ESAs in perioperative anemia management: Who, what, how and why?

Preoperative anemia is frequent and is associated with poor patient outcomes and higher transfusion rates. Perioperative blood transfusion is also associated with poor outcomes. These observations justify efforts to increase hemoglobin levels in anemic patients before surgeries with a moderate to high bleeding risk. Erythropoiesis-stimulating agents (ESAs) were developed in the 80s and are now widely used for the treatment of renal and cancer-related anemia. In the perioperative settings, ESAs were successfully proposed for preoperative blood donation programs in the 90s. Since then, substantial evidence has been available demonstrating that high-dose ESAs associated with iron (ideally intravenously), administered 3-4 weeks before surgery, increase perioperative hemoglobin levels and reduce the need for blood transfusion in some surgeries. Different strategies might be proposed ranging from a systematic treatment for all patients with hemoglobin below 13 g/dL (especially in orthopedic and cardiac surgeries) to a more personalized approach to anemia treatment (targeting anemia related to inflammation or renal insufficiency). ESAs might increase the risk of adverse events, including thromboembolism, and the benefit-risk ratio must be carefully weighted for high-risk patients (particularly for those undergoing cancer surgery). The cost-effectiveness of ESA use remains to be evaluated.