A meta-analysis and systematic review evaluating the use of erythropoietin in total hip and knee arthroplasty

Figures & data

Figure 1 Risk of bias summary.

Notes: QUADAS-2 was used to analysis the quality of including trials. The green circles mean “Yes.” Yellow circles mean “Unsure” and red circles mean “No.”
Abbreviation: QUADAS-2, Quality Assessment of Diagnostic Accuracy Studies-2.

Figure 2 Study flow diagram.

Abbreviation: RCT, randomized controlled trial.

Table 1 Characteristics of included studies

Study	Number of patients	Intervention		Transfusion criteria	Transfusion time	Hospital days
		Experimental	Control
Bernabeu-Wittel et al,^Citation19 2016	200	EPO group: SC single dose of 40,000 IU of EPO	Control: subcutaneous single-dose placebo (saline)	Hb<,70 g/L, severe symptoms plus Hb level between 71 and 89 g/L	N/A	8 days
So-Osman et al,^Citation20 2014	683	EPO group: EPO 40,000 IU SC weekly for 3 weeks before operation EPO + PABD group: EPO 40,000 IU SC weekly for 3 weeks before operation and autologous blood reinfusion	Control group: no treatment PABD group: autologous blood Reinfusion	N/A	N/A	8.8 days
Buljan et al,^Citation21 2012	93	EPO group: rHuEPO 15,000 IU or 30,000 IU IV twice weekly for 3 weeks PABD: 12% of total blood volume donated on the 10th and 3rd preoperative days	PABD: 12% of total blood volume donated on the 10th and 3rd preoperative days	Hb 80 g/L and/or clinical symptoms of anemia	N/A	N/A
Na et al,^Citation22 2011	108	EPO group: rhuEPO-β: 3,000 IU SC 3 times	Control group: no treatment	Hb <70 g/L	N/A	N/A
Moonen et al,^Citation23 2008	100	EPO group: EPO-α: 40,000 IU weekly for 4 weeks	PABD	N/A	N/A	N/A
Keating et al,^Citation15 2007	251	EPO group: 600 IU/kg weekly for 3 weeks and with 24 h postoperatively	PABD: 1 U before TKA, 2 U before THA	Hb <80 g/L	N/A	N/A
Deutsch et al,^Citation24 2006	50	EPO group: 40,000 IU SC 14 days and 7 days before operation	PABD group: 2 U if Hb between 110 and 130 g/L	Hct <25%	N/A	N/A
Rosencher et al,^Citation25 2005	86	EPO group: 40,000 IU SC per week beginning 3 weeks before operation	PABD: once a week starting 3 weeks before surgery, as long as Hct >3%	Hct between 21% and 30%	N/A	N/A
Weber et al,^Citation26 2005	695	EPO alfa 40,000 IU subcutaneously once weekly for 3 weeks before surgery and on the day of surgery	Placebo	Hb <80 g/L	N/A	10.8 days
Hardwick et al,^Citation27 2004	40	Epoetin alfa: 40,000 IU weekly for 2 weeks	PABD: 1 or 2 U before operation	N/A	N/A	3.1 days
Avall et al,^Citation28 2003	23	EPO: 10,000 IU SC for 5 times PABD: 1 U before 3, 2, and 1 week before surgery	PABD: 1 U before 3, 2 and 1 week before surgery	Hb <85 g/L or when in danger of inadequate oxygenation	N/A	N/A
Bezwada et al,^Citation29 2003	93	Epoetin alfa: 40,000 IU or 20,000 IU SC per week beginning from 4 weeks before operation	PABD: 1 U for unilateral arthroplasty and 2 U for bilateral arthroplasty	Hb <80 g/L and/or persistent or hemodynamically unstable	N/A	N/A
Aksoy and Tokgozoglu,^Citation30 2001	40	rHuEPO: 300 IU/kg twice a week for 2 weeks, then once 3 days before operation PABD: 1 unit at 4 days interval until Hb <100 g/L	PABD	Hb <80g/L or hemodynamically unstable	N/A	N/A
Olijhoek et al,^Citation31 2001	110	Epoetin alfa: 600 IU/kg weekly for 3 weeks	Placebo	N/A	N/A	N/A
Gombotz et al,^Citation32 2000	40	rHuEPO: 600 U/kg SC on day 14 and, if needed, on day 7 before surgery	PABD: starting 4 weeks before surgery (goal: 3 U per donor)	N/A	N/A	N/A
Feagan et al,^Citation33 2000	160	Epoetin alfa: 40,000 IU or 20,000 IU SC per week beginning from 4 weeks before operation	Placebo	N/A	N/A	N/A
Faris et al,^Citation34 1996	185	1. EPO (300 U/kg) daily or 2. EPO 100 U/kg daily	Placebo	N/A	N/A	N/A
Hasegawa et al,^Citation35 1999	37	Epoetin beta: 6,000 U + PABD	PABD group: autologous blood reinfusion	N/A	N/A	N/A
Wurnig et al,^Citation36 2001	110	Epoetin beta: 250 IU/kg	Placebo	Hb <85 g/L	N/A	N/A
Stowell et al,^Citation37 1999	428	Weekly doses of SC EPO alfa (600 U/kg) on preoperative days: 21, 14, and 7, and on the day of surgery	PABD	N/A	N/A	N/A
Mercuriali,^Citation38 1996	44	EPO at 600 U/kg; patients received EPO at 300 U/kg	Placebo	Hct <34%	N/A	N/A
Price et al,^Citation39 1996	173	EPO at 600 U/kg	PABD	N/A	N/A	N/A
Goodnough et al,^Citation40 1994	91	Patients received EPO at 600 U/kg; patients received EPO at 300 U/kg	Placebo	Hct <33%	N/A	N/A
Beris et al,^Citation41 1993	101	EPO 150–180 U/kg (10,000 U) SC given 3 times per week: 4 and 2 weeks before surgery	PABD	N/A	N/A	N/A
Canadian group,^Citation42 1993	218	1. 14 days of EPO (300 U/kg to a maximum of 30,000 U) or 2. EPO for the 9 days after placebo	Placebo	Hb <90 g/L	N/A	N/A
Total	4,159

