Skip to main content
SpringerLink
Log in

Association of iron supplementation with risk of transfusion, hospital length of stay, and mortality in geriatric patients undergoing hip fracture surgeries: a meta-analysis

  • Review
  • Published:
European Geriatric Medicine Aims and scope Submit manuscript

Key summary points

AbstractSection Aim

To investigate the association between iron supplementation and blood transfusion risks, hospital length of stay, postoperative infection, and mortality in geriatric patients with hip fracture surgeries.

AbstractSection Findings

Data from this meta-analysis suggest that iron supplementation, especially preoperative intravenous use of iron at 200–300 mg, is associated with a reduction in the rate and volume of blood transfusions, infections and length of hospital stay in older patients with hip fracture surgeries.

AbstractSection Message

These findings support the preoperative intravenous use of iron at 200–300 mg in older adults undergoing hip fracture surgeries.

Abstract

Aims

To assess the efficacy and safety of iron supplementation for perioperative anemia in geriatric patients with hip fracture.

Methods

A systematic search was conducted for studies published using PubMed, EMBASE and Cochrane Library Databases that compared iron supplementation with placebo in patients undergoing hip fracture surgery. The outcomes were blood transfusion rate and volume, length of stay, infection and mortality (last follow-up). Sub-group and sensitivity analyses were performed in cases of substantial heterogeneity.

Results

The meta-analysis (6 studies: 1201 patients) indicated that iron supplements were not associated with reducing blood transfusion rate (OR 0.92, 95% CI 0.60–1.41; P = 0.69), but high heterogeneity (I2 = 61%) was detected and a significant association was found in sensitivity analysis of four studies (n = 637; OR 0.68, 95% CI 0.49–0.95; P = 0.02). A significant reduction was detected in transfusion volume (two studies: n = 234; MD − 0.45 units/patient, 95% CI − 0.74 to − 0.16; P = 0.002), hospital stay (five studies: n = 998; MD − 1.42, 95% CI − 2.18 to − 0.67; P = 0.0002) and caused no increased risk of mortality (five studies: n = 937; OR 0.94, 95% CI 0.65–1.36; P = 0.76) and infection (four studies: n = 701; OR 0.58, 95% CI 0.38–0.90; P = 0.01). Sub-group analyses of four studies showed that the preoperative intravenous use of iron at 200–300 mg (two studies) may be the beneficial option for hip fractures patients.

Conclusions

Iron supplementation, especially preoperative intravenous use of 200–300 mg iron, is safe and associated with reducing transfusion requirement and hospital stay. Unfortunately, data were too limited to draw a definite conclusion. Further evaluation is required before recommending iron supplementation for older patients with hip fracture surgeries.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6

Similar content being viewed by others

References

  1. Beattie WS, Karkouti K, Wijeysundera DN, Tait G (2009) Risk associated with preoperative anemia in noncardiac surgery a single-center cohort study. Anesthesiology 110(3):574–581. https://doi.org/10.1097/ALN.0b013e31819878d3

    Article  PubMed  Google Scholar 

  2. AAOS (2014) Management of hip fractures in the elderly. 2014:17. https://www.aaos.org/Research/guidelines/HipFxSummaryofRecommendations.pdf Accessed 21 Feb 2015

  3. Carson JL, Duff A, Berlin JA, Lawrence VA, Poses RM, Huber EC et al (1998) Perioperative blood transfusion and postoperative mortality. Jama J Am Med Assoc 279(3):199–205. https://doi.org/10.1001/jama.279.3.199

    Article  CAS  Google Scholar 

  4. Nemeth E, Ganz T (2014) Anemia of inflammation. Hematol Oncol Clin N Am 28(4):671–681. https://doi.org/10.1016/j.hoc.2014.04.005

    Article  Google Scholar 

  5. Warner MA, Shore-Lesserson L, Shander A, Patel SY, Perelman SI, Guinn NR (2020) Perioperative anemia: prevention, diagnosis, and management throughout the spectrum of perioperative care. Anesth Analg 130(5):1364–1380. https://doi.org/10.1213/ane.0000000000004727

    Article  PubMed  Google Scholar 

  6. Girelli D, Nemeth E (2016) Hepcidin in the diagnosis of iron disorders. Blood 127(23):2809–2813. https://doi.org/10.1182/blood-2015-12-639112

