escherichia coli or vehicle. Erythropoietin was administered at a dose of 1000 IU/kg subcutaneously at different time points after LPS administration. We also investigated the effect of erythropoietin on the development of septic shock caused by cecal perforation.

MEASUREMENTS AND MAIN RESULTS

Treatment of mice with erythropoietin, within 2 hours after LPS administration, improved the mortality rate. Treatment of cecal perforated mice with erythropoietin extended survival by 12 hours, but all animals died by 72 hours in both groups. Erythropoietin attenuated apoptosis in the lungs, liver, small intestine, thymus, and spleen, as assessed by terminal deoxynucleotidyl transferase-mediated nucleotide nick-end labeling staining, active caspase-3 immunostaining and immunoblotting, and measurements of caspase-3/7 activity. Erythropoietin also reduced inducible nitric oxide synthase expression, nitric oxide production, peroxynitrite formation, and tissue hypoxia. In contrast, erythropoietin did not affect the degree of LPS-induced inflammation, as assessed by measurements of blood levels of interleukin-1beta, interleukin-6, tumor necrosis factor-alpha, growth-related oncogene/keratinocyte-derived cytokine, and high mobility group box 1, the phosphorylation levels of nuclear factor kappaB, and the number of neutrophils infiltrating the lungs and the liver.

CONCLUSIONS

The results of the study demonstrate that administration of a large dose of erythropoietin after induction of experimental endotoxemia improved survival and that the beneficial effects of erythropoietin were associated with inhibition of apoptosis, nitric oxide production, and tissue hypoxia, without alterations in inflammatory responses.

[Is there still a role for recombinant erythropoietin in the management of anaemia of critical illness?]

There is a high prevalence of anaemia among patients admitted to the intensive care unit (ICU), and it may have a negative effect on patient's outcome. The most common treatment for anaemia in the ICU patient is allogeneic blood transfusion (ABT), yet it has been found to be a risk factor associated with an increased risk of morbidity and mortality in critical care patients. As a reduction of erythropoietin secretion and action is observed in most ICU patients, the administration of (rHuEPO) has emerged as a therapeutic option. Unfortunately, the results from different studies show that rHuEPO treatment results in a small reduction of ABT requirements when "restrictive" transfusion criteria are applied, which has only been supported by three of the studies. Yet this did not result in a decreased mortality rate, except for patients with a diagnosis on admission of trauma in two studies, even though one study reported a dose-dependent increase of thrombotic vascular events among patients without thromboprophylaxis. Altogether, clinical data suggest a role for rHuEPO in the treatment of anaemia in trauma patients, especially in those sustaining neurotrauma, whereas for non-trauma patients without an approved indication, rHuEPO administration is an expensive approach, does not seem to improve outcome, and might result in serious adverse effects. Consequently, more basic and clinical studies are required to ascertain which patients are more likely to benefit from these treatments, as well as to identify the optimal doses and administration schedules, and iron administration.

The role of erythropoietin in the acute phase of trauma management: evidence today

Trauma patients often present in a state of haemorrhagic shock. Blood products remain the gold standard of resuscitation, but allogeneic blood transfusions (ABTs) are associated with several risks. The stimulating effect of recombinant-erythropoietin (EPO-A) on erythropoiesis has raised interest in its administration as an alternative. The existing evidence on the early use of EPO-A in the acute phase of trauma patients management consists of only 14 publications. The level of evidence of these studies and the number of treated patients was not found to be adequate to support its generalised use, despite their favourable results. Its safety profile, the preliminary proofs of its efficacy, and the additional cyto-protective properties of EPO-A strongly encourage further controlled studies assessing its use in the acute setting of initial trauma management.

Year in review 2007: Critical Care--shock

The research papers on shock published in Critical Care throughout 2007 are related to three major subjects: the modulation of the macrocirculation and microcirculation during shock, focusing on arginine vasopressin, erythropoietin and nitric oxide; studies on metabolic homeostasis (acid–base status, energy expenditure and gastrointestinal motility); and basic supportive measures in critical illness (fluid resuscitation and sedation, and body-temperature management). The present review summarizes the key results of these studies and provides a brief discussion in the context of the relevant scientific and clinical background.

Erythropoietin during porcine aortic balloon occlusion-induced ischemia/reperfusion injury

BACKGROUND

Aortic occlusion causes ischemia/reperfusion injury, kidney and spinal cord being the most vulnerable organs. Erythropoietin improved ischemia/reperfusion injury in rodents, which, however, better tolerate ischemia/reperfusion than larger species. Therefore, we investigated whether erythropoietin attenuates porcine aortic occlusion ischemia/reperfusion injury.

