366 9. Fisher JM. Prostaglandins and kidney erythropoietin production. Nephron 1980; 25: 53-56 10. Kurtz A, Pfeilshifier J, Malmstrom K., Woodson RD, Bauer C. Mechanism of N a G transport: Stimulated prostaglandin formactron in MDCK cells. Am J Physiol 1987; 252: c307c314
Preoperative collection of autologous blood in a patient with end-stage renal disease Sir, To prevent the infectious complications and the risk of HLA sensitization due to homologous blood transfusion [1], autologous blood transfusion has been proposed [2]. This procedure is performed regularly in healthy subjects who need elective surgery. The efficacy of autologous blood donation depends on the initial haematocrit and on the possibility of bone marrow to increase erythropoiesis. Additional treatment with recombinant human erythropoietin (rHuEpo) is a logical approach to maximize erythropoiesis [3], when endogenous erythropoietin response is insufficient to stimulate maximally the marrow in autologous blood donation. The present case illustrates this procedure in a renal patient. A 35-year-old woman with end-stage renal disease, on regular haemodialysis, had to undergo surgery for bilateral ovarian cysts. The transfusion need for such an intervention is approximately 1 unit of packed cells in our centre. As this patient was a renal allograft transplant candidate, with already a high degree of HLA antibodies, autologous blood transfusion was proposed. Renal anaemia was partially corrected with rHuEpo and iron supplementation (i.v.) for 2 years. Haematocrit was maintained around 30% with a weekly dose of 3000 IU s.c. Nine weeks before surgery, the rHuEpo dose was doubled to 6000 IU s.c. weekly. Haematocrit increased to 33.1% in 4 weeks. At that time 250 ml of blood were then taken, which was well tolerated by the patient. The same rHuEpo scheme was continued, and 10 days later a second blood donation of 250 ml was performed. Haematocrit was only slightly affected by the blood donations, as shown in Figure 1. On the operation day, haematocrit was 36.2%. Blood loss during the intervention was estimated at 450 ml and the patient was given back her blood. As the postoperative haematocrit was below 30%, 6000 IU rHuEpo weekly was continued for another 4 weeks. Later the pre-donation weekly dose of 3000 IU was restored. This case illustrates the possibility of avoiding homologous blood transfusion in a patient with end-stage renal disease. Treatment with rHuEpo increased red blood cell
Fig. 1. Haematocrit response to increment of rHuEpo and blood donation.
Nephrol Dial Transplant (1992): Letters
mass and permitted the donation of blood for storage (maximum 5 weeks) and later use. We only needed 1 unit of packed cells for this patient, which was collected in two sessions because of the low bodyweight of 40 kg and the haematocrit. Renal patients do not benefit from more units when haematocrit is about 30%. Naturally, autologous blood transfusion causes some organizational problems [4] and is limited to selected patients. It cannot be used in cases of emergency, if a large quantity of blood is needed, or if the patient is in a bad clinical condition. Our patient fulfilled most of the criteria since she was waiting for a renal transplant and needed elective surgery. Before the availability of rHuEpo, autologous blood donation would not have been possible in end-stage renal disease. Our experience is encouraging, especially as we did not observe any complications related to rHuEpo treatment in this patient. Nevertheless, further investigation is needed in the renal patient population to determine possible risks. Renal Unit, and Blood Transfusion Center Department of Internal Medicine Free University of Brussels Brussels Belgium
P. Van der Niepen J.J. Sennesael L. Steenssens D.L. Verbeelen
I Walker RH Transfusion nsks. Am J Clin Paihol 1987; 88: 374-378 2. Mann M, Sacks HJ, Goldfinger D Safety of aulologous blood donation prior to elective surgery for a variety of potentially 'high risk' patients Transfusion 1983; 23: 229-232 3. Goodnough LT, Brittenham GM. Limitations of the erythropoietic response to serial phlebotomy: implications for autologous blood donor programs. J Lab Clin Med 1990, 115: 28-35 4. Messmer K. Practical methods to avoid homologous blood transfusion: an introduction. In: Practical Methods to Avoid Homologous Blood Transfusion. Adis International, Manchester, 1989
