Lung transplantation in a Jehovah's Witness.

Patients of the Jehovah's Witness faith generally do not accept transfusions of blood or blood products but some will accept cadaveric organs for transplantation. We report a left single lung transplantation in a 48-year-old Hispanic female with idiopathic pulmonary fibrosis and secondary pulmonary hypertension. We believe this is the first reported case of lung transplantation in a Jehovah's Witness.     

Heart transplantation in Jehovah's Witnesses. An initial experience and follow-up

More than 25 years of experience performing heart surgery on Jehovah's Witnesses has culminated in successful cardiac transplantation without administering blood products in five patients (mean age, 44.4 +/- 8.3 years) of this faith. The use of blood-conserving methods, iron supplementation, bone marrow-sparing maintenance immunotherapy, and brisk postoperative diuresis has added to the efficacy of cardiac transplantation in these patients. No perioperative deaths occurred, and early follow-up studies have shown that these patients have not been more susceptible to higher graft rejection rates due to the lack of pretransplant blood transfusions. As more Jehovah's Witnesses undergo heart transplantation in the future, comparison with other recipients who allow pretransplant blood transfusions may lead to a better understanding of rejection immunobiology. We conclude that cardiac transplants may be safely offered to Jehovah's Witnesses without fear of a uniformly poor outcome.     

A single-center experience of renal transplantation in thirteen Jehovah's Witnesses

The beneficial effects of pretransplant blood transfusions on the success rate of renal transplantation have been so overwhelmingly emphasized that there is virtually no information on the fate of grafts in nontransfused patients transplanted during the last decade. Since 1979, all patients who have undergone renal transplantation at the University of Minnesota have routinely received random blood transfusions except Jehovah's Witnesses. Jehovah's Witnesses refuse transfusions but will accept renal allografts. From 1979 to May 30, 1987, primary renal allografts were placed in thirteen nontransfused Jehovah's Witnesses; six patients received kidneys from mismatched living-related donors, two patients received HLA-identical sibling grafts, and five patients received cadaveric renal allografts. The range of follow-up of the thirteen patients was 3-93 months, with a mean of 45 months and a median of 50 months. The outcomes after renal transplantation in Jehovah's Witnesses were compared with those of a paired control group (n = 25) matched for age, date of transplant, donor source, and diabetic status. The overall three-year actuarial patient and graft survival rates of the Jehovah's Witnesses were 83 per cent and 66 per cent, versus 80 per cent and 77 per cent for the controls. Although the outcomes after renal transplantation in Jehovah's Witnesses were similar to those of the control group, the Jehovah's Witnesses had an increased susceptibility to rejection episodes. The cumulative percentage of incidence of primary rejection episodes was 77 per cent at three months in the Jehovah's Witnesses versus 44 per cent at 21 months in the matched control group. The consequence of early allograft dysfunction from rejection was particularly detrimental to Jehovah's Witnesses who developed severe anemia (hemoglobin (Hgb)* 4.5 g per cent)-two early deaths occurred in the subgroup with this combination of problems. The overall results suggest that renal transplantation can be safely and efficaciously applied to most Jehovah's Witnesses but those with anemia who undergo early rejection episodes are a high-risk group relative to other transplant patients.     

Liver transplantation in Jehovah''s witnesses

For religious reasons, Jehovah's witnesses refuse transfusion of blood products (red cells, platelets, plasma), but may accept organ transplantation. The authors developed a multidisciplinary protocol for liver transplantation in Jehovah's witnesses. In a 6-year period, nine Jehovah's witness patients were listed for liver transplantation. They received preoperative erythropoietin therapy, with iron and folic acid that allowed significant haematocrit increase. Two patients underwent partial spleen embolization to increase platelet count. Seven patients underwent cadaveric whole liver transplantation, and two right lobe living-related liver transplantation, using continuous circuit cell saving system and high dose aprotinin. No patient received any blood product during the surgical procedure. One patient suffering from deep anaemia after living-related liver transplantation was transfused as required by his family, but died from aspergillus infection. One 6-year-old child was transfused against her parent's will. The authors demonstrated that it is possible to increase haematocrit and platelet levels in cirrhotic patients awaiting liver transplantation. They were able to reduce intraoperative need for blood products, allowing liver transplantation in prepared Jehovah's witness patients. This experience may be beneficial for non-Jehovah's witness liver transplant recipients.     