MATERIALS AND METHODS

Before occluding the aorta for 45 mins by inflating intravascular balloons, we randomly infused either erythropoietin (n = 8; 300 IU/kg each over 30 mins before and during the first 4 hrs of reperfusion) or vehicle (n = 6). During aortic occlusion, mean arterial pressure was maintained at 80% to 120% of baseline by esmolol, nitroglycerine, and adenosine 5'-triphosphate. During reperfusion, noradrenaline was titrated to keep mean arterial pressure >80% of baseline. Kidney perfusion and function were assessed by fractional Na-excretion, p-aminohippuric acid and creatinine clearance, spinal cord function by lower extremity reflexes and motor evoked potentials. Blood isoprostane levels as well as blood and tissue catalase and superoxide dismutase activities allowed evaluation of oxidative stress. After 8 hrs of reperfusion, kidney and spinal cord specimens were taken for histology (hematoxylin-eosin, Nissl staining) and immunohistochemistry (TUNEL assay for apoptosis).

RESULTS

Parameters of oxidative stress and antioxidative activity were comparable. Erythropoietin reduced the noradrenaline requirements to achieve the hemodynamic targets and may improve kidney function despite similar organ blood flow, histology, and TUNEL staining. Neuronal damage and apoptosis was attenuated in the thoracic spinal cord segments without improvement of its function.

CONCLUSION

During porcine aortic occlusion-induced ischemia/reperfusion erythropoietin improved kidney function and spinal cord integrity. The lacking effect on spinal cord function was most likely the result of the pronounced neuronal damage associated with the longlasting ischemia.

Beneficial effects of erythropoietin in preclinical models of shock and organ failure

Erythropoietin protects many organs against the tissue injury and dysfunction caused by ischaemia/reperfusion and excessive inflammation. This editorial comment discusses the effects of erythropoietin in preclinical models of septic shock, endotoxemia, hemorrhagic shock, spinal cord trauma and zymosan-induced multiple organ failure.

[Prevalence and treatment of anemia in critically ill patients]

Anemia is a common condition among medical and surgical patients admitted to the intensive care unit (ICU) and generally has a multifactorial origin. In order to avoid the deleterious effects of anemia, 40% of ICU patients receive allogenic blood transfusion (ABT). This figure increases up to 70% if the ICU stay is longer than 7 days. However, ABT is associated with a dose-dependent increase in morbidity and mortality. In contrast, the administration of exogenous erythropoietin plus iron supplements, especially iv iron, improves anemia and reduces ABT requirements, although it does not reduce mortality. To ascertain whether treatment of anemia in the critically ill with exogenous erythropoietin and iron might improve outcomes and to optimize drug administration schedules and dosage, further studies with sufficient statistical power and adequate follow-up are warranted.

Blood management: a primer for clinicians

Blood transfusions are common in the hospital setting. Despite the large commitment of resources to the delivery of blood components, many clinicians have only a vague understanding of the complexities associated with blood management and transfusion therapy. The purpose of this primer is to broaden the awareness of health care practitioners in terms of the risks versus benefits of blood transfusions, their economics, and alternative treatments. By developing and implementing comprehensive blood management programs, hospitals can promote safe and clinically effective blood utilization practices. The cornerstones of blood management programs are the implementation of evidence-based transfusion guidelines to reduce variability in transfusion practice, and the employment of multidisciplinary teams to study, implement, and monitor local blood management strategies. Pharmacists can play a key role in blood management programs by providing technical expertise as well as oversight and monitoring of pharmaceutical agents used to reduce the need for allogeneic blood.

Impact of delayed initiation of erythropoietin in critically ill patients

Background

The purpose of this study was to evaluate the impact of recombinant human erythropoietin (rHuEPO) use for anemia of critical illness at a practice site where delayed initiation is common.

Methods

Retrospective medical record review involving patients treated with rHuEPO for anemia of critical illness. Those patients given rHuEPO or diagnosed with end-stage renal disease (ESRD) prior to ICU admission were excluded. The primary endpoints were rHuEPO use and RBC transfusion patterns.

Results

Complete data were collected for consecutive admissions of 126 patients. Average age (SD) and APACHE II score were 56.5 (18.6) years and 25 (7.8), respectively. The median ICU (IQR) and hospital length of stay (LOS) were 24 (11.25, 39) and 29 (17, 44.75) days, respectively. Treatment with rHuEPO was started an average of 12.5 +/- 10.5 days after ICU admission and given for 3.8 +/- 3.8 doses. Eighty percent of patients were transfused with an average total of 5.42 +/- 5.08 units received. RBC exposure inversely correlated with a lower mean hemoglobin response to rHuEPO. ICU LOS (p < 0.0001), hemoglobin at 24 hours (p = 0.055), transfusion within 48 hours of admit (p < 0.0001), and postoperative status (p = 0.019) were the best predictors of transfusion requirements (r² = 0.37).

Conclusion

Delayed initiation of rHuEPO for anemia of critical illness resulted in comparable hemoglobin and transfusion benefits. Future studies are needed to establish clinical benefit and role in therapy. RBC exposure may blunt the erythropoietic effects of rHuEPO, potentially frustrating benefits to those of greatest apparent need.