1
|
Nazal MR, Underdown MJ, Hopkins LD, McLean TW. Nontranfusional Management of Severe Anemia in an Adolescent Jehovah's Witness Patient. J Adolesc Health 2021; 69:166-167. [PMID: 33712383 DOI: 10.1016/j.jadohealth.2021.01.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 01/27/2021] [Accepted: 01/31/2021] [Indexed: 11/29/2022]
Abstract
Severe anemia in Jehovah's Witness patients has long been a complex and sometimes divisive issue, especially in children and adolescents. In adolescent patients old enough to express their wishes, the decision to transfuse becomes more complicated. We present the case of a 12-year-old Jehovah's Witness female with severe anemia (hemoglobin of 2.6 g/dL) secondary to menorrhagia. She was successfully managed without transfusion, for which the patient and her family were deeply grateful. This case demonstrates that it is possible to manage severe iron deficiency anemia without transfusion.
Collapse
Affiliation(s)
- Mark R Nazal
- Department of Pediatrics (Section of Hematology/Oncology), Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Mary J Underdown
- Department of Pediatrics (Section of Hematology/Oncology), Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Lawrence D Hopkins
- Obstetrics-Gynecology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Thomas W McLean
- Department of Pediatrics (Section of Hematology/Oncology), Wake Forest School of Medicine, Winston-Salem, North Carolina.
| |
Collapse
|
2
|
Weiskopf RB, Glassberg E, Guinn NR, James MFM, Ness PM, Pusateri AE. The need for an artificial oxygen carrier for disasters and pandemics, including COVID-19. Transfusion 2020; 60:3039-3045. [PMID: 32978804 PMCID: PMC7537157 DOI: 10.1111/trf.16122] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 09/18/2020] [Accepted: 09/19/2020] [Indexed: 01/29/2023]
Affiliation(s)
| | - Elon Glassberg
- The Israel Defense Force Medical Corps, Ramat Gan, Israel.,Departments of Surgery, Bar-Ilan University Faculty of Medicine, Safed, Israel, and The Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Nicole R Guinn
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Michael F M James
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Cape Town, South Africa
| | - Paul M Ness
- Transfusion Medicine Division, Department of Pathology, Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
| | | |
Collapse
|
3
|
El Chaer F, Ballen KK. Treatment of acute leukaemia in adult Jehovah's Witnesses. Br J Haematol 2019; 190:696-707. [PMID: 31693175 DOI: 10.1111/bjh.16284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 09/18/2019] [Indexed: 01/28/2023]
Abstract
Since Jehovah's Witness (JW) patients diagnosed with leukaemia refuse blood transfusions, they are often denied intensive chemotherapy for fear they could not survive myeloablation without blood transfusion support. Treatment of JW patients with acute leukaemia is challenging and carries a higher morbidity and mortality; however, the refusal of blood products should not be an absolute contraindication to offer multiple treatment modalities including haematopoietic stem cell transplantation. In this review we discuss their optimal management and describe alternative modalities to blood transfusions to provide sufficient oxygenation and prevent bleeding.
Collapse
Affiliation(s)
- Firas El Chaer
- Department of Medicine, Division of Hematology and Oncology, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Karen K Ballen
- Department of Medicine, Division of Hematology and Oncology, University of Virginia School of Medicine, Charlottesville, VA, USA
| |
Collapse
|
4
|
Abstract
PURPOSE OF REVIEW This review highlights the complexity of caring for gynecologic patients who refuse blood transfusion and discusses the importance of early, targeted perioperative and intraoperative medical optimization. We review alternative interventions and the importance of medical management to minimize blood loss and maximize hematopoiesis, particularly in gynecologic patients who may have significant uterine bleeding. The review also focuses on intraoperative interventions and surgical techniques to prevent and control surgical blood loss. RECENT FINDINGS With improvements in surgical technique, greater availability of minimally invasive surgery, and increased use of preop UAE and cell salvage, definitive surgical management can be safely performed. New technologies have been developed that allow for safer surgeries or alternatives to traditional surgical procedures. Many medical therapies have been shown to decrease blood loss and improve surgical outcomes. Nonsurgical interventions have also been developed for use as adjuncts or alternatives to surgery. SUMMARY The care of a patient who declines blood transfusion may be complex, but gynecologic surgeons can safely and successfully offer a wide variety of therapies depending on the patient's goals and needs. Medical management should be implemented early. A multidisciplinary team should be mobilized to provide comprehensive and patient-centered care.
