Aetiology of Preoperative Anaemia in Patients Undergoing Elective Cardiac Surgery—the Challenge of Pillar One of Patient Blood Management

Preoperative anaemia is common in patients undergoing cardiac surgery. Whilst there is a strong association with increased morbidity and mortality, it is currently unclear whether treatment of anaemia leads to patient benefit. This retrospective study aimed to determine the aetiology of preoperative anaemia in a cohort of patients undergoing elective cardiac surgery over two years at a tertiary hospital. Laboratory data obtained at the preoperative assessment clinic visit were assessed to stratify patients into four groups—iron deficiency anaemia (IDA), possible IDA, anaemia of chronic disease (ACD) and non-anaemic patients with low ferritin according to the ‘Preoperative haemoglobin assessment and optimisation template’ of the Australian Patient Blood Management (PBM) Guidelines. Of patients with preoperative anaemia, 23.1% had IDA, 6.6% had possible IDA and 70.3% had possible ACD. Of the patients with possible ACD, 30% had a ferritin <100 μg/l, representing limited iron stores or coexisting absolute iron deficiency in the setting of chronic disease. In addition, 46.2% of those with possible ACD had iron studies indicative of functional iron deficiency. Time between assessment and surgery was as little as one day in a third of patients and in only 7% was it more than seven days. Our findings indicate that about one-third of our patients with preoperative anaemia had evidence of iron deficiency, a potentially reversible cause of anaemia. In addition, a significant number had either limited iron stores that may render them iron deficient by surgery, or a functional iron deficiency.

Download Full-text

Functional iron deficiency markers are absent during pregnancy despite evidence of low iron stores

Annals of Clinical Biochemistry International Journal of Laboratory Medicine ◽

10.1177/0004563219837290 ◽

2019 ◽

Vol 56 (4) ◽

pp. 450-456 ◽

Cited By ~ 2

Author(s):

Martijn WHJ Demmers ◽

Marijke Niens ◽

Gerrie van der Haar ◽

Hester J van der Zaag-Loonen ◽

Johannes JML Hoffmann ◽

...

Keyword(s):

Iron Deficiency ◽

Pregnant Women ◽

Univariate Analysis ◽

Mean Cell Volume ◽

Functional Iron Deficiency ◽

Iron Stores ◽

Iron Deficient ◽

Haemoglobin Content ◽

Maternal Iron ◽

Reticulocyte Haemoglobin Content

Introduction Functional iron deficiency parameters predict iron-restricted erythropoiesis more precisely than ferritin. Ferritin and erythropoiesis can be affected by inflammation and hormonal alterations. We hypothesize that the association between low ferritin concentrations and iron-restricted erythropoiesis is not comparable between pregnant and non-pregnant women. Materials and methods Pregnant women ( n = 926) were included at week 12 of gestation. Ferritin concentrations, %hypochromic erythrocytes (%HYPO), %microcytic erythrocytes (%MICRO), reticulocyte haemoglobin content (MCHr), mean cell volume (MCV) and mean cell haemoglobin (MCH) were analysed. Data were compared with non-pregnant women ( n = 1302). Results Functional iron deficiency parameters (%HYPO, %MICRO, MCHr) were present in, respectively, 3.9%, 14.3% and 2.3% off all pregnant women. Univariate analysis of low ferritin (<20 μg/L) showed significant differences between non-pregnant versus pregnant women; %HYPO (10.92% vs. 0.92%), increased %MICRO (4.33% vs. 1.00%) and decreased MCHr (24.9 pg vs. 29.5 pg), respectively. In the logistic regression analysis, MCHr, %MICRO and MCV were independently associated with low ferritin concentrations in pregnant women, while %HYPO and %MICRO were independently associated variables in non-pregnant women with low ferritin concentrations. Discussion Functional iron deficiency is significantly less frequent in pregnant women compared with iron-deficient non-pregnant women. During pregnancy, iron metabolism might be differentially regulated for optimal fetal growth and development despite low maternal iron stores.