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  7. Salido JA, Marin LA, Gomez LA, Zorrilla P, Martinez C (2002) Preoperative hemoglobin levels and the need for transfusion after prosthetic hip and knee surgery - analysis of predictive factors. J Bone Jt Surg Am Vol 84A(2):216–220. https://doi.org/10.2106/00004623-200202000-00008

    Article  Google Scholar 

  8. Abdullah HR, Sim YE, Hao Y, Lin GY, Liew GHC, Lamoureux EL et al (2017) Association between preoperative anaemia with length of hospital stay among patients undergoing primary total knee arthroplasty in Singapore: a single-centre retrospective study. BMJ Open 7(6):e016403. https://doi.org/10.1136/bmjopen-2017-016403

    Article  PubMed  PubMed Central  Google Scholar 

  9. Brunskill SJ, Millette SL, Shokoohi A, Pulford EC, Doree C, Murphy MF et al (2015) Red blood cell transfusion for people undergoing hip fracture surgery. Cochrane Database Syst Rev. https://doi.org/10.1002/14651858.CD009699.pub2

    Article  PubMed  Google Scholar 

  10. Foss NB, Kehlet H (2006) Hidden blood loss after surgery for hip fracture. J Bone Jt Surg Br Vol 88B(8):1053–1059. https://doi.org/10.1302/620x.88b8

    Article  Google Scholar 

  11. Theusinger OM, Leyvraz PF, Schanz U, Seifert B, Spahn DR (2007) Treatment of iron deficiency anemia in orthopedic surgery with intravenous iron: efficacy and limits: a prospective study. Anesthesiology 107(6):923–927. https://doi.org/10.1097/01.anes.0000291441.10704.82

    Article  CAS  PubMed  Google Scholar 

  12. Wells G, Shea B, O’Connell D, Peterson J, Welch V, Losos M, Tugwell P (2013) The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. https://www.ohri.ca/programs/clinical_epidemiology/oxford.asp

  13. Prasad N, Rajamani V, Hullin D, Murray JM (2009) Post-operative anaemia in femoral neck fracture patients: ddoes it need treatment? A single blinded prospective randomised controlled trial. Injury 40(10):1073–1076. https://doi.org/10.1016/j.injury.2009.02.021

    Article  CAS  PubMed  Google Scholar 

  14. Crooks J, O’Malley K, Stevenson IH (1976) Pharmacokinetics in the elderly. Clin Pharmacokinet 1(4):280–296. https://doi.org/10.2165/00003088-197601040-00003

    Article  CAS  PubMed  Google Scholar 

  15. Lipschitz DA, Udupa KB, Milton KY, Thompson CO (1984) Effect of age on hematopoiesis in man. Blood 63(3):502–509

    Article  CAS  Google Scholar 

  16. Parker MJ (2010) Iron supplementation for anemia after hip fracture surgery: a randomized trial of 300 patients. J Bone Jt Surg Am Vol 92(2):265–269. https://doi.org/10.2106/jbjs.i.00883

    Article  Google Scholar 

  17. Cuenca J, Garcia-Erce JA, Martinez AA, Solano VM, Molina J, Munoz M (2005) Role of parenteral iron in the management of anaemia in the elderly patient undergoing displaced subcapital hip fracture repair: preliminary data. Arch Orthop Trauma Surg 125(5):342–347. https://doi.org/10.1007/s00402-005-0809-3

    Article  PubMed  Google Scholar 

  18. Serrano-Trenas JA, Ugalde PF, Cabello LM, Chofles LC, Lázaro PS, Benítez PC (2011) Role of perioperative intravenous iron therapy in elderly hip fracture patients: a single-center randomized controlled trial. Transfusion 51(1):97–104. https://doi.org/10.1111/j.1537-2995.2010.02769.x

    Article  CAS  PubMed  Google Scholar 

  19. Cuenca J, Garcia-Erce JA, Munoz M, Izuel M, Martinez AA, Herrera A (2004) Patients with pertrochanteric hip fracture may benefit from preoperative intravenous iron therapy: a pilot study. Transfusion 44(10):1447–1452. https://doi.org/10.1111/j.1537-2995.2004.04088.x

    Article  CAS  PubMed  Google Scholar 

  20. Yang Y, Li H, Li B, Wang Y, Jiang S, Jiang L (2011) Efficacy and safety of iron supplementation for the elderly patients undergoing hip or knee surgery: a meta-analysis of randomized controlled trials. J Surg Res 171(2):e201–e207. https://doi.org/10.1016/j.jss.2011.08.025