Collapse
|
5
|
Chang Lee R, Sukumaran S, Koczwara B, Woodman R, Kichenadasse G, Roy A, Vatandoust S, Karapetis C. Patterns of care in Jehovah's Witnesses patients with solid tumours and lymphoma. Cancer Rep (Hoboken) 2019; 2:e1148. [PMID: 32721085 DOI: 10.1002/cnr2.1148] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Revised: 10/08/2018] [Accepted: 10/08/2018] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Supportive care of Jehovah's Witnesses (JWs) diagnosed with cancer can be challenging, as they do not accept red blood cell (RBC) transfusions. AIM The study was designed to determine treatment preferences and pattern of care offered to JWs diagnosed with cancer and its impact on cancer management. METHODS AND RESULTS A retrospective cohort study of JWs with solid malignancies or lymphoma in our institution between 2005 and 2015 was conducted. Survival statistics were estimated using Kaplan Meier survival curves and Cox proportional regression model. A total of 63 JWs were identified with a median age of 70 years. At diagnosis, 34% (n = 22) had anaemia. All 63 declined RBC transfusion, including 19 patients who later developed transfusion threshold during anti-cancer treatment. Forty-three percent (n = 27) JWs had advanced (stage 4) disease, and 76% (n = 48) had Eastern Cooperative Oncology Group of 0 to 1. JWs were willing to accept surgery and radiation rather than chemotherapy. Treatment was deemed to be suboptimal in 22% (n = 14) JWs due to early treatment discontinuation, administration of non-standard chemotherapy regimen, or dose reduction due to anaemia and denial of blood transfusion. Twenty-seven percent (n = 17) received hematopoietic growth factors (erythropoiesis-stimulating agents and pegfilgrastim). There was no mortality directly attributed to anaemia or refusal of blood transfusion in the entire cohort. CONCLUSION Jehovah's Witnesses declined RBC transfusion at diagnosis and during cancer therapy even if medically indicated. Management pathways need to be prospectively defined for this group of patients.
Collapse
Affiliation(s)
| | - Shawgi Sukumaran
- Flinders Medical Centre, FCIC, Bedford Park, SA, 5042, Australia.,Flinders University, Bedford Park, SA, 5042, Australia
| | - Bogda Koczwara
- Flinders Medical Centre, FCIC, Bedford Park, SA, 5042, Australia.,Flinders University, Bedford Park, SA, 5042, Australia
| | | | - Ganessan Kichenadasse
- Flinders Medical Centre, FCIC, Bedford Park, SA, 5042, Australia.,Flinders University, Bedford Park, SA, 5042, Australia
| | - Amitesh Roy
- Flinders Medical Centre, FCIC, Bedford Park, SA, 5042, Australia.,Flinders University, Bedford Park, SA, 5042, Australia
| | - Sina Vatandoust
- Flinders Medical Centre, FCIC, Bedford Park, SA, 5042, Australia.,Flinders University, Bedford Park, SA, 5042, Australia
| | - Chris Karapetis
- Flinders Medical Centre, FCIC, Bedford Park, SA, 5042, Australia.,Flinders University, Bedford Park, SA, 5042, Australia
| |
Collapse
|
6
|
