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.     

Live donor liver transplantation without blood products: strategies developed for Jehovah's Witnesses offer broad application

OBJECTIVE: Developing strategies for transfusion-free live donor liver transplantation in Jehovah's Witness patients. SUMMARY BACKGROUND DATA: Liver transplantation is the standard of care for patients with end-stage liver disease. A disproportionate increase in transplant candidates and an allocation policy restructuring, favoring patients with advanced disease, have led to longer waiting time and increased medical acuity for transplant recipients. Consequently, Jehovah's Witness patients, who refuse blood product transfusion, are usually excluded from liver transplantation. We combined blood augmentation and conservation practices with live donor liver transplantation (LDLT) to accomplish successful LDLT in Jehovah's Witness patients without blood products. Our algorithm provides broad possibilities for blood conservation for all surgical patients. METHODS: From September 1998 until June 2001, 38 LDLTs were performed at Keck USC School of Medicine: 8 in Jehovah's Witness patients (transfusion-free group) and 30 in non-Jehovah's Witness patients (transfusion-eligible group). All transfusion-free patients underwent preoperative blood augmentation with erythropoietin, intraoperative cell salvage, and acute normovolemic hemodilution. These techniques were used in only 7%, 80%, and 10%, respectively, in transfusion-eligible patients. Perioperative clinical data and outcomes were retrospectively reviewed. Data from both groups were statistically analyzed. RESULTS: Preoperative liver disease severity was similar in both groups; however, transfusion-free patients had significantly higher hematocrit levels following erythropoietin augmentation. Operative time, blood loss, and postoperative hematocrits were similar in both groups. No blood products were used in transfusion-free patients while 80% of transfusion-eligible patients received a median of 4.5+/- 3.5 units of packed red cell. ICU and total hospital stay were similar in both groups. The survival rate was 100% in transfusion-free patients and 90% in transfusion-eligible patients. CONCLUSIONS: Timely LDLT can be done successfully without blood product transfusion in selected patients. Preoperative preparation, intraoperative cell salvage, and acute normovolemic hemodilution are essential. These techniques may be widely applied to all patients for several surgical procedures. Chronic blood product shortages, as well as the known and unknown risk of blood products, should serve as the driving force for development of transfusion-free technology.     

Isolated limb perfusion for an irresectable melanoma recurrence in a Jehovah's witness.

Isolated limb perfusion (ILP) is a treatment option for irresectable melanoma lesions, because with ILP 20-fold higher concentrations of chemotherapy can be achieved locally than is systemically possible and high response rates are subsequently achieved. Jehovah's witnesses do not accept any form of blood transfusion, either autologous or homologous blood or only blood products. The use of an extracorporeal circuit, without the use of any blood products is acceptable for Jehovah's witnesses. The case of a 59-year-old Jehovah's witness with an irresectable melanoma recurrence for which an ILP. Because of adequate blood flow through the perfused limb, the limb did not become acidotic, even though there was a significant drop in the Hb concentration in the limb during the ILP. Isolated limb perfusions without the use of any blood transfusion products are technically possible, but an adequate preoperative hemoglobin concentration is a prerequisite.     

Right trisectionectomy of the liver for intrahepatic cholangiocarcinoma with bile duct invasion in a Jehovah's Witness

Intrahepatic cholangiocarcinoma (ICC) is well known to have a very poor prognosis. Aggressive surgical strategies in the treatment of ICC, including major hepatectomy, have been reported to afford patients the best chance for significant survival. Recent advancements in surgical techniques concerning live donor liver transplantation have dramatically improved the results of major hepatectomy. However, surgical treatment of biliary malignancy is complex and is known to increase the likelihood of blood transfusion. We describe a Jehovah's Witness patient with ICC and concomitant bile duct invasion who had a successful right trisectionectomy with bile duct resection, lymph node dissection, and Rouxen-Y hepatico-jejunostomy without blood transfusion. A multidisciplinary preparation was crucial in obtaining this positive outcome. Importantly, bloodless liver transection techniques with inflow clamping, meticulous dissection, and hemostasis should be utilized for major hepatectomy in a Jehovah's Witness. The success of this case may alert clinicians to consider a hepatectomy as a possible option in the treatment of ICC in a Jehovah's Witness.     

