The effect of perioperative erythropoietin-stimulating agents and intravenous iron on patient outcomes following solid organ transplantation: A systematic review.

Solid organ transplant is associated with high rates of anaemia and transfusion, but there is little comparative data on interventions such as erythropoietin-stimulating agents (ESAs) and intravenous (IV) iron. We conducted a systematic review examining the association of ESAs and IV iron with outcomes in adults undergoing solid organ transplant. This review was registered with PROSPERO (CRD42023474722). EMBASE and MEDLINE were searched from inception to April 11, 2025. Identified studies included adults (≥18 years of age) undergoing heart, liver, lung, or kidney transplant who received any ESA and/or IV iron before, during, or up to 1 month following solid organ transplant surgery compared to patients who did not. Article screening, full text review and data extraction were performed by two independent reviewers. The primary outcome of interest was transfusion volume, with secondary outcomes including haematological parameters, graft-related outcomes and rates of major morbidity and mortality. Results were analysed descriptively and compiled into tables, and the risk of bias was assessed using the CLARITY framework. From 1693 studies identified, 22 were included (kidney transplant, n = 16; heart transplant or Left Ventricular Assist Device as a bridge to transplant, n = 4; liver transplant, n = 2). Due to heterogeneity in design, interventions and outcomes, meta-analysis was not attempted. The quality of evidence was graded as Very Low. On the whole, a comprehensive strategy implementing ESAs and IV iron may improve haematological parameters and facilitate transfusion avoidance. High-quality prospective studies assessing the impact of protocols for haemoglobin optimisation and transfusion avoidance in solid organ transplant are needed.