McConachie S, Wahby K, Almadrahi Z, Wilhelm S. Early Experiences With PEGylated Carboxyhemoglobin Bovine in Anemic Jehovah’s Witnesses: A Case Series and Review of the Literature. J Pharm Pract 2018; 33:372-377. [DOI: 10.1177/0897190018815373] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Jehovah’s Witnesses (JW) represent a complex patient population due to their refusal to accept blood transfusions on religious grounds. Pharmacologic management of anemic JW patients is limited to stimulation of hematopoiesis by iron and erythropoietin supplementation and reduction of blood loss by prothrombin complex concentrates (PCCs). Hemoglobin-based oxygen carriers (HBOCs) represent the only pharmacologic modality for JW patients capable of acutely increasing a patient’s oxygen carrying capacity in the setting of organ failure, yet clinical safety and efficacy data are lacking in this population. We report 3 cases in which the HBOC, PEGylated carboxyhemoglobin bovine (Sanguinate®), was requested under emergent circumstances for severely anemic (hemoglobin <5 g/dL) JW patients who refused blood transfusions. Two patients received PEGylated carboxyhemoglobin infusions for severe anemia, while the third patient died prior to receiving the medication. One patient who received Sanguinate died after 5 units of medication. The other patient’s hemoglobin recovered and she was discharged in stable condition. This series demonstrates the complex nature of the critically anemic JW population and highlights the clinical considerations of using HBOCs in clinical practice and the critical need for further research before they can be broadly recommended.
Collapse
Affiliation(s)
- Sean McConachie
- Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, MI, USA
- Beaumont Hospital, Dearborn, MI, USA
| | | | | | - Sheila Wilhelm
- Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, MI, USA
| |
Collapse
|
7
|
McConachie SM, Almadrahi Z, Wahby KA, Wilhelm SM. Pharmacotherapy in Acutely Anemic Jehovah’s Witnesses: An Evidence-Based Review. Ann Pharmacother 2018; 52:910-919. [DOI: 10.1177/1060028018766656] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Objective: To determine the pharmacological treatment methods available to anemic Jehovah’s Witnesses (JW). Data Sources: MEDLINE and PubMed were searched from inception through February 2018 using the search terms Jehovah’s Witnesses, treatment, erythropoietin, hemoglobin-based oxygen carrier, Sanguinate, Hemopure, bleeding, and anemia. Study Selection and Data Extraction: All clinical trials, cohort studies, case-control studies, and observational trials involving pharmacotherapy in anemic JW patients were evaluated. Case reports and bibliographies were also analyzed for inclusion. Data Synthesis: Two studies involving the use of erythropoietin (EPO) and one study involving recombinant factor VIIa were included. Information was also included from other pharmacotherapeutic modalities that had case report data only. Current published evidence is limited with regard to evidence-based management of JW patients. High-dose EPO, intravenous iron supplementation, and hemostatic agents have demonstrated good clinical outcomes in case reports. EPO doses as high as 40 000 units daily have been advocated by some experts; however, pharmacokinetic studies do not support dose-dependent effects. Hemoglobin-based oxygen carriers (HBOCs) are currently not Food and Drug Administration approved. They are available through expanded access programs and may represent a lifesaving modality in the setting of severe anemia. Conclusions: There are currently not enough data to make definitive recommendations on the use of pharmacological agents to treat severe anemia in the JW population. Further evidence utilizing EPO and HBOCs will be beneficial to guide therapy.