    Article  CAS  PubMed  Google Scholar 

  21. Shin HW, Park JJ, Kim HJ, You HS, Choi SU, Lee MJ (2019) Efficacy of perioperative intravenous iron therapy for transfusion in orthopedic surgery: a systematic review and meta-analysis. PLoS ONE. https://doi.org/10.1371/journal.pone.0215427

    Article  PubMed  PubMed Central  Google Scholar 

  22. García-Erce JACJ, Gómez-Ramírez S et al (2009) Posibilidades de tratamiento de la anemia perioperatoriaen cirugía ortopédica y traumatología. Anemia 2:17–27

    Google Scholar 

  23. Moher D, Cook DJ, Eastwood S, Olkin I, Rennie D, Stroup DF (2000) Improving the quality of reports of meta-analyses of randomised controlled trials: the QUOROM statement. Onkologie 23(6):597–602. https://doi.org/10.1159/000055014

    Article  PubMed  Google Scholar 

  24. Mantel N, Haenszel W (1959) Statistical aspects of the analysis of data from retrospective studies of disease. J Natl Cancer Inst 22(4):719–748

    CAS  PubMed  Google Scholar 

  25. DerSimonian R, Laird N (1986) Meta-analysis in clinical trials. Control Clin Trials 7(3):177–188

    Article  CAS  Google Scholar 

  26. Higgins JPT, Green S, eds (2011) Cochrane handbook for systematic reviews of interventions; version 5.1.0 [updated March 2011]. The cochrane collaboration. https://www.cochrane-handbook.org. Published 2011. Accessed 28 June 2011

  27. Bernabeu-Wittel M, Romero M, Ollero-Baturone M, Aparicio R, Murcia-Zaragoza J, Rincon-Gomez M et al (2016) Ferric carboxymaltose with or without erythropoietin in anemic patients with hip fracture: a randomized clinical trial. Transfusion 56(9):2199–2211. https://doi.org/10.1111/trf.13624

    Article  CAS  PubMed  Google Scholar 

  28. Izuel Rami M, Gomez Barrera M, Villar Fernandez I, Rabanaque Hernandez MJ, Cuenca Espierrez J, Garcia-Erce JA (2007) Budget impact analysis of a blood saving program for urgent traumatological surgery. Med Clin 128(1):7–11

    Article  Google Scholar 

  29. Izuel-Rami M, Cuenca Espierrez J, Garcia-Erce JA, Gomez-Barrera M, Carcelen Andres J, Rabanaque Hernandez MJ (2005) Perioperative anaemia in geriatric patients with hip fracture. Farmacia hospitalaria : organo oficial de expresion cientifica de la Sociedad Espanola de Farmacia Hospitalaria 29(4):250–257

    Article  CAS  Google Scholar 

  30. Gomez-Ramirez S, Angeles Maldonado-Ruiz M, Campos-Garrigues A, Herrera A, Munoz M (2019) Short-term perioperative iron in major orthopedic surgery: state of the art. Vox Sang 114(1):3–16. https://doi.org/10.1111/vox.12718

    Article  PubMed  Google Scholar 

  31. Bisbe ECJ, Sáez M et al (2008) Prevalence of preoperative anemia and hematinic deficiencies in patients scheduled for major orthopedic surgery. Transfus Altern Transfus Med 4:166–173

    Article  Google Scholar 

  32. Munoz M, Garcia-Erce JA, Remacha AF (2011) Disorders of iron metabolism. Part II: iron deficiency and iron overload. J Clin Pathol 64(4):287–296. https://doi.org/10.1136/jcp.2010.086991

    Article  CAS  PubMed  Google Scholar 

  33. O'Lone EL, Hodson EM, Nistor I, Bolignano D, Webster AC, Craig JC (2019) Parenteral versus oral iron therapy for adults and children with chronic kidney disease. Cochrane Database Syst Rev. https://doi.org/10.1002/14651858.CD007857.pub3

    Article  PubMed  PubMed Central  Google Scholar 

  34. Kulnigg S, Stoinov S, Simanenkov V, Dudar LV, Karnafel W, Garcia LC et al (2008) A novel intravenous iron formulation for treatment of anemia in inflammatory bowel disease: the ferric carboxymaltose (FERINJECT((R))) randomized controlled trial. Am J Gastroenterol 103(5):1182–1192. https://doi.org/10.1111/j.1572-0241.2007.01744.x

