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	Since this article does not have an abstract, we have provided the first 150 words of the full text and any section headings.

To the Editor: The meta-analysis of cell-free hemoglobin-based blood substitutes and risk of myocardial infarction (MI) and death by Dr Natanson and colleagues¹ and the accompanying Editorial by Drs Fergusson and McIntyre² raise serious concerns for clinicians treating life-threatening anemia in South Africa, the only country where a hemoglobin solution (Hemopure, Biopure Corp, Cambridge, Massachusetts) is registered for clinical use.

The safety concerns discussed by Natanson et al were already recognized and addressed in the case-series study of the experience with infusion of the first 750 units of Hemopure to 336 patients in clinical practice in South Africa, published in 2006.³ The increased risk of noncardiovascular death in patients receiving Hemopure has also been noted in South Africa. A tendency to raise blood pressure and increase circulating blood volume was noted in the initial South African experience.³ We are concerned that this publication was not identified on the authors' literature . . . [Full Text of this Article]

Lewis J. Levien, MBBCh, PhD
Department of Surgery
Life Fourways Hospital
Johannesburg, South Africa

Richard E. Hodgson, MBChB
iti20178@mweb.co.za
Department of Anaesthesia and Critical Care
Nelson R. Mandela School of Medicine
Durban, South Africa

Michael F. M. James, MBChB, PhD
Department of Anaesthesia
University of Cape Town
Cape Town, South Africa

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