Neurosurgical procedures in Jehovah's Witnesses: an increased risk?

OBJECTIVE: Because of the growing numbers of members worldwide in the sect of Jehovah's Witnesses, the refusal of blood and blood products due to religious reasons is increasingly encountered in clinical practice. As an alternative to blood transfusion, Jehovah's Witnesses accept blood-free volume substitution, and they sometimes accept the intraoperative reinfusion of autologous blood via a so-called cell saver. The aim of this study was to examine whether the refusal of blood transfusion affects the surgical indications for neurosurgery and whether morbidity and mortality rates are higher after neurosurgical interventions in Jehovah's Witnesses. METHODS: The pre-, intra-, and postoperative hemoglobin and hematocrit values as well as coagulation parameters of a group of Jehovah's Witnesses (n = 103) were compared with those of a valid control group. RESULTS: The total intraoperative blood loss during spinal and intracranial surgery in Jehovah's Witnesses was often less than in controls, which suggests a less traumatic surgical procedure. Hemodynamically relevant blood loss occurred in two spinal and four intracranial interventions. The patients were managed without receiving blood transfusions or blood products, although increased time in the intensive care unit and increased convalescence days were necessary. Mean surgical times were 17.5 minutes longer for spinal interventions and 36.7 minutes longer for intracranial interventions than for patients in the control group. This may be attributed to a more careful and thus slower surgical technique and to longer and more extensive hemostasis. The length of hospitalization was 15% longer for Jehovah's Witnesses than for controls. CONCLUSION: The morbidity and mortality rates for Jehovah's Witnesses undergoing neurosurgery were not higher than those of the control group. Thus, it can be concluded that Jehovah's Witnesses did not have a higher risk when microsurgical techniques and extensive anesthetic monitoring were applied during neurosurgery. Because the surgical success rate for Jehovah's Witnesses corresponded to that of the control group, the increase in costs because of longer treatment times is compensated in the long run by avoiding a lengthier illness, sometimes with more expensive conservative therapy.     

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.     

Use of recombinant human erythropoietin to facilitate liver transplantation in a Jehovah's Witness

A 46-yr-old woman with rapidly progressing primary biliary cirrhosis presented for liver transplantation. The use of preoperative recombinant human erythropoietin enabled this to be achieved without prohibited blood products. Perioperative management of this patient and general principles of management of Jehovah's Witnesses undergoing major surgery are discussed.      

Two successful cardiovascular surgeries in Jehovah's witnesses

Anesthesia for Jehovah's witnesses is sometimes problematic, especially when they have an open heart surgery. We could successfully manage two Jehovah's witnesses who underwent mitral valve replacement and thoracic aneurysm repair without transfusion. Prior to surgery, it is crucial for a operation to carefully assess the patient's cardiovascular reserve, estimated hemorrhage volume, permissive range of hemorrhage, alternative methods of blood transfusion, and risk of death.     

The risk of contracting an infectious disease from blood transfusion

In the general population, the likelihood of an individual receiving a transfusion has been calculated to be about 0.89% per year, increasing dramatically with age. Massive intraoperative hemorrhage from trauma, cardiopulmonary bypass, and orthotopic liver transplantation need substantial replacement therapy. In renal transplantation, blood transfusion is a debated induction tool for specific allograft tolerance, since it causes a nonspecific down-regulation of immune function. In transplantations, in humoral immune deficiencies, in hematological disorders, and in HIV infection, the intravenous immunoglobulin prophylaxis may alter the monocyte/macrophage system host immunity and immune surveillance against infection, tissue or cell damage, and malignancy. Some persons, like Jehovah's Witnesses, object to transfusion of blood products, posing ethical and practical issues concerning treatment of blood disorders, transplantation, and trauma. In this review we examined the actual risk of contracting an infectious disease from an allogeneic blood transfusion to contribute to an uneasy decision-making process. We have found that the procedure is presently considerably safe.     