The Ross operation in a Jehovah's Witness: a paradigm for heart surgery in children without transfusion

A 3-year-old 18 kg male child of the Jehovah's Witness faith presented with severe aortic regurgitation. A successful Ross procedure was performed using a pulmonary autograft, without the use of blood or blood product transfusion. Blood conservation strategy included: (1) preoperative treatment with recombinant human erythropoietin; (2) intraoperative strategies, including technical modifications to the Ross procedure, and the prophylactic use of fibrin glue; (3) utilization of a heparin-bonded cardiopulmonary bypass circuit and assisted venous drainage; and 4) the use of prebypass phlebotomy, cell-saving device and autotransfusion. The patient was discharged home on postoperative day 7 with a hemoglobin level of 11.9.     

Use of Venovenous Extracorporeal Membrane Oxygenation as a Bridge to Urgent Lung Transplantation in a Case of Acute Respiratory Failure

Several transplant centers consider pretransplant extracorporeal membrane oxygenation (ECMO) as a contraindication for lung transplantation because of the poor outcomes. However, some technical improvements have changed the scenario; there is increasing evidence of ECMO efficacy as a bridge to lung transplantation. This report describes the successful use of venovenous ECMO as a bridge to an urgent bilateral lung transplantation and as treatment for primary graft dysfunction in a case of hyperacute pulmonary fibrosis in a 58-year-old man. Our experience demonstrated that ECMO, using Quadrox, supported respiratory functions for 28 days without any detrimental effects, serving as a successfully bridge to urgent lung transplantation.     

Liver transplantation from a non-heart-beating donor after pulmonary failure: Report of a case

We report a case of successful liver transplantation after controlled donor after cardiac death procurement from a donor who died of pulmonary failure. The donor was a 28-year-old woman with idiopathic pulmonary fibrosis, whose life support could not continue when her condition deteriorated rapidly while waiting for a suitable donor for lung transplantation. She was on noninvasive negative pressure ventilatory support before the donor organs were procured.     

Late lung retransplantation using extracorporeal membrane oxygenation as a bridge: case report

Lung retransplantation is the only therapeutic option for acute and chronic graft failure, but only a few cases have been described to have been performed with extracorporeal membrane oxygenation (ECMO) support. We describe the successful case of a 46-year-old man treated with right lung transplantation and left lung retransplantation supported by venovenous ECMO.Lung retransplantation is the only therapeutic option to treat severe primary graft dysfunction, major technical problems, and refractory chronic rejection following pulmonary transplantation. Despite a number of comprehensive studies on lung retransplantation, only a few works have addressed the use of extracorporeal membrane oxygenation (ECMO) as a bridge to the surgical reoperation. ^{[1], [2], [3] and [4]} Herein we have presented a patient treated with pulmonary bilateral retransplantation subsequent to ECMO therapy for progressive deterioration of pulmonary function in single lung transplantation.     

Balloon angioplasty for pulmonary artery stenosis after lung transplantation

We report here a successful case of balloon angioplasty for a stenosis of the pulmonary artery after lung transplantation. A 49-year-old patient with end stage diffuse bronchiectasis with sinusitis underwent bilateral living donor lobar lung transplantation. After treatment of postoperative right pneumothorax, a perfusion lung scan revealed deficient perfusion in the left lung. Pulmonary angiography showed a severe stenosis in the left pulmonary artery just distal to the anastomosis. Percutaneous balloon angioplasty improved both pulmonary perfusion and respiratory function.     

