Comment on “The Important Role for Intravenous Iron in Perioperative Patient Blood Management in Major Abdominal Surgery: A Randomized Controlled Trial”

Comment on “The Important Role for Intravenous Iron in Perioperative Patient Blood Management... LETTERS TO THE EDITOR It is clear from the C-reactive protein Comment on ‘‘The Reply: The Important Role measurements that a proportion of the Important Role for patients in the study by Froessler et al had for Intravenous Iron in evidence of systemic inflammation before Intravenous Iron in Perioperative Patient surgery and given the above, iron deficiency was apparent rather than real in these patients Perioperative Patient Blood Management in and as a consequence some patients may not Blood Management in Major Abdominal Surgery: have benefited from an iron infusion. Indeed, it may be speculated that the benefit of the Major Abdominal Surgery: A Randomized iron infusion was confined to those patients A Randomized who did not have evidence of systemic Controlled Trial inflammation. Controlled Trial’’ We encourage the authors to report such analysis and other workers considering the use of iron infusion, to correct anemia, to monitor Reply: To the Editor: the systemic inflammatory response in the pre e would like to thank McSorley et al t is with interest that we read the article by and postoperative period. W for their interest in our work and their I Froessler et al reporting a randomized comment on our article ‘‘The Important Role controlled study of the use of parenteral iron Disclosure: The authors of this manu- for Intravenous Iron in Perioperative Patient to correct preoperative anemia and reduce script have no conflicts of interest to disclose. Blood Management in Major Abdominal perioperative blood transfusion in patients Surgery: A Randomized Controlled Trial’’. undergoing major abdominal surgery. The McSorley et al highlight the import- Stephen T. McSorley, MBChB authors conclude that the use of parenteral ance of our results and emphasize on the David Mansouri, PhD iron preoperatively in those patients deemed desirability of a reduction in the requirement Paul G. Horgan, PhD to be anemic due to iron deficiency was of for perioperative allogeneic blood transfu- Donald C. McMillan, PhD significant benefit, in particular, that it was sion (ABT). However, they raise a reasonable Academic Unit of Surgery, School of associated with reduced perioperative blood question about the recruitment into our study Medicine, University of Glasgow, Glasgow transfusion, higher preoperative hemoglobin based on the measurement of iron stores Scotland, UK concentration, and reduced length of stay. using ferritin, transferrin saturation, and s.mcsorley@doctors.org.uk This was consistent with prior meta-analysis hemoglobin levels, and consider this to be reporting similar results with the use of intra- potentially problematic. venous iron preparations. Clearly, as they We agree that many patients under- REFERENCES state, a reduction in the requirement for going major abdominal surgery for cancer 1. Froessler B, Palm P, Weber I, et al. The important perioperative allogeneic blood transfusion have evidence of a systemic inflammatory role for intravenous iron in perioperative patient is desirable for a number of reasons, includ- response often reflected in elevated C-reac- blood management in major abdominal surgery: a randomized controlled trial. Ann Surg. 2016;2 ing the relative scarcity of it as a healthcare tive protein (CRP) levels. In our study, CRP 64:41–46. resource, concerns with transmission of levels were similar and mildly elevated at 2. Litton E, Xiao J, Ho KM. Safety and efficacy of blood borne infection, other adverse effect randomization and 4 weeks after surgery in intravenous iron therapy in reducing requirement such as transfusion reaction, an association both groups. The ferritin level is considered for allogeneic blood transfusion: systematic with increased postoperative complica- the surrogate marker for iron deficiency ane- review and meta-analysis of randomised clinical 3 2 tions, and the underlying concern that blood trials. Br Med J. 2013;347:f4822. mia (IDA) ; however, serum ferritin is raised transfusion has the potential to increase 3. McDermott FD, Heeney A, Kelly ME, et al. in the presence of inflammation, cancer, or Systematic review of preoperative, intraoperative the risk of disease recurrence after cancer trauma, such as occurs in surgery in our and postoperative risk factors for colorectal anas- surgery. cohort. As it becomes challenging in this tomotic leaks. Br J Surg. 2015;102:462–479. However, recruitment into their study setting not to misinterpret IDA based on 4. Amato A, Pescatori M. Perioperative blood trans- was based on the measurement of iron stores ferritin alone, we proposed an alternate fusions for the recurrence of colorectal cancer. using ferritin, transferrin saturation, and Cochrane Database Syst Rev. 2006;25:CD005033. method of diagnosis where a higher ferritin hemoglobin levels. This is potentially prob- 5. vonDrygalski A, Adamson JW. Iron metabolism in cut-off and transferrin saturation were used, man. J Parenter Enteral Nutr. 2013;37:599–606. lematical since many patients undergoing along with inflammatory markers such as 6. Baynes R, Bezwoda W, Bothwell TH, et al. The major abdominal surgery do so for cancer CRP, to diagnose IDA. non-immune inflammatory response: serial and have evidence of a systemic inflamma- The improved hematopoietic response changes in serum iron, iron binding capacity, tory response (eg, C-reactive protein to intravenous (IV) iron in our participants lactoferrin, ferritin and C-reactive protein. Scand J Clin Lab Invest. 1986;145:657–663. >10 mg/L as measured in their study). The was uniform and significant. Similar out- 7. McSorley ST, Jones I, McMillan DC, et al. Quan- systemic inflammatory response is known to comes have been researched in many other titative data on the magnitude of the systemic perturb these measurements such that there is clinical settings where inflammation is com- inflammatory response and its relationship with 5–7 an apparent iron deficiency. Moreover, the monly found. Superiority of IV iron over oral serum measures of iron status. Trans Res. presence of a preoperative systemic inflam- iron administration was demonstrated in 2016;176:119–126. matory response is recognized to predict poor chronic kidney disease (CKD), congestive 8. Roxburgh CS, McMillan DC. Role of systemic inflammatory response in predicting survival in outcomes in patients undergoing cancer heart failure (CHF), in postpartum anemia, 8,9 patients with primary operable cancer. Future surgery. Therefore, the systemic inflamma- chemotherapy-induced anemia, and inflam- Oncol. 2010;6:149–163. 3–7 tory response is potentially an important matory bowel disease (IBD). In a recent 9. Roxburgh CS, Horgan PG, McMillan DC. The confounder with clear implications for the publication, Khalafallah and Dennis perioperative immune/inflammatory insult in preoperative treatment of iron deficiency and reported that a single dose of postoperative cancer surgery: time for intervention? Oncoim- munology. 2013;2:e27324. the interpretation of study results. administered IV ferric carboxymaltose Annals of Surgery  Volume 267, Number 3, March 2018 www.annalsofsurgery.com | e49 Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Annals of Surgery Wolters Kluwer Health