Liver transplantation in a Jehovah’s Witness with ankylosing spondylitis

PURPOSE: Orthotopic liver transplantation is typically associated with large volume blood loss. Technological and pharmacological advances permit liver transplantation in patients who formerly were not candidates for this surgery because of strict limitations on blood product administration. We describe a liver transplant in a Jehovah's Witness with ankylosing spondylitis. CLINICAL FEATURE: A 49-yr-old Jehovah's Witness with ankylosing spondylitis and end stage liver disease secondary to sclerosing cholangitis underwent orthotopic liver transplantation. Recombinant human erythropoietin (4,000 IU sc every two days for four weeks, then 4,000 IU sc every week) established a normal hemoglobin concentration preoperatively (> 140 g x L(-1) compared with 120 g x L(-1) baseline). Intraoperatively, strategies for reducing risk of blood product transfusion included avoidance of hypothermia (T>35 degrees C), minimal blood sampling (four 1 ml samples), normovolemic hemodilution (two units), administration of Aprotinin (2 million units bolus dose followed by infusion of 500,000 u x hr(-1)), and return of blood (1,500 ml) scavenged from the operative field. Estimated blood loss was 2,200 mi. The preoperative and postoperative hemoglobin concentration was 147 g x L(-1) (hematocrit 0.45) and 123 g x L(-1) (hematocrit 0.37), respectively. No blood products were required and he was discharged three weeks postoperatively without complication. CONCLUSION: Technological and pharmacological advances allow patients to undergo surgery traditionally associated with large volume blood loss with reduced risk of blood product administration.     

Cardiac surgery in Jehovah''s witnesses. A review of 36 cases

Between January 1971 and January 1985, 31 Jehovah's witnesses underwent 24 bypass and 12 non-bypass cardiothoracic operations at the National Heart Hospital. Fifty-eight% of the group were under 16 years of age. There was one death in the non-bypass group unrelated to blood loss. Six deaths occurred in the bypass group. In one of these, blood loss contributed to the cause of death and in two patients, blood loss was directly related to the cause of death. The anaesthetic management of Jehovah's witnesses undergoing cardiac surgery is discussed.     

Pancreaticoduodenectomy without homologous blood transfusion in an anemic Jehovah's Witness.

Whipple pancreaticoduodenectomy is an accepted procedure for management of periampullary and pancreatic carcinomas and has modern mortality rates of less than 10%. The procedure is associated with significant operative blood loss. Therefore, blood transfusion is an important supportive measure. We report the case of a bleeding ampullary carcinoma in a Jehovah's Witness who refused transfusion of all homologous blood products. Despite a preoperative hemoglobin level of 51 g/L, curative pancreaticoduodenectomy was successfully performed. The success of the procedure can be primarily attributed to careful surgical technique, intraoperative autotransfusion, avoidance of postoperative complications, minimization of perioperative phlebotomies, use of human recombinant erythropoietin, and, possibly, the use of the perfluorocarbon emulsion Fluosol DA-20%. The case illustrates several important principles for the surgical treatment of patients with severe anemia who refuse transfusion of homologous blood products.     

Simultaneous pancreas-kidney transplantation in Jehovah's Witness patients

The safety and efficacy of renal and liver transplantation has been reported for Jehovah's Witness (JW) patients, with patient, and graft survival similar to that of non-JW patients. We report our experience in five JW recipients of simultaneous pancreas-kidney transplants. None of the patients received transfusion of blood or blood products, either before or after transplant. Like the other solid organ transplants, patient, and graft survival was similar to that of the non-JW group. Specific technical issues related to the operative procedure include the use of the cell saver until the donor duodenum is opened (enteric contamination). Post-operatively, care should be taken to minimize drawing of blood and optimize erythrocyte synthesis with erythropoetin, folic acid, vitamin B12, and iron. Finally, it is critical that the pre-operative evaluation demonstrates sufficient cardiac reserve to allow the JW patient to tolerate a possible temporary anemic state.     

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.     

Lung transplantation in a Jehovah's witness. Case report in a twinning procedure

Jehovah's Witnesses, patients who refuse blood transfusions, are generally not considered as candidates for lung transplantation owing to the frequent requirement for transfusions. A successful procedure in a Jehovah's Witness is presented and to our knowledge this is the 2(nd) reported case. The patient, a 38-year-old female, type I diabetes, affected by idiopatic pulmonary fibrosis underwent left lung transplantation. From the same pulmonary bloc a twinning procedure was obtained by means of right lung transplantation in a 58-year-old man affected by the same pathology. Surgical strategies employed in achieving a successful outcome, ethical and moral aspects are discussed.     

