Iron supplementation to treat anaemia in adult critical care patients: a systematic review and meta-analysis

Akshay Shah; Noémi B Roy; Stuart McKechnie; Carolyn Doree; Sheila A Fisher; Simon J Stanworth

doi:10.1186/s13054-016-1486-z

Iron supplementation to treat anaemia in adult critical care patients: a systematic review and meta-analysis

Crit Care. 2016 Sep 29;20(1):306. doi: 10.1186/s13054-016-1486-z.

Authors

Akshay Shah¹, Noémi B Roy², Stuart McKechnie³, Carolyn Doree⁴, Sheila A Fisher⁴, Simon J Stanworth^{5

6}

Affiliations

¹ Nuffield Department of Anaesthetics, Level 2 John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK. akshayshah@doctors.org.uk.
² Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, UK.
³ Nuffield Department of Anaesthetics, Level 2 John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
⁴ Systematic Review Initiative, NHS Blood & Transplant, Oxford, UK.
⁵ NHS Blood and Transplant, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK.
⁶ Radcliffe Department of Medicine, University of Oxford, Oxford, UK.

Abstract

Background: Anaemia affects 60-80 % of patients admitted to intensive care units (ICUs). Allogeneic red blood cell (RBC) transfusions remain the mainstay of treatment for anaemia but are associated with risks and are costly. Our objective was to assess the efficacy and safety of iron supplementation by any route, in anaemic patients in adult ICUs.

Methods: Electronic databases (CENTRAL, MEDLINE, EMBASE) were searched through March 2016 for randomized controlled trials (RCT)s comparing iron by any route with placebo/no iron. Primary outcomes were red blood cell transfusions and mean haemoglobin concentration. Secondary outcomes included mortality, infection, ICU and hospital length of stay, mean difference (MD) in iron biomarkers, health-related quality of life and adverse events.

Results: Five RCTs recruiting 665 patients met the inclusion criteria; intravenous iron was tested in four of the RCTs. There was no difference in allogeneic RBC transfusion requirements (relative risk 0.87, 95 % confidence interval (CI) 0.70 to 1.07, p = 0.18, five trials) or mean number of RBC units transfused (MD -0.45, 95 % CI -1.34 to 0.43, p = 0.32, two trials) in patients receiving or not receiving iron. Similarly, there was no difference between groups in haemoglobin at short-term (up to 10 days) (MD -0.25, 95 % CI -0.79 to 0.28, p = 0.35, three trials) or mid-term follow up (last measured time point in hospital or end of trial) (MD 0.21, 95 % CI -0.13 to 0.55, p = 0.23, three trials). There was no difference in secondary outcomes of mortality, in-hospital infection, or length of stay. Risk of bias was generally low although three trials had high risk of attrition bias; only one trial had low risk of bias across all domains.

Conclusion: Iron supplementation does not reduce RBC transfusion requirements in critically ill adults, but there is considerable heterogeneity between trials in study design, nature of interventions, and outcomes. Well-designed trials are needed to investigate the optimal iron dosing regimens and strategies to identify which patients are most likely to benefit from iron, together with patient-focused outcomes.

Trial registration: PROSPERO International prospective register of systematic reviews CRD42015016627 . Registered 2 March 2015.

Keywords: Anaemia; Haemoglobin; Iron; Meta-analysis; Red blood cell; Transfusion.