Patient refuses blood transfusion and blood products. Patient is ok with all blood fractions. Doctors will not perform surgery due to HB fluctuates between 7 & 10. EPO is not effective. Creatine is elevated. Possibility for renal failure is high. Needs CABG X3.

What tools are there for a succesful surgery? What do you recommend? Any success in CABG cases with Hb under 10?

Is the intractable anemia due to renal insufficiency? Why is EPO not effective? Is patient receiving oral or IV iron? He/she might be in a stage of functional iron deficiency which occurs when EPO stimulates bone marrow but iron, an ingredient in blood formation is deficient.

Hb of 7 or 8 gms is very low for someone to undergo CABG. Could the renal problem (if there is) be corrected or ameliorated preop?

Perhaps, consultation with specialists in Transfusion-free Centers, especially those where cardiac surgery is done, would be a better option.

Regards,

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Angelina A. Gapay, MD

Dr Gapay, Thank you so much for your response.

Our friend wasn't told why EPO was not effective. She is in stage 3 with creatine elevated to 1.6. She was given Oral Iron throughout her hospital stay and then discharged. Their wasn't any clear explanation why her HB wasn't improving or why it went low other than they scoped her to see if she had active bleeding. The family requested that EPO continue at discharge and a nurse is now coming to administer a shot of 10k units every other day along with the oral iron. Her healthcare agent is also in the process of locating a surgeon within the health system that she belongs to.

Everyone feels awkward since the discharge since she is at high risk for a heart attack. Can a healthcare system release patients who just don't seem to be getting better?

She really is at high risk for heart attack, especially with the presence of anemia. Ideally, with your patient not responding to management of medical problems, she should be referred to nephrologist and cardiologist who should confer with the cardiac surgeon re perioperative concerns. I hope she can be optimized prior to surgery.

I'm no longer familiar with the latest in CABG surgery as we don't do it in our hospital.

regards,

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Angelina A. Gapay, MD

Hello, I am pleased to say that the patient (personal friend) referenced in this thread is doing fine. her kidneys improved and her hb went up to 14.1. after surgery it dropped to 11.4. and is maintained. thank you all for your suggestions.

What accounts for the hemoglobin increase? Did she continue on the EPO? Was she given IV iron? It would be good to know these things as they could be helpful for others seeking similar treatment.

She was kept on EPO shots, a nurse came out to administer them. EPO shots were continued all the way until she reached 14.9 then the surgery was performed after a few lab draws which brought her down to 14.3. They say epo should be stopped at a certain point but not in this case.

She was kept on a strict nutrional support diet. As a diabetic she was was not given the proper attention initially and we feel this may have contributed to her hemoglobin not rising during her 1st stay at the hospital.

Was the EPO treatment supported with the "proper" iron, folic acid, B12, vit c? In a chronically ill patient these nutritional supports are very critical.

The fluctuation of Hg and the surprising final levels, considering perioperative blood loss, are of great interest.

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Mr. Jan B. Wade
Blood Management Consultant
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