Recombinant human erythropoietin treatment reverses hepatic iron overload in hemodialysis patients Sir, Before the use of recombinant human erythropoietin (rHuEpo), red cell transfusions were necessary to correct anaemia in haemodialysis patients. But regular transfusions led to iron overload and sometimes to secondary haemochromatosis characterized by dysfunction of liver, heart, endocrine, and muscle cells. Several methods are available to evaluate iron overload, including serum iron measurement, serum ferritin, transferrin saturation, and liver biopsy. Cecchin et al [1] found that hepatic computed tomography density is efficient in detecting iron overload in chronic haemodialysis. Recently it has been proven that iron overload, expressed as increased serum ferritin, can be corrected by rHuEpo treatment [2]. Using hepatic computed tomography density we have evaluated the liver iron store in haemodialysed patients with iron overload treated by rHuEpo. Ten patients were included, two males and eight females aged 26-75 years (mean±SD, 47.8± 14 years) undergoing thrice-weekly regular haemodialysis for 43-233 months (108.7±53.3 months). All patients had iron overload after regular red cell transfusions, 8-24 units per year, sometimes accompanied by oral iron administration. rHuEpo was administered intravenously three times weekly at the end of each haemodialysis session. Initial doses were 150 units kg BW per week, the goal being to
367
Nephrol Dial Transplant (1992): Letters
Table 1. Mean + SD values of ferritin, per cent saturation of transferrin, haemoglobin, haemotocrit, and rHuEpo doses before Epo treatment (Mo) and 4 (M4) and 8 months (M8) later
MO M4 M8
Serum ferritin (ng 1)
Transferrin saturation
HCTD (Hounsfield units)
Haemoglobin (gdl)
Haematocrit (%)
rHuEpo (U kg B\V week)
3956*562 2366± 1311* 2343*1613'
68.83:12 42.9±2P 36.93:18.7'
82.2*8 79± 15
6.4*1 10.5±I.l J 10.5*0.7'
0.19 0.31a 0.311
130*60 130±46 130*46
•"Significant difference (P
Preoperative collection of autologous blood in a patient with end-stage renal disease Sir, To prevent the infectious complications and the risk of HLA sensitization due to homologous blood transfusion [1], autologous blood transfusion has been proposed [2]. This procedure is performed regularly in healthy subjects who need elective surgery. The efficacy of autologous blood donation depends on the initial haematocrit and on the possibility of bone marrow to increase erythropoiesis. Additional treatment with recombinant human erythropoietin (rHuEpo) is a logical approach to maximize erythropoiesis [3], when endogenous erythropoietin response is insufficient to stimulate maximally the marrow in autologous blood donation. The present case illustrates this procedure in a renal patient. A 35-year-old woman with end-stage renal disease, on regular haemodialysis, had to undergo surgery for bilateral ovarian cysts. The transfusion need for such an intervention is approximately 1 unit of packed cells in our centre. As this patient was a renal allograft transplant candidate, with already a high degree of HLA antibodies, autologous blood transfusion was proposed. Renal anaemia was partially corrected with rHuEpo and iron supplementation (i.v.) for 2 years. Haematocrit was maintained around 30% with a weekly dose of 3000 IU s.c. Nine weeks before surgery, the rHuEpo dose was doubled to 6000 IU s.c. weekly. Haematocrit increased to 33.1% in 4 weeks. At that time 250 ml of blood were then taken, which was well tolerated by the patient. The same rHuEpo scheme was continued, and 10 days later a second blood donation of 250 ml was performed. Haematocrit was only slightly affected by the blood donations, as shown in Figure 1. On the operation day, haematocrit was 36.2%. Blood loss during the intervention was estimated at 450 ml and the patient was given back her blood. As the postoperative haematocrit was below 30%, 6000 IU rHuEpo weekly was continued for another 4 weeks. Later the pre-donation weekly dose of 3000 IU was restored. This case illustrates the possibility of avoiding homologous blood transfusion in a patient with end-stage renal disease. Treatment with rHuEpo increased red blood cell
Fig. 1. Haematocrit response to increment of rHuEpo and blood donation.
