How important is transfusion avoidance in 2013?

Prior to the advent of recombinant erythropoietin in the late-1980s, blood transfusions were the mainstay of anaemia management in patients with end-stage renal failure, many of whom required "top-up" transfusions every 2 to 4 weeks to relieve the debilitating symptoms of severe anaemia. Erythropoietin therapy, however, allowed for the first time, such patients to achieve a sustained correction of anaemia, and there was a dramatic fall in both the use of red cell transfusions in dialysis units, as well as the associated transfusional iron overload prevalent in dialysis patients. Avoidance of blood transfusions improved access to, and outcomes of, kidney transplantation, due to reduced HLA sensitization. In recent years, however, there have been safety concerns regarding the use of erythropoiesis-stimulating agents (ESAs), and there are signs that the use of blood transfusions is once again increasing. The aim of this review is to reassess how important transfusion avoidance is in 2013, and whether we should still have the same concerns about HLA sensitization that we had 20 years ago.