Risk of anaemia increases in chronic kidney disease patients, and is in proportion to the stages of kidney disease.
The lecture will focus on pathogenesis of anaemia, of which relative deficit of erythropoietin and hypoxia-sensing mechanism are involved. In addition, role of iron deficiency has been increasingly recognized.
The abovementioned factors provide insights to managing anaemia in kidney disease patients. Besides case illustration to highlight the challenges of anaemia, practice-changing studies will be discussed.
The lecture will also discuss the management of patients with stage 4 to 5 chronic kidney disease and who have opted for palliative care. In particular, we reported our local observational study in which 39 such patients receiving erythropoiesis stimulating agent (ESA) were matched with a control group of 39 patients without ESA. With one-year observation period, patients in the control group had higher transfusion rate (incidence rate ratio IRR 3.63; 95% CI 2.49 – 5.31, P < 0.00001) and higher hospital admission rate (IRR 2.34; 95% CI 1.80 – 3.03, P < 0.000001) than the ESA group even after adjustment for comorbidities.

Patient blood management (PBM), with the principles of optimizing erythropoiesis, minimizing blood loss and optimizing patient-specific tolerance to anaemia, plays an increasingly important role in the management of both obstetric and gynaecological (O&G) patients. Severe iron-deficiency anaemia among the O&G patients can be caused by (1) chronic periodic blood loss i.e. menorrhagia from various causes, as well as (2) acute massive blood loss from gynaecological or obstetric emergencies. How to reduce the need for repeated blood transfusions in the O&G patients and how to raise their haemoglobin (Hb) levels safely, cost-effectively and with sustained efficacy become two great challenges in O&G practice nowadays. 
In this presentation, the data on blood transfusion requirement among the gynaecology patients in Hong Kong, both from surgical and non-surgical causes, will be presented. A brief literature review on the use of intravenous (IV) iron therapy, as an alternative to blood transfusion, for the management of severe iron-deficiency anaemia among the gynaecology, antenatal and postpartum patients will be given. 
The results from a local retrospective cohort study at Kwong Wah Hospital on the use of IV iron infusion with a simplified dose-standardized protocol for the treatment of menorrhagic patients with severe iron-deficiency anaemia (Hb level between 6-8 g/dL) will be presented. In this study, 114 patients were recruited, after counselling on the alternatives of blood transfusion versus IV iron therapy. Each patient was treated with two doses of IV Venofer, 200mg each, given within 2 weeks, followed with oral iron supplement. A significant rise in Hb and Ferritin levels was observed 4 weeks after starting IV iron treatment. Over 99% of patients had their anemic symptoms resolved after treatment. Only one case of mild allergy was reported. 
Last but not the least, some of the important recommendations in the recently-released Hospital Authority Guideline on “Management of Iron-deficiency and Iron-deficiency Anaemia in O&G Units” will be highlighted. The suggestions on future directions to be considered in PBM in O&G practice will also be presented.

Clinical blood transfusion, since its introduction in the early 19th century, remains an important treatment modality in modern medicine. However, blood transfusion is associated with significant risks of complications, which are still here to stay despite the rapid advances in medicine over the last 200 years.
With global population ageing and the resulting supply demand imbalance, efforts have been made to reduce blood treatment. Furthermore, there is growing evidence that transfusion might be associated with unfavorable clinical outcomes.
Therefore Patient Blood Management (PBM), which is an evidence-based, patient-centered, and multidisciplinary approach to optimizing the care of patients who might need transfusion, is emerging in western countries over the last 20 years.
While PBM is gradually becoming the new standard of care and, in principle, it should belong to every clinician, anaesthetist, who possesses a solid foundation in clinical pathophysiology and a perfect armamentarium of technical skills, together with the unique role of taking care of the patients during the entire peri-operative journey, is well-placed to lead the practice of PBM, at least in operative settings.
Enhanced Recovery After Surgery (ERAS) similarly finds Hong Kong its arena for proliferation in recent years, since its earlier footprints in the western countries. Indeed, PBM has been considered one of the ERAS elements. Indeed, PBM is so important in modern medicine that it is more appropriate to phase that ERAS and PBM are supplementing each other. For example, early detection and optimizing of pre-operative anaemia at pre-anaesthetic clinic, as an optimizing patients’ RBC mass strategy in PBM, is also a risk stratification and optimization element in ERAS.
To conclude, shift away from standard transfusion practice to PBM is a paradigm shift. Anaesthetist, being periopeative physician, has an important role to play in the practice and development of it.

As part of our ERAS programme, Patient Blood Management (PBM) came into place in Tseung Kwan O Hospital (TKOH) since 2016. PBM is a multidisciplinary, evidence based approach to optimize use of donor blood and to improve clinical outcomes by avoiding unnecessary exposure to blood components.

In TKOH experience, we first started PBM in surgical patients undergoing major colorectal surgery, and then Total Knee Replacement surgery, and later patients undergoing major gynaecological surgeries. Iron sucrose was first used in the beginning of our programme, which had later been replaced by Iron Isomaltoside since its introduction in April 2018, due to its higher single dose limit, thus allowed a shorter time interval to surgery. We identified, evaluated and managed anemia preoperatively. Should iron deficiency anemia be found, we would start either oral or intravenous iron therapy promptly. Intraoperatively, we carefully manipulated patient’s haemodynamics, optimized haemostasis and avoided coagulopathy. While postoperatively, we followed up patients as a team with surgeon, and monitored and managed any postop anemia.

For the period from April 2017 to Mar 2019, a total of 66 surgical patients and 25 gynaecological patients had been given intravenous iron therapy preoperatively. The average rise in Hb level was 2.49 g/dL in the gynaecological group, and 1.55 g/dL in the surgical group. The overall transfusion rate was lowered to 4% in the gynaecological group after the implementation of PBM compared to 8% before, and was 6% in the surgical group compared to 11% before. 

We believe PBM had been a great success in TKOH. It significantly reduced transfusion rate and its associated morbidity and costs. With the trend of increasing demand for blood transfusion outweighing the supply of donated blood product, we believe PBM is the future trend to come.