Download Full-text

Iron Deficiency and Erythropoiesis: New Diagnostic Approaches

Clinical Chemistry ◽

10.1373/49.10.1573 ◽

2003 ◽

Vol 49 (10) ◽

pp. 1573-1578 ◽

Cited By ~ 322

Author(s):

Carlo Brugnara

Keyword(s):

Chronic Disease ◽

Iron Deficiency ◽

Transferrin Saturation ◽

Microcytic Anemia ◽

Deficiency Anemia ◽

Anemia Of Chronic Disease ◽

Body Iron ◽

Iron Stores ◽

Human Erythropoietin ◽

Iron Deficient

Abstract Iron deficiency anemia is one of the most common diseases worldwide. In the majority of cases, the presence of hypochromic microcytic anemia and biochemical evidence for depletion of body iron stores makes the diagnosis relatively straightforward. However, in several clinical conditions, classic biochemical indices such as serum iron, transferrin saturation, and ferritin may not be informative or may not change rapidly enough to reflect transient iron-deficient states (functional iron deficiency), such as the ones that develop during recombinant human erythropoietin (r-HuEPO) therapy. The identification and treatment of iron deficiency in settings such as r-HuEPO therapy, anemia of chronic disease, and iron deficiency of early childhood may be improved by the use of red cell and reticulocyte cellular indices, which reflect in almost real time the development of iron deficiency and the response to iron therapy. In the anemia of chronic disease, measurements of plasma cytokines and iron metabolism regulators such as hepcidin (when available) may be helpful in the characterization of the pathophysiologic basis of this condition. The ratio of serum transferrin receptor (sTfR) to serum ferritin (R/F ratio) has been shown to have excellent performance in estimating body iron stores, but it cannot be used widely because of the lack of standardization for sTfR assays. The combination of hematologic markers such as reticulocyte hemoglobin content, which decreases with iron deficiency, and R/F ratio may allow for a more precise classification of anemias.

Download Full-text

Socio-economic assessment of patient blood management practical implementation in surgical treatment of coronary heart disease (I20–I25)

Kardiologiia ◽

10.18087/cardio.2021.3.n1557 ◽

2021 ◽

Vol 61 (3) ◽

pp. 77-86

Author(s):

E. Z. Golukhova ◽

A. A. Kupryashov ◽

G. A. Khicheva ◽

E. V. Kuksina ◽

O. I. Volkova ◽

...

Keyword(s):

Cardiac Surgery ◽

Heart Disease ◽

Iron Deficiency ◽

Iron Deficiency Anemia ◽

Deficiency Anemia ◽

Economic Damage ◽

Routine Practice ◽

Years Of Life Lost ◽

Patient Blood Management ◽

Blood Management

Aim To evaluate possible social and economic benefits of correcting preoperative iron deficiency /iron deficiency anemia as a comorbidity in a model population in the process of transition from the routine practice to the optimized preparation of patients to elective surgery (as exemplified by several circulatory diseases: I20 – I25, class IX ICD 10).Material and methods By building imitation models depending on the patient blood management (PBM) practice, changes in years of life lost/saved adjusted for disability were evaluated, including in monetary terms, in relation to the annual number of operations performed for ischemic heart disease (IHD) (I20 – I25) in the age group of 17 years and older, as well as a potential effect of PBM on the applied health economics.Results With implementation of the PBM systemic measures in cardiac surgery, the potentially prevented annual social and economic damage will amount to more than 38 thousand years of life saved and more than 20.2 billion rubles in monetary terms. Furthermore, it will be possible to exclude 9435 hemotransfusion from the cardiosurgical practice, which will annually save more than 2.3 thousand liters of blood with a total cost of 77.7 million rubles in favor of clinical situations that have no alternative.Conclusion The implementation of PBM in cardiac surgery, the discipline with the highest levels of preoperative iron deficiency/anemia and the use of blood components, will not only improve the clinical outcomes and cost-effectiveness of surgical interventions, but will also prevent social and economic damage to the country.

Download Full-text

Optimal patient blood management in cardiac surgery using viscoelastic point-of-care testing

British Journal of Anaesthesia ◽

10.1093/bja/aex284 ◽

2017 ◽

Vol 119 (3) ◽

pp. 544-545 ◽

Cited By ~ 2

Author(s):

E.A. Vlot ◽

S. Rigter ◽

P.G. Noordzij

Keyword(s):

Cardiac Surgery ◽

Point Of Care ◽

Patient Blood Management ◽

Blood Management ◽

Point Of Care Testing

Download Full-text

Reticulocyte hemoglobin measurement – comparison of two methods in the diagnosis of iron-restricted erythropoiesis

Clinical Chemistry and Laboratory Medicine (CCLM) ◽

10.1515/cclm.2005.207 ◽

2005 ◽

Vol 43 (11) ◽

Cited By ~ 67

Author(s):

Lothar Thomas ◽

Susanne Franck ◽

Maren Messinger ◽

Jo Linssen ◽

Marcus Thomé ◽

...