Comment on “The Important Role for Intravenous Iron in Perioperative Patient Blood Management in Major Abdominal Surgery: A Randomized Controlled Trial”

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Wolters Kluwer Health
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Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
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0003-4932
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1528-1140
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10.1097/SLA.0000000000002053
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Abstract

LETTERS TO THE EDITOR It is clear from the C-reactive protein Comment on ‘‘The Reply: The Important Role measurements that a proportion of the Important Role for patients in the study by Froessler et al had for Intravenous Iron in evidence of systemic inflammation before Intravenous Iron in Perioperative Patient surgery and given the above, iron deficiency was apparent rather than real in these patients Perioperative Patient Blood Management in and as a consequence some patients may not Blood Management in Major Abdominal Surgery: have benefited from an iron infusion. Indeed, it may be speculated that the benefit of the Major Abdominal Surgery: A Randomized iron infusion was confined to those patients A Randomized who did not have evidence of systemic Controlled Trial inflammation. Controlled Trial’’ We encourage the authors to report such analysis and other workers considering the use of iron infusion, to correct anemia, to monitor Reply: To the Editor: the systemic inflammatory response in the pre e would like to thank McSorley et al t is with interest that we read the article by and postoperative period. W for their interest in our work and their I Froessler et al reporting a randomized comment on our article ‘‘The Important Role controlled study of the use of parenteral iron Disclosure: The authors of this manu- for Intravenous Iron in Perioperative Patient to correct preoperative anemia and reduce script have no conflicts of interest to disclose. Blood Management in Major Abdominal perioperative blood transfusion in patients Surgery: A Randomized Controlled Trial’’. undergoing major abdominal surgery. The McSorley et al highlight the import- Stephen T. McSorley, MBChB authors conclude that the use of parenteral ance of our results and emphasize on the David Mansouri, PhD iron preoperatively in those patients deemed desirability of a reduction in the requirement Paul G. Horgan, PhD to be anemic due to iron deficiency was of for perioperative allogeneic blood transfu- Donald C. McMillan, PhD significant benefit, in particular, that it was sion (ABT). However, they raise a reasonable Academic Unit of Surgery, School of associated with reduced perioperative blood question about the recruitment into our study Medicine, University of Glasgow, Glasgow transfusion, higher preoperative hemoglobin based on the measurement of iron stores Scotland, UK concentration, and reduced length of stay. using ferritin, transferrin saturation, and s.mcsorley@doctors.org.uk This was consistent with prior meta-analysis hemoglobin levels, and consider this to be reporting similar results with the use of intra- potentially problematic. venous iron preparations. Clearly, as they We agree that many patients under- REFERENCES state, a reduction in the requirement for going major abdominal surgery for cancer 1. Froessler B, Palm P, Weber I, et al. The important perioperative allogeneic blood transfusion have evidence of a systemic inflammatory role for intravenous iron in perioperative patient is desirable for a number of reasons, includ- response often reflected in elevated C-reac- blood management in major abdominal surgery: a randomized controlled trial. Ann Surg. 2016;2 ing the relative scarcity of it as a healthcare tive protein (CRP) levels. In our study, CRP 64:41–46. resource, concerns with transmission of levels