How I Treat Anemia with Red Blood Cell Transfusion and Iron

Abstract

Severe anemia is commonly treated with red blood cell transfusion. Clinical trials have demonstrated that a restrictive transfusion strategy of 7-8 g/dL is as safe as a liberal transfusion strategy of 9-10 g/dL in many clinical settings. Evidence is lacking for subgroups of patients, including those with pre-existing coronary artery disease, acute myocardial infarction, congestive heart failure, and myelodysplastic neoplasms. We present three clinical vignettes that highlight the clinical challenges in caring for patients with coronary artery disease with gastrointestinal bleeding, congestive heart failure, and myelodysplastic neoplasms. We emphasize that transfusion practice should be guided by patient symptoms and preferences in conjunction with the hemoglobin concentration. Along with the transfusion decision, evaluation, and management of the etiology of the anemia is essential. Iron-restricted erythropoiesis is a common cause of anemia severe enough to be considered for red blood cell transfusion but diagnosis and management of absolute iron deficiency anemia, the anemia of inflammation with functional iron deficiency, or their combination may be problematic. Intravenous iron therapy is generally the treatment of choice for absolute iron deficiency in patients with complex medical disorders, with or without coexisting functional iron deficiency.