Abbreviations: EPO, erythropoietin; Hb, hemoglobin; Hct, hematocrit; IV, intravenous; N/A, not applicable; PABD, preoperative autologous blood donation; rHuEPO, recombinant human erythropoietin; SC, subcutaneous; THA, total hip arthroplasty; TKA, total knee arthroplasty.

Figure 3 Patients needing ABT.

Abbreviations: ABT, allogeneic blood transfusion; EPO, erythropoietin; M–H, Mantel–Haenszel; OR, odds ratio; PABD, preoperative autologous blood donation.

Figure 4 Units of allogeneic blood transfused.

Abbreviations: EPO, erythropoietin; PABD, preoperative autologous blood donation.

Figure 5 Preoperative Hb.

Abbreviations: EPO, erythropoietin; Hb, hemoglobin; PABD, preoperative autologous blood donation.

Figure 6 Hb levels 24–48 hours postsurgery.

Abbreviations: EPO, erythropoietin; PABD, preoperative autologous blood donation.

Figure 7 Hb levels 3–5 days postsurgery.

Abbreviations: EPO, erythropoietin; Hb, hemoglobin; PABD, preoperative autologous blood donation.

Figure 8 Hb level at discharge/last observation.

Abbreviations: EPO, erythropoietin; Hb, hemoglobin; PABD, preoperative autologous blood donation.

Figure 9 TKA patients needing ABT.

Abbreviations: ABT, allogeneic blood transfusion; EPO, erythropoietin; M–H, Mantel–Haenszel; OR, odds ratio; PABD, preoperative autologous blood donation; TKA, total knee arthroplasty.

Figure 10 THA patients needing ABT.

Abbreviations: ABT, allogeneic blood transfusion; EPO, erythropoietin; M–H, Mantel–Haenszel; OR, odds ratio; PABD, preoperative autologous blood donation; THA, total hip arthroplasty.

Figure 11 The risk of VTE.

Abbreviations: EPO, erythropoietin; M–H, Mantel–Haenszel; OR, odds ratio; PABD, preoperative autologous blood donation; VTE, venous thromboembolism.

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