Collapse
Affiliation(s)
- Sean M. McConachie
- Wayne State University, Detroit, MI, USA
- Harper University Hospital, Detroit, MI, USA
| | | | | | | |
Collapse
|
8
|
Management of the Jehovah's Witness in Obstetrics and Gynecology: A Comprehensive Medical, Ethical, and Legal Approach. Obstet Gynecol Surv 2017; 71:488-500. [PMID: 27526872 DOI: 10.1097/ogx.0000000000000343] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
IMPORTANCE Obstetricians and gynecologists frequently deal with hemorrhage so they should be familiar with management of patients who refuse blood transfusion. Although there are some reports in the literature about management of Jehovah's Witness patients in obstetrics and gynecology, most of them are case reports, and a comprehensive review about these patients including ethicolegal perspective is lacking. OBJECTIVE This review outlines the medical, ethical, and legal implications of management of Jehovah's Witness patients in obstetrical and gynecological settings. EVIDENCE ACQUISITION A search of published literature using PubMed, Ovid Medline, EMBASE, and Cochrane databases was conducted about physiology of oxygen delivery and response to tissue hypoxia, mortality rates at certain hemoglobin levels, medical management options for anemic patients who refuse blood transfusion, and ethical/legal considerations in Jehovah's Witness patients. RESULTS Early diagnosis of anemia and immediate initiation of therapy are essential in patients who refuse blood transfusion. Medical management options include iron supplementation and erythropoietin. There are also some promising therapies that are in development such as antihepcidin antibodies and hemoglobin-based oxygen carriers. Options to decrease blood loss include antifibrinolytics, desmopressin, recombinant factor VII, and factor concentrates. When surgery is the only option, every effort should be made to pursue minimally invasive approaches. CONCLUSION AND RELEVANCE All obstetricians and gynecologists should be familiar with alternatives and "less invasive" options for patients who refuse blood transfusions.
Collapse
|
9
|
Hashida T, Nakada T, Takahashi W, Abe R, Oda S. Extremely severe anaemia in a critically ill patient who declined a blood transfusion. Transfus Med 2015; 25:195-7. [PMID: 25960112 DOI: 10.1111/tme.12206] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Accepted: 04/22/2015] [Indexed: 11/30/2022]
Affiliation(s)
- T Hashida
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - T Nakada
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - W Takahashi
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - R Abe
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - S Oda
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| |
Collapse
|
10
|
Agapidou A, Vakalopoulou S, Papadopoulou T, Chadjiaggelidou C, Garypidou V. Successful Treatment of Severe Anemia using Erythropoietin in a Jehovah Witness with Non-Hodgkin Lymphoma. Hematol Rep 2014; 6:5600. [PMID: 25568760 PMCID: PMC4274479 DOI: 10.4081/hr.2014.5600] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2014] [Revised: 09/17/2014] [Accepted: 10/03/2014] [Indexed: 11/23/2022] Open
Abstract
Blood transfusion many times works in a life-saving way when a patient is facing a critical situation. However, some patients, such as Jehovah’s Witnesses, may refuse their administration because it opposes to their religion beliefs. Thus, clinicians are forced to respect patients’ preferences and seek other treatments in order to overcome the obstacle of the transfusion. In 1989, recombinant human erythropoietin (rHuEPO) was approved by the United States Food and Drug Administration (FDA) for the treatment of anemia associated with chronic renal failure. This is an amino acid glycol-protein that stimulates red blood cell production in the same manner as endogenous erythropoietin. Other treatment indications approved by the FDA include anemia due to chronic kidney disease, anemia secondary to zidovudine therapy in patients with human immunodeficiency virus infection, and anemia secondary to cancer chemotherapy. The drug also has been used for many off-label indications. Many Jehovah’s Witnesses have accepted rHuEPO as a treatment option to maintain and enhance erythropoiesis. This paper reports the case of a 57-year-old Jehovah’s Witness man, who was diagnosed with severe anemia due to aggressive non Hodgkin lymphoma and refused transfusion of blood; thanks to the treatment with rHuEPO he has managed to complete chemotherapy and has survived a life threatening situation.
Collapse
Affiliation(s)
- Alexandra Agapidou
- Department of Hematology, Second Propaedeutic Internal Medicine, Aristotle University of Thessaloniki , Greece
| | - Sofia Vakalopoulou
- Department of Hematology, Second Propaedeutic Internal Medicine, Aristotle University of Thessaloniki , Greece
| | - Theodosia Papadopoulou
- Department of Hematology, Second Propaedeutic Internal Medicine, Aristotle University of Thessaloniki , Greece
| | - Christina Chadjiaggelidou
- Department of Hematology, Second Propaedeutic Internal Medicine, Aristotle University of Thessaloniki , Greece
| | - Vasileia Garypidou
- Department of Hematology, Second Propaedeutic Internal Medicine, Aristotle University of Thessaloniki , Greece
| |
Collapse
|
11
|
Posluszny JA, Napolitano LM. How do we treat life-threatening anemia in a Jehovah's Witness patient? Transfusion 2014; 54:3026-34. [DOI: 10.1111/trf.12888] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Revised: 08/17/2014] [Accepted: 08/18/2014] [Indexed: 12/14/2022]
Affiliation(s)
- Joseph A. Posluszny
- Division of Acute Care Surgery [Trauma, Burns, Critical Care, Emergency Surgery]; Department of Surgery; University of Michigan; Ann Arbor Michigan
| | - Lena M. Napolitano
- Division of Acute Care Surgery [Trauma, Burns, Critical Care, Emergency Surgery]; Department of Surgery; University of Michigan; Ann Arbor Michigan
| |
Collapse
|
12
|
Heh-Foster AM, Naber M, Pai MP, Lesar TS. Epoetin in the 'untransfusable' anaemic patient: a retrospective case series and systematic analysis of literature case reports. Transfus Med 2014; 24:204-8. [PMID: 24697987 DOI: 10.1111/tme.12120] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Revised: 02/17/2014] [Accepted: 03/10/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Erythropoiesis stimulating agents [erythropoietin (EPO)] have been recommended to treat anaemic patients who cannot receive or refuse blood tranfusion ('untransfusable' patients). OBJECTIVE The objective of the study was to quantify the association of EPO use with haemoglobin (Hgb) recovery in anaemic untransfusable hospitalised patients. METHODS/MATERIALS EPO treated anaemic untransfusable patients were identified through the combination of a retrospective case review and a systematic review of the medical literature. Literature reports of untransfusable patients not treated with any EPO were used as a comparator group. Hgb concentrations before and following EPO use were abstracted and used to determine the rate of Hgb recovery for each case. Multilevel mixed effects modelling was used to determine the association of Hgb recovery with EPO use. RESULTS A total of 76 EPO treated cases (19 cases from the retrospective hospital case review and 57 from the literature), and 33 non-EPO treated comparator patients from the literature were included in the study. Hgb increased similarly over time in all groups at an overall mean standard error (SE) rate of 0·13 (0·01) g dL(-1) day(-1) . The Hgb recovery rate was higher in patients with lower baseline Hgb, regardless of EPO use. No association was found between the rate of Hgb recovery and EPO use, dose or therapy duration. CONCLUSIONS In anaemic, 'untransfusable' hospitalised patients, EPO use was not associated with increased Hgb recovery at anytime within 28 days.
Collapse
Affiliation(s)
- A M Heh-Foster
- Department of Pharmacy, St. Joseph's Hospital Medical Center, Syracuse, New York, USA
| | | | | | | |
Collapse
|
13
|
High-risk anaemic Jehovah's Witness patients should be managed in the intensive care unit. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2013; 11:330-2. [PMID: 23522897 DOI: 10.2450/2013.0043-13] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
|
14
|
Beliaev AM, Marshall RJ, Smith W, Windsor JA. Treatment monitoring and mortality risk adjustment in anaemic Jehovah's Witnesses. ANZ J Surg 2012; 83:161-4. [DOI: 10.1111/j.1445-2197.2012.06228.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2012] [Indexed: 11/27/2022]
Affiliation(s)
- Andrei M. Beliaev
- Department of General Surgery; Auckland City Hospital; Auckland; New Zealand
| | - Roger J. Marshall
- Department of Epidemiology and Statistics; University of Auckland; Auckland; New Zealand
| | - Warren Smith
- Department of Cardiology; Auckland City Hospital; Auckland; New Zealand
| | - John A. Windsor
- Department