were similar and mildly elevated at 2. Litton E, Xiao J, Ho KM. Safety and efficacy of blood borne infection, other adverse effect randomization and 4 weeks after surgery in intravenous iron therapy in reducing requirement such as transfusion reaction, an association both groups. The ferritin level is considered for allogeneic blood transfusion: systematic with increased postoperative complica- the surrogate marker for iron deficiency ane- review and meta-analysis of randomised clinical 3 2 tions, and the underlying concern that blood trials. Br Med J. 2013;347:f4822. mia (IDA) ; however, serum ferritin is raised transfusion has the potential to increase 3. McDermott FD, Heeney A, Kelly ME, et al. in the presence of inflammation, cancer, or Systematic review of preoperative, intraoperative the risk of disease recurrence after cancer trauma, such as occurs in surgery in our and postoperative risk factors for colorectal anas- surgery. cohort. As it becomes challenging in this tomotic leaks. Br J Surg. 2015;102:462–479. However, recruitment into their study setting not to misinterpret IDA based on 4. Amato A, Pescatori M. Perioperative blood trans- was based on the measurement of iron stores ferritin alone, we proposed an alternate fusions for the recurrence of colorectal cancer. using ferritin, transferrin saturation, and Cochrane Database Syst Rev. 2006;25:CD005033. method of diagnosis where a higher ferritin hemoglobin levels. This is potentially prob- 5. vonDrygalski A, Adamson JW. Iron metabolism in cut-off and transferrin saturation were used, man. J Parenter Enteral Nutr. 2013;37:599–606. lematical since many patients undergoing along with inflammatory markers such as 6. Baynes R, Bezwoda W, Bothwell TH, et al. The major abdominal surgery do so for cancer CRP, to diagnose IDA. non-immune inflammatory response: serial and have evidence of a systemic inflamma- The improved hematopoietic response changes in serum iron, iron binding capacity, tory response (eg, C-reactive protein to intravenous (IV) iron in our participants lactoferrin, ferritin and C-reactive protein. Scand J Clin Lab Invest. 1986;145:657–663. >10 mg/L as measured in their study). The was uniform and significant. Similar out- 7. McSorley ST, Jones I, McMillan DC, et al. Quan- systemic inflammatory response is known to comes have been researched in many other titative data on the magnitude of the systemic perturb these measurements such that there is clinical settings where inflammation is com- inflammatory response and its relationship with 5–7 an apparent iron deficiency. Moreover, the monly found. Superiority of IV iron over oral serum measures of iron status. Trans Res. presence of a preoperative systemic inflam- iron administration was demonstrated in 2016;176:119–126. matory response is recognized to predict poor chronic kidney disease (CKD), congestive 8. Roxburgh CS, McMillan DC. Role of systemic inflammatory response in predicting survival in outcomes in patients undergoing cancer heart failure (CHF), in postpartum anemia, 8,9 patients with primary operable cancer. Future surgery. Therefore, the systemic inflamma- chemotherapy-induced anemia, and inflam- Oncol. 2010;6:149–163. 3–7 tory response is potentially an important matory bowel disease (IBD). In a recent 9. Roxburgh CS, Horgan PG, McMillan DC. The confounder with clear implications for the publication, Khalafallah and Dennis perioperative immune/inflammatory insult in preoperative treatment of iron deficiency and reported that a single dose of postoperative cancer surgery: time for intervention? Oncoim- munology. 2013;2:e27324. the interpretation of study results. administered IV ferric carboxymaltose Annals of Surgery  Volume 267, Number 3, March 2018 www.annalsofsurgery.com | e49 Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.

Journal

Annals of SurgeryWolters Kluwer Health

Published: Mar 1, 2018

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