We are advising the orthopaedic SpR, Ms Fi Moor, about a 71 year old lady listed for urgent THR who has a normocytic anaemia (Hb 84) and requires optimisation pre-op. You have requested the following info:

PMH: Hypertension, type 2 diabetes, rheumatoid arthritis, CKD stage 2

No recent surgery, trauma. Diet normal.

DH: Ramipril, metformin, atorvastatin, methotrexate, aspirin, folic acid

Main symptoms are pain and lack of mobility in hip. No SOB, not dizzy, no chest pain.

Surgeons think procedure is low bleeding risk, but ‘you never know.’ They would ideally like Hb > 100 g/l.

Further tests as requested:

Ferritin            180 ug/l

Serum iron      5 umol/L

Transferrin      1,480 mg/L

Tsat                 10%

TIBC                 43 umol/L

B12                  239 ng/L

Folate              >20.0 ug/l

U&Es               Na 141, K 4.5, Ur 12.2, Cr 180, eGFR 65

LFTs                 Normal

Bone profile    Normal

CRP                  48

ESR                  40

Film has been reviewed by BMS: ‘Minor anisopoikilocytosis with occasional left-shifted neutrophil. No primitive cells, no dysplasia.’

Surgery is planned in the next few months.

Do you require any further investigations?

What treatment would you suggest to optimise Hb before surgery?

Please reply to us (@TeamHaem) on Twitter and always include #TeamHaem to allow others to follow your comments. Please join in the debate and learn about haematological problems along the way. The case will continue to evolve over the coming week so keep checking #TeamHaem on Twitter for more information.

Please note – all cases on TeamHaem are entirely fictional to protect patient confidentiality.TeamHaem are not a position of authority.  It is an educational platform to allow discussion and learning.