Chronic ulcers experienced by individuals, such as those with SCI, with hemoglobin values less than 100 g/L may be difficult to heal because of impaired tissue oxygenation. It is important to distinguish between iron deficiency anemia and anemia of chronic disease. This condition occurs in individuals with chronic inflammatory and/or infectious processes; a chronic non-healing pressure ulcer is a chronic inflammatory condition. Anemia of chronic disease is thought to be the result of impaired red blood cell production because of persistent elevated levels of circulating inflammatory cytokines (Spivak 2002). The endogenous hormone erythropoietin and recombinant human erythropoietin (rHuEPO) play crucial roles in the regulation of hematopoiesis and induce red blood cell production. It has direct hemodynamic and vasoactive effects and modulates the inflammatory process, thereby potentially reversing the conditions believed to underlie chronic pressure ulcers. Treatment with rHuEPO has been shown to be effective in increasing hemoglobin values in five individuals with stage IV pressure ulcers related to anemia of chronic disease (Turba et al. 1992) and in the complete healing of a chronic leg ulcer in a single case report (Al-Momen 1991). One study has been performed that investigated the value of rHuEPO in the healing of chronic wounds among those with SCI.
A retrospective chart review of four individuals with SCI and stage IV chronic pressure ulcers was performed by Keast and Fraser (2004). Following treatment with 75 IU/kg of rHuEPO subcutaneously thrice weekly for six weeks, the mean baseline hemoglobin for the subjects increased from 88±7.4 g/L to 110±3.7 g/L. Mean ulcer surface area decreased from 42.3±40.2 cm2 to 38.4±44.3 cm2 over six weeks of treatment despite the fact that one of the subjects showed a significant increase in WSA as a result of surgical de-roofing performed to eliminate all undermining. All subjects showed a decrease in the depth of the target ulcer from 2.3±1.2 cm to 1.2±1.0 cm. Observations suggested that some of the subjects demonstrated increased ability to fight recurrent infections; all subjects reported that they felt more energetic and better able to participate in their rehabilitation activities. No adverse effects were observed. rHuEPO shows promise not only in resolving the anemia of chronic disease associated with stage IV pressure ulcers but also in the healing of these wounds in persons with SCI although further study is warranted.
There is level 4 evidence (from one case series; Keast & Fraser 2004) that recombinant human erythropoietin aids in the healing of stage IV chronic non-healing pressure ulcers post SCI.
- Recombinant human erythropoietin shows promise in assisting with the healing of stage IV chronic non-healing pressure ulcers post SCI.