Nephrol Dial Transplant (1992): Letters
mass and permitted the donation of blood for storage (maximum 5 weeks) and later use. We only needed 1 unit of packed cells for this patient, which was collected in two sessions because of the low bodyweight of 40 kg and the haematocrit. Renal patients do not benefit from more units when haematocrit is about 30%. Naturally, autologous blood transfusion causes some organizational problems [4] and is limited to selected patients. It cannot be used in cases of emergency, if a large quantity of blood is needed, or if the patient is in a bad clinical condition. Our patient fulfilled most of the criteria since she was waiting for a renal transplant and needed elective surgery. Before the availability of rHuEpo, autologous blood donation would not have been possible in end-stage renal disease. Our experience is encouraging, especially as we did not observe any complications related to rHuEpo treatment in this patient. Nevertheless, further investigation is needed in the renal patient population to determine possible risks. Renal Unit, and Blood Transfusion Center Department of Internal Medicine Free University of Brussels Brussels Belgium
P. Van der Niepen J.J. Sennesael L. Steenssens D.L. Verbeelen
I Walker RH Transfusion nsks. Am J Clin Paihol 1987; 88: 374-378 2. Mann M, Sacks HJ, Goldfinger D Safety of aulologous blood donation prior to elective surgery for a variety of potentially 'high risk' patients Transfusion 1983; 23: 229-232 3. Goodnough LT, Brittenham GM. Limitations of the erythropoietic response to serial phlebotomy: implications for autologous blood donor programs. J Lab Clin Med 1990, 115: 28-35 4. Messmer K. Practical methods to avoid homologous blood transfusion: an introduction. In: Practical Methods to Avoid Homologous Blood Transfusion. Adis International, Manchester, 1989
Recombinant human erythropoietin treatment reverses hepatic iron overload in hemodialysis patients Sir, Before the use of recombinant human erythropoietin (rHuEpo), red cell transfusions were necessary to correct anaemia in haemodialysis patients. But regular transfusions led to iron overload and sometimes to secondary haemochromatosis characterized by dysfunction of liver, heart, endocrine, and muscle cells. Several methods are available to evaluate iron overload, including serum iron measurement, serum ferritin, transferrin saturation, and liver biopsy. Cecchin et al [1] found that hepatic computed tomography density is efficient in detecting iron overload in chronic haemodialysis. Recently it has been proven that iron overload, expressed as increased serum ferritin, can be corrected by rHuEpo treatment [2]. Using hepatic computed tomography density we have evaluated the liver iron store in haemodialysed patients with iron overload treated by rHuEpo. Ten patients were included, two males and eight females aged 26-75 years (mean±SD, 47.8± 14 years) undergoing thrice-weekly regular haemodialysis for 43-233 months (108.7±53.3 months). All patients had iron overload after regular red cell transfusions, 8-24 units per year, sometimes accompanied by oral iron administration. rHuEpo was administered intravenously three times weekly at the end of each haemodialysis session. Initial doses were 150 units kg BW per week, the goal being to
367
Nephrol Dial Transplant (1992): Letters
Table 1. Mean + SD values of ferritin, per cent saturation of transferrin, haemoglobin, haemotocrit, and rHuEpo doses before Epo treatment (Mo) and 4 (M4) and 8 months (M8) later
MO M4 M8
Serum ferritin (ng 1)
Transferrin saturation
HCTD (Hounsfield units)
Haemoglobin (gdl)
Haematocrit (%)
rHuEpo (U kg B\V week)
3956*562 2366± 1311* 2343*1613'
68.83:12 42.9±2P 36.93:18.7'
82.2*8 79± 15
6.4*1 10.5±I.l J 10.5*0.7'
0.19 0.31a 0.311
130*60 130±46 130*46
•"Significant difference (P