Surgery and blood transfusion in Jehovah's witnesses: a medical-legal review

Conflict between two ethical and legal conditions such as life and freedom is frequent in medical practice. Jurisdiction has handed down contradictory decisions and edicts when placing life (and therefore the lex artis of physicians) above Jehovah's witnesses' right to refuse blood transfusions. However, in principle, the right to life takes precedence over the patient's autonomy because, based on professional ethics, physicians have a duty to attempt a cure. Thus the patient's liberty is infringed, giving rise to interventions that may give rise to complaints and lawsuits. The present article provides an overview of each and every situation that could give rise to doubts, as well as an analysis of jurisdiction and the legal responsibilities involved in surgical decisions about Jehovah's witnesses.     

Intraoperative cell salvage during radical prostatectomy: a safe technique for Jehovah's Witnesses

Radical retropubic prostatectomy (RRP) is an operation historically associated with the potential for significant blood loss. Patients who refuse a blood transfusion, such as Jehovah's witnesses, may be only offered radiation therapy as potentially curative treatment for prostate cancer because of the potential for a transfusion. Intraoperative cell salvage (IOCS) is an effective blood management strategy for patients who are not willing to accept predonated autologous or allergenic blood. We present our management for Jehovah's Witness patients with clinically localized prostate cancer, emphasizing our blood management approach. This is the first such report.     

A novel approach to gallbladder cancer in a Jehovah's Witness

Transfusion of blood or blood products peri- or postoperatively is often necessary in patients undergoing liver resections for hepatic or biliary tract neoplasms. In Jehovah's Witnesses this inevitably poses a difficult dilemma for clinicians. A 66-year-old female Jehovah's Witness with a T1b gallbladder cancer was referred to our specialist unit for further treatment after having had a routine laparoscopic cholecystectomy in another hospital. Although an abdominal computed tomography scan preoperatively showed a normal liver with no evidence of regional lymph node involvement, histologically the tumor was found in the posterior wall of the gallbladder adherent to the liver bed and had a full thickness involvement of the muscular layer, raising suspicion of a local invasion into the liver bed. The patient, having refused liver resection, was treated with a laparoscopic radiofrequency ablation under intraoperative ultrasound guidance using a newly developed "cooled-tip" needle and a 500-kHz radiofrequency generator. A "zone of necrosis" measuring 3.5 cm in diameter was created in the liver bed and adjacent tissues. The procedure lasted 90 min with no blood loss. Postoperatively, the patient was discharged on the third postoperative day and remained disease free at the 9-month follow-up. Although the follow-up in this case was too short to determine the long-term result of this approach, we believe that this is a single unique case posing a challenging problem to clinicians for which radiofrequency ablation may have a role in offering an alternative to major resections.     

How to approach major surgery where patients refuse blood transfusion (including Jehovah's Witnesses)

Jehovah's Witnesses do not permit the use of allogeneic blood products. An increasing number of patients are refusing blood transfusion for non-religious reasons. In addition, blood stores are decreasing, and costs are increasing. Transfusion avoidance strategies are, therefore, desirable. Bloodless surgery refers to the co-ordinated peri-operative care of patients aiming to avoid blood transfusion, and improve patient outcomes. These principles are likely to gain popularity, and become standard practice for all patients. This review offers a practical approach to the surgical management of Jehovah's Witnesses, and an introduction to the principles of bloodless surgery that can be applied to the management of all patients.     

Beriplex P/N: an alternative to fresh frozen plasma in severe haemorrhage

The management of Jehovah's Witnesses suffering from severe haemorrhage can be very difficult. Those patients who are taking oral anticoagulant therapy pose an additional risk and the difficulty may be compounded by the development of coagulopathy. Several alternatives to blood products have been reported to be useful in this situation. We report the successful management of an emergency postsurgical wound bleeding in a Jehovah's Witness using Beriplex (a concentrate of factors II, VII, IX and X). The patient, who was taking warfarin, presented 10 days after an elective laminectomy with significant bleeding from the surgical wound and coagulopathy. Despite early surgical measures, there was continuing haemorrhage. This was arrested by giving Beriplex intra-operatively. To our knowledge this is the first reported case of the use of Beriplex in a Jehovah's Witness for control of emergency haemorrhage and coagulopathy.