Temporary partial intra-iliac balloon occlusion for the treatment of acetabulum fracture in a Jehovah's Witness: a case report

Blunt trauma patients with acetabular fractures can lose as much as 2 L of blood after injury, and approximately 40% of these patients require blood transfusions. Fractures involving the anterior and posterior columns may require more than 1 surgery for adequate fracture fixation, increasing the potential for greater blood loss. Although blood transfusions may be medically necessary in these cases, Jehovah's Witnesses often refuse transfusion as a matter of religious conviction. The religious tenets of this faith preclude the use of blood transfusions and certain other blood products, based on an interpretation of Acts 15:29. To treat patients with these beliefs, various techniques have been developed to minimize blood loss as an alternative to transfusion. Temporary arterial balloon occlusion, also known as an "internal tourniquet," was first reported in 1954 for use in severe penetrating abdominal trauma. It was later used to control basilar artery bleeding and to limit blood loss in Jehovah's Witness patients undergoing revision total hip or knee arthroplasty. This case report documents the successful use of temporary balloon occlusion to minimize blood loss during an open reduction internal fixation of a both-column acetabulum fracture in a Jehovah's Witness patient. The method used for achieving this intra-iliac balloon occlusion is described in detail so that others also may implement this technique.     

Pulmonary Embolus after Retrieval of a Temporary Inferior Vena Caval Filter in a Jehovah's Witness Undergoing Gastric Bypass Surgery

We present the case of pulmonary embolus after retrieval of a temporary inferior vena caval (IVC) filter in a Jehovah's Witness patient who underwent uneventful laparoscopic gastric bypass surgery. The 40-year-old female was admitted to the hospital 2 days after retrieval of the filter with bilateral pulmonary emboli for which she received anticoagulation therapy and consequently developed thoracic bleeding. We present this complicated case to highlight the risk of pulmonary emboli after IVC filter removal without anticoagulation, and to demonstrate the additional risk in managing a Jehovah's Witness patient.     

Acute hemodilution in an anemic Jehovah's Witness during extensive abdominal wall resection and reconstruction

A 47-year-old anemic Jehovah's Witness with Gardner's syndrome presented with a large abdominal wall desmoid tumor requiring extensive resection with a musculocutaneous flap reconstruction. At surgery a technique of acute limited normovolemic hemodilution (ALNH) was used to minimize blood loss and avoid blood transfusions. Complications that follow transfusions of homologous blood are reviewed, and a recommendation is made to use ALNH because of its advantages in those patients in whom significant blood loss is expected.     

Bilateral sequential lung transplant for ectodermal dysplasia

A case of bilateral sequential lung transplantation for anhidrotic ectodermal dysplasia is presented. The patient was a 16-year-old male with end-stage lung disease secondary to chronic severe respiratory infection. Although a relatively rare disease, the common association of fatal pulmonary compromise in those affected with this disorder warrants consideration of lung transplantation as a viable therapeutic option.     

Aortocoronary bypass in Jehovah's Witnesses: review of 46 patients.

The hemodilution technique for cardiopulmonary bypass using blood substitutes for priming has permitted open heart operations in Jehovah's Witnesses who refuse to accept blood, and has reduced the need for massive blood transfusion in certain procedures including aortocoronary bypass. A series of 46 Jehovah's Witness patients underwent aortocoronary bypass procedures. Of these, two patients died, representing a mortality of 4.3 per cent. Neither patient's death was related to lack of blood transfusions. The hospital stay and recovery time of all the other patients was not affected by failure to transfuse blood. The excellent short- and long-term results of this particular group paralleled those observed in our larger series of over 2700 other patients who have undergone coronary bypass surgery since 1969. Among these patients not of the Jehovah's Witness religion, blood transfusion was not necessary in about 30 per cent, while the remainder averaged less than two units per patient. Our results with Jehovah's Witness patients encourage our policy of avoiding blood transfusions whenever possible in all operations. Further justification for our conservative attitude is provided by the current shortage of blood in relation to a projected continuous increase of aortocoronary bypass procedures in the future.     

Emergent lung retransplantation after discovery of two primary malignancies in the donor.

A 50-year-old woman underwent single lung transplantation for advanced chronic obstructive pulmonary disease. Shortly after the procedure, it was discovered that the donor suffered from both a renal cell carcinoma and a spindle-cell sarcoma of the ascending aorta, which had metastasized to the spleen. The patient was emergently listed for a retransplantation and underwent bilateral lung transplantation after a new donor became available 4 days after the initial transplantation procedure. After 24 months, the patient is without evidence of malignancy. This case illustrates the role of immediate retransplantation for patients who have inadvertently received thoracic organs from donors harboring occult malignancies.     

