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.     

Open-heart surgery in Jehovah's Witnesses

During a 7-year period, 11 adult members of the religious sect Jehovah's Witnesses underwent cardiac surgery with extracorporeal circulation. No homologous blood transfusions were given. Blood-conserving procedures were employed, viz. initial collection of autologous blood, haemofiltration or processing (Cell Saver) of blood collected during extracorporeal circulation and reinfusion of shed mediastinal blood. The total perioperative blood loss averaged 1080 ml (15 ml/kg body weight), equalling 19% of total body blood volume. The mean haemoglobin on discharge from hospital was 11.0 g/100 ml. There was no perioperative mortality. Postoperative pulmonary function was good and there was no serious morbidity. Jehovah's witnesses with serious, surgery-necessitating heart disease can be offered operation comprising recognized blood-conserving procedures.     

Cardiac operation in children of Jehovah's Witnesses

The perioperative courses of 5 open heart operations in children of Jehovah's Witnesses are reviewed. The age of patients ranged from 6 to 13 years old and the body weight, from 21.5 kg to 38.5 kg. All the patients survived and are doing well now. The cardiopulmonary bypasses, primed with lactated Ringer's solution, were performed safely with the use of moderate hypothermia. Hemodilution techniques are the key for the safe exocorporeal circulation and we set the lowest limit of body weight at 20 kg. Postoperative bleeding occurred in one case and was treated by early exploration. All the cases did not receive any blood or blood products during hospitalization. Therefore we can conclude that cardiac operations over 20 kg of body weight can be safely performed without any blood or blood products. With regard to social aspects, especially in case of emergency, we should make the decision regarding transfusion under the guidance proposed by the Japanese Medical Association.     

Anaesthesia and critical care of Jehovah's Witnesses

The Jehovah's Witness religion is a Christian movement, foundedin the US in the 1870s, with 6 million members worldwide (150,000in the UK). Members of this faith have strong beliefs basedupon passages from the Bible that are interpreted as prohibitingthe ‘consumption’ of blood. Their beliefs preventthem from accepting transfusion of whole blood or its primarycomponents. They also believe that blood that has been removedfrom the body is ‘unclean’ and should be disposedof. The use of procedures that involve the removal and storageof their own blood are often unacceptable (Table 1). View this table: [in this window] [in a new window]   Table 1 Acceptability of blood products and transfusion-related procedures in Jehovah's Witnesses   Blood-free major surgery in the Jehovah's Witness patient presentsa challenge to the anaesthetic and surgical team. The problemsassociated with their management highlights a growing health-careissue – the supply, safety and appropriate use of bloodproducts. Techniques learnt from treating them may prove beneficialto all patients undergoing major surgery.     

Revision Total Hip Arthroplasty in Jehovah's Witnesses

Revision total hip arthroplasty (THA) is associated with greater blood loss than primary THA. Jehovah's Witnesses will not accept transfusions of blood or blood products and are thus at an increased risk for complications due to perioperative anemia. The purpose of this study was to report the clinical outcomes, radiographic outcomes, morbidity, and mortality of Jehovah's Witnesses who were medically optimized and underwent revision THA.Databases from 2 institutions were reviewed to identify 10 patients (11 THAs) who were Jehovah's Witnesses undergoing revision THA with a minimum 24-month follow-up. At most recent follow-up, all patients were doing well clinically, with Harris Hip Scores greater than 80 points. Radiographic evaluation demonstrated well-positioned components and no progressive radioluciencies. No major perioperative medical or surgical complications occurred in patients undergoing THA. Revision THA for aseptic causes results in good clinical outcomes in patients who are preoperatively optimized before undergoing surgery.     

Strategies and outcomes of cardiac surgery in Jehovah's Witnesses

Abstract Background: Jehovah's Witnesses (JW) are a Christian faith, with an estimated 1.1 million members in the United States, well recognized for their refusal of blood and blood products. JW may not be considered for cardiac surgery due to perceived higher risks of morbidity and mortality. This study reviews our contemporary strategies and experience with JW undergoing routine and complex cardiac surgery. Methods: From November 2001 to April 2010, 40 JW were referred for cardiac surgery at a single quaternary referral institution. A retrospective analysis of demographic data, perioperative management, and clinical outcomes was examined. Published validated clinical risk calculator and model for prediction of transfusion were used to identify high‐risk patients (risk of mortality >6% or probability of transfusion >0.80). Results: The mean age was 70 (± 9.5) years with 21 men and 19 women. Patients were classified as high risk (45%, n = 18) and low risk (55%, n = 22) with demographics and comorbidities listed in Table 2 . Operative procedures included: isolated coronary artery bypass grafting (CABG) (n = 19), isolated valve replacement/repair (n = 7), valve/CABG (n = 7), reoperative valve replacement (n = 4), reoperative CABG (n = 2), valve/ascending aorta replacement (n = 1), and CABG/ascending aorta replacement (n = 1). All JW were evaluated by The Department of Bloodless Medicine to individually define acceptable blood management strategies. The mean preoperative hemoglobin was 14.1 g/dL (±1.6). Overall mortality was 5% (n = 2) all of which were in the high‐risk group. Discussion: Using a multidisciplinary approach to blood management, JW can safely undergo routine and complex cardiac surgery with minimal morbidity and mortality . (J Card Surg 2011;26:135‐143)