    Article  CAS  PubMed  Google Scholar 

  35. Shah A, Palmer AJR, Fisher SA, Rahman SM, Brunskill S, Doree C et al (2018) What is the effect of perioperative intravenous iron therapy in patients undergoing non-elective surgery? A systematic review with meta-analysis and trial sequential analysis. Perioper Med 7:30. https://doi.org/10.1186/s13741-018-0109-4

    Article  Google Scholar 

  36. Halm EA, Wang JJ, Boockvar K, Penrod J, Silberzweig SB, Magaziner J et al (2004) The effect of perioperative anemia on clinical and functional outcomes in patients with hip fracture. J Orthop Trauma 18(6):369–374

    Article  Google Scholar 

  37. Haleem S, Lutchman L, Mayahi R, Grice JE, Parker MJ (2008) Mortality following hip fracture: Trends and geographical variations over the last 40 years. Injury Int J Care Injured 39(10):1157–1163. https://doi.org/10.1016/j.injury.2008.03.022

    Article  CAS  Google Scholar 

  38. Zhang L, Yin P, Lv H, Long A, Gao Y, Zhang L et al (2016) Anemia on admission is an independent predictor of long-term mortality in hip fracture population: a prospective study with 2-year follow-up. Medicine 95(5):e2469. https://doi.org/10.1097/MD.0000000000002469

    Article  PubMed  PubMed Central  Google Scholar 

  39. Avenell A, Smith TO, Curtain JP, Mak JC, Myint PK (2016) Nutritional supplementation for hip fracture aftercare in older people. Cochrane Database Syst Rev. https://doi.org/10.1002/14651858.CD001880.pub6

    Article  PubMed  PubMed Central  Google Scholar 

  40. Engoren M, Mitchell E, Perring P, Sferra J (2008) The effect of erythrocyte blood transfusions on survival after surgery for hip fracture. J Trauma Injury Infect Crit Care 65(6):1411–1415. https://doi.org/10.1097/TA.0b013e318157d9f9

    Article  Google Scholar 

  41. Chertow GM, Mason PD, Vaage-Nilsen O, Ahlmen J (2006) Update on adverse drug events associated with parenteral iron. Nephrol Dial Transplant 21(2):378–382. https://doi.org/10.1093/ndt/gfi253

    Article  CAS  PubMed  Google Scholar 

  42. Musallam KM, Tamim HM, Richards T, Spahn DR, Rosendaal FR, Habbal A et al (2011) Preoperative anaemia and postoperative outcomes in non-cardiac surgery: a retrospective cohort study. Lancet 378(9800):1396–1407. https://doi.org/10.1016/s0140-6736(11)61381-0

    Article  PubMed  Google Scholar 

  43. Shokoohi A, Stanworth S, Mistry D, Lamb S, Staves J, Murphy MF (2012) The risks of red cell transfusion for hip fracture surgery in the elderly. Vox Sang 103(3):223–230. https://doi.org/10.1111/j.1423-0410.2012.01606.x

    Article  CAS  PubMed  Google Scholar 

Download references

Funding

This work was supported by Sichuan Science and Technology Program (2018SZ0246) and National Nature Science Foundation of China (No. 81571003).

Author information

Author notes

  1. Lang Li contributed to the work equally and should be regarded as co-first author.

Authors and Affiliations

  1. Department of Orthopedics, West China Hospital, Sichuan University, No. 37, Guoxue Lane, Wuhou District, Chengdu, 610000, China

    Ran Chen, Lang Li, Zhou Xiang & Xiao-Ling Hou

  2. Trauma Center, State Key Laboratory of Trauma, Burns and Combined Injury, Daping Hospital, Army Medical University, Chongqing, 400042, China

    Ran Chen

  3. Department of Orthopedics, Hospital of Chengdu Office of People’s Government of Tibetan Autonomous Region, Chengdu, 610041, Sichuan, China

    Lang Li

  4. School of Stomatology, Zhejiang Chinese Medical University, Hangzhou, 310006, China

    Hong Li

Authors
  1. Ran Chen
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Lang Li
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Zhou Xiang
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Hong Li
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Xiao-Ling Hou
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Xiao-Ling Hou.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

Not required since it is a review of already published works.

Informed consent

For this type of study, formal consent is not required.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary file1 (DOCX 115 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Chen, R., Li, L., Xiang, Z. et al. Association of iron supplementation with risk of transfusion, hospital length of stay, and mortality in geriatric patients undergoing hip fracture surgeries: a meta-analysis. Eur Geriatr Med 12, 5–15 (2021). https://doi.org/10.1007/s41999-020-00366-3

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s41999-020-00366-3

Keywords

Search

Navigation