Keyword(s):

Chronic Disease ◽

Iron Deficiency ◽

Biochemical Markers ◽

Iron Status ◽

Anemia Of Chronic Disease ◽

Forward Scatter ◽

Functional Iron Deficiency ◽

Hematology Analyzer ◽

Advia 120 ◽

Hemoglobin Measurement

AbstractThe aims of this study were to diagnose iron-restricted erythropoiesis (functional iron deficiency) in patients with classic iron deficiency (ID), anemia of chronic disease (ACD) and the combined state of ID/ACD with the use of two hematological methods for the measurement of reticulocyte hemoglobinization. In comparison, the biochemical markers of iron status were determined. We studied 474 anemic patients admitted to hospital with a broad spectrum of diseases. We measured indicators of reticulocyte hemoglobinization. CHr was determined on an Advia 120 hematology analyzer. A Sysmex XE-2100 hematology analyzer was used to determine RET-Y, the forward scatter of fluorescence-labeled reticulocytes, which can also be expressed as the reticulocyte hemoglobin equivalent (RET-H

Download Full-text

Patient blood management strategies in cardiac surgery

State of the Art Surgical Coronary Revascularization ◽

10.1093/med/9780198758785.003.0037 ◽

2021 ◽

pp. 217-224

Author(s):

Aryeh Shander ◽

Victor A. Ferraris

Keyword(s):

Cardiac Surgery ◽

Blood Transfusion ◽

Management Strategies ◽

Patient Blood Management ◽

Blood Management ◽

Cardiac Surgery Patient ◽

Surgery Patient ◽

Surgery Management

This chapter discusses patient blood management strategies in cardiac surgery, including sections on the burden of anaemia in cardiac surgery, blood transfusion in cardiac surgery, patient blood management in cardiac surgery (management of anaemia, optimization of haemostasis, autotransfusion techniques, and other supportive measures), and outcomes of patient blood management programmes.

Download Full-text

Severe iron deficiency anaemia

Emergencies in Gastroenterology and Hepatology ◽

10.1093/med/9780199231362.003.0003 ◽

2013 ◽

pp. 35-42

Author(s):

Daniel Marks ◽

Marcus Harbord

Keyword(s):

Chronic Disease ◽

Iron Deficiency ◽

Blood Loss ◽

Iron Deficiency Anaemia ◽

Parasite Load ◽

Deficiency Anaemia ◽

Iron Stores ◽

Menopausal Women ◽

Post Menopausal ◽

Developed World

Implication of iron deficiency Causes of iron deficiency Overt or occult bleeding Diagnosing iron deficiency Presentation and investigations Treatment Anaemia of chronic disease In the developed world, the commonest cause of iron deficiency anaemia (IDA) and its prelude iron deficiency is menstrual blood loss. Worldwide, hookworm infection is prevalent and causes IDA in those with heavy parasite load. About 4% of men/post-menopausal women have iron deficiency, and 1–2% have related IDA. Iron deficiency rises to ~20% in pre-menopausal women (remainder often have considerably reduced iron stores)....

Download Full-text

The Treatment of Iron Deficiency Anemia

Blood ◽

10.1182/blood.v10.6.567.567 ◽

1955 ◽

Vol 10 (6) ◽

pp. 567-581 ◽

Cited By ~ 38

Author(s):

DANIEL H. COLEMAN ◽

ALEXANDER R. STEVENS ◽

CLEMENT A. FINCH

Keyword(s):

Iron Deficiency ◽

Gastrointestinal Symptoms ◽

The Body ◽

Deficiency Anemia ◽

Deficient Diet ◽

Significant Group ◽

Body Iron ◽

Iron Stores ◽

Iron Deficient ◽

Full Complement

Abstract In the normal individual the amount of iron absorbed and lost from the body each day is exceedingly small. There are certain periods during life when body iron requirements are increased; the most important of these is infancy. Here, existing iron stores are rapidly depleted, and a deficient diet can soon produce iron deficiency. Once a full complement of body iron has been accrued, the adult is independent of iron intake and becomes iron deficient only through blood loss. In the production of iron deficiency, iron stores are exhausted before anemia appears. If any question in diagnosis from usual laboratory tests exists, the direct. examination of marrow for hemosiderin will establish the diagnosis. It is of obvious importance to confirm the diagnosis by specific therapy and to determine the cause of the iron depletion. Response to oral iron is highly predictable and failure of response usually in dictates a mistaken diagnosis. In a small but significant group of patients, either unable to take iron because of gastrointestinal symptoms, unable to absorb iron, or in need of iron reserves, parenteral administration of iron has distinct advantages. The saccharated oxide of iron is an effective preparation for this purpose.

Download Full-text