Table 2.
Patient Demographics

Hypotensive anesthesia for scoliosis surgery in Jehovah's Witnesses

Hypotensive anesthesia has been advocated in spinal surgery for the purpose of diminishing operative blood loss. This study evaluated its effectiveness in 12 Jehovah's Witnesses undergoing Harrington instrumentation and fusion who refused transfusion. Previous series from this institute did not use deliberate hypotension because of routinely low blood loss. Compared with matched controls operated on under normotensive anesthesia, the Jehovah's Witness patients had lower absolute blood loss but also shorter operative time. Applied linear-regression analysis demonstrated that the diminished blood loss was associated with shorter operative time (P = 0.0002) rather than lower blood pressure. The majority of blood losses in spinal instrumentation with fusion occurs with decortication. This rapid bleeding occurs at venous pressures which are unaffected by arterial blood pressure manipulation. The authors conclude that spinal surgery is possible in Jehovah's Witnesses without transfusion and that operative technique is the single most important determinant of blood loss.     

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.     

Heart transplantation in Norway. One-year experience

Eight patients underwent orthotopic heart transplantation in Norway during 1984, with retransplantation in one case. The age range of the 5 men and 3 women was 19-53 years. The preoperative diagnosis was cardiomyopathy in 6 patients, ischaemic heart disease in one, and a combination of the two disorders in one patient. The immunosuppressive regimen, with cyclosporin A and low-dose prednisolone, and the treatment of graft rejection, followed the Stanford University protocol. There was no operative mortality. Three patients died shortly after the transplantation, 2 of them after about a week from acute rejection; in one of these 2 cases a second transplant was made, but was followed by pulmonary and renal complications. The third death occurred about 10 weeks postoperatively, from donor heart failure due to Toxoplasma myocarditis. The 5 survivors are clinically in good condition.     

Transfusion free surgery: single institution experience of 27 consecutive liver transplants in Jehovah's Witnesses

BACKGROUND: Despite the risks associated with transfusion, the medical community continues to view blood as a safe and abundant product. In this article, we provide an effective strategy to accomplish orthotopic liver transplantation without transfusion. STUDY DESIGN: From June 1999 through July 2004, 27 liver transplantations were performed in Jehovah's Witness patients at the USC-University Hospital (24 adults, 3 children). Nineteen of these were living donor (LD) and eight were deceased donor (DD) liver transplants. Preoperative blood augmentation with erythropoietin and iron was achieved. At induction, all LD and six of eight DD recipients underwent acute normovolemic hemodilution (ANH), and the operation was conducted under conditions of moderate anemia. Cell scavenging techniques were used. Acute normovolemic hemodilution and salvaged blood were returned as needed during bleeding or on completion of transplantation. RESULTS: The preoperative liver disease severity score was higher in the deceased donor group. We had 100% graft and patient survivals in the LD group, and 75% in the DD recipients. Two DD recipients died. The remaining are all alive and well, with a mean followup of 965 days (range 266 to 1,979 days) in the LD group and 624 days (range 119 to 1,132 days) in the DD group. CONCLUSIONS: Preoperative blood augmentation and acute normovolemic hemodilution provide a safe cushion against operative blood loss. Elective living donor liver transplantation allows full implementation of a transfusion-free strategy in the setting of early hepatic failure, portal hypertension, and anemia. This feat is an important step toward global standardization of transfusion-free surgical practice and an important response to widespread blood shortages and transfusion risks.     

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.     

Advances in general and vascular surgical care of Jehovah's Witnesses

BACKGROUND: Jehovah's Witnesses are an enlarging religious community in the US and throughout the world. Members of this faith refuse administration of blood during medical or surgical therapy even if death may occur as a consequence. The surgeon is consequently faced with difficulties and moral dilemmas of caring for these patients. PATIENTS AND METHODS: From July 1, 1975 to March 1, 1999, the author performed 132 general and vascular surgical procedures on pediatric and adult patients who were Jehovah's Witnesses. RESULTS: A surgical series of 132 patients who are Jehovah's Witnesses is reported. The series includes general surgical procedures in children and adults. Also, vascular surgical procedures in adults are reported. Thirty-one procedures were of significant magnitude to possibly require a blood transfusion. No patient in this series received a blood transfusion. No patient was refused an indicated surgical procedure. Fourteen complications incurred in this series which included one death. The age range of patients in this surgical series was 9 months to 91 years. There was no difference in the male to female ratio. The spectrum of cases reported represents the entire range of procedures seen in general and vascular surgical practices. CONCLUSIONS: The surgical care of Jehovah's Witnesses has become less of an operative risk over the last decade. There are now significant alternatives to the transfusion of blood, such as erythropoietin, iron dextran, aprotinin and Fluosol-DA 20%. Technological surgical developments and advances, such as the cell saver, argon beam coagulator, acute limited normovolemic hemodilution, autologous whole plasma fibrin gel, and controlled hypotensive anesthesia during anesthesia have contributed substantially to a reduction in the operative loss of blood. The time honored rule of hemoglobin of 10 g/dl and a hematocrit of 30% should not require strict adherence in the postoperative care of most patients. The acceptance of a lower transfusion trigger point of hematocrit of 22% and a hemoglobin of 7 g/dl can significantly reduce transfusion requirements without an increase in morbidity. Ethical considerations are discussed and evaluated when treatment restrictions, such as blood transfusion and other life-preserving therapies are limited by religious beliefs or living wills.