Technique of successful clinical double-lung transplantation

Lung transplantation has become a successful method in the therapy for end-stage pulmonary disease. While single-lung transplantation provides benefit to patients with pulmonary fibrosis, bilateral lung transplants are required for septic or emphysematous lung disease. We describe the technique employed in 6 patients to transplant en bloc both lungs with the recipient heart left in place. The lungs are connected by a left atrial cuff, main pulmonary artery, and trachea. The completed implantation has a tracheal anastomosis securely wrapped in omentum, a left atrial anastomosis posterior to the heart, and a pulmonary artery anastomosis anteriorly. Airway ischemia resulted in the death of 1 patient. This procedure allows complete excision of all diseased pulmonary tissue, retention of the recipient's own heart, and separate excision of the donor heart for use in another recipient, thereby markedly increasing the supply of donor lungs for transplantation.     

Severity of anemia and operative morbidity and mortality. Report on 3 clinical cases in Jehovah's Witnesses and review of the literature

It has been reported that patients who refuse blood transfusions, such as Jehovah's witnesses, can undergo major surgery. In a review of the literature, however, we critically examined the severity of anaemia in relation to operative mortality and morbidity rates. We report three cases of Jehovah's witnesses who underwent major surgery and presented complication during the postoperative period. Case 1: a 50-year-old man with oesophageal achalasia who underwent Heller's myotomy and Nissen's fundoplication. The postoperative period was complicated by massive haemorrhage and the patient was reoperated on postoperative day 1. After four years, he underwent total oesophagectomy because of severe chronic oesophagitis. On postoperative day 13 the patient suffered anteroseptal myocardial ischaemia, which was treated with medical therapy. Case 2: a 40-year-old man, admitted for ulcerative rectocolitis, who underwent total colectomy. On postoperative day 1 he presented massive haemorrhage and shock. He was reoperated and the postoperative period was complicated by myocardial ischaemia, renal failure and an enterocutaneous fistula. Case 3: a 65-year-old woman with ulcerative rectocolitis who underwent total colectomy and a temporary ileostomy. She suffered venous thrombosis of the lower limbs and pulmonary oedema. The patient died 14 months after surgery as a result of massive haemolysis by cryoagglutinins and cardiac arrest.     

Posterior spinal fusion without blood replacement in Jehovah's Witnesses

Posterior spinal fusion without blood replacement is a formidable procedure that most orthopedic surgeons are reluctant to attempt. This procedure has been performed without transfusions on 19 patients, all of whom were Jehovah's Witnesses. The operations were performed over four spinal segments at a time and were planned so that the procedure could be terminated when 10% of the patient's estimated total blood volume had been lost. Allogeneic donor bone was used to minimize blood loss whenever this was acceptable to the patient. The procedure was associated with a high incidence of pseudarthrosis, all cases of which occurred when allogeneic bone was used. No deaths or life-threatening complications were encountered. Thus, posterior spinal fusion can be performed in Jehovah's Witnesses without transfusion, but the procedure should be conducted only by the experienced spinal surgeon.     

Urgent contralateral pneumonectomy after single lung transplantation for lymphangioleiomyomatosis

Left single lung transplantation in a 33-year-old woman affected by end-stage lymphangioleiomyomatosis was complicated by spontaneous and diffuse bleeding from the right lung at the end of the procedure. The right lung was completely deteriorated and the only option to stop the bleeding was a right pneumonectomy. At 14 months after transplantation, the single allograft showed good lung function with acceptable volumes. Single lung transplant and contralateral pneumonectomy can be considered a safe procedure in case of complications related to native lung either in case of lymphangioleiomyomatosis than for other lung diseases (emphysema, cystic fibrosis).     

Avoiding blood products during liver transplantation

Liver transplantation is a major surgical procedure usually requiring large amount of blood products (red cells, platelets, fresh-frozen plasma). We developed a multidisciplinary transfusion-free protocol for liver transplantation in Jehovah's witnesses who refuse the use of blood products but accept organ transplantation. Between September 1998 and November 2004, 9 of 29 Jehovah's witnesses evaluated for liver transplantation were transplanted after medical preparation. None of these patients received any blood product during the surgical procedure. This experience may be beneficial for the entire liver transplantation population, as excessive transfusion has been linked to increased morbidity and mortality in liver transplantation.