High-Dose Intravenous Iron Supplementation During Hospitalization Improves Hemoglobin Level and Transfusion Rate Following Total Knee or Hip Arthroplasty: A Systematic Review and Meta-Analysis

Background: Intravenous (IV) iron supplementation is a potential strategy to address anemia and reduce the need for blood transfusion following total knee or hip arthroplasty (TKA or THA). We aimed to investigate the effect and safety of IV iron supplementation as optimal blood management in patients after TKA or THA.

Methods: The MEDLINE, Embase, Cochrane Library, CINAHL, and Scopus databases were systematically searched for studies comparing patients undergoing total knee arthroplasty or total hip arthroplasty with and without IV iron supplementation. Blood transfusion rate and postoperative hemoglobin drop were assessed for effectiveness, while adverse events and surgical site infection were evaluated for the safety of IV iron supplementation. Additionally, subgroup analyses were performed to investigate the effect of IV iron supplementation based on the iron dose or patient's indication. There were 14 studies included.

Results: The use of IV iron supplementation significantly decreased the blood transfusion rate compared to no supplementation after TKA or THA (odds ratio [OR] 0.43; 95% confidence interval [CI], 0.27 to 0.68; P < 0.001) as clinical manifestations were considered for the transfusion, although no significant difference was found between postoperative days one and seven. Furthermore, IV iron supplementation significantly reduced postoperative Hb drop compared to no supplementation at postoperative two to six weeks (postoperative weeks two to three: mean difference [MD], -0.61; 95% CI, -1.01 to -0.20; P = 0.003 and postoperative weeks four to six: MD, -0.50; 95% CI, -0.70 to -0.31; P < 0.001). The safety profile did not significantly differ between the two groups. Adverse events occurred in 0.5% of the treatment group. Subgroup analysis showed that high-dose iron in high-risk patients led to a faster recovery of Hb drop than low-dose iron in routine patients following TKA or THA.

Conclusions: Perioperative IV iron supplementation was effective and safe in blood management for reducing blood transfusion and Hb drop in patients following TKA or THA. High-dose iron supplementation provided faster recovery of Hb than low-dose iron, which was more effective in high-risk patients.

Level of evidence: Meta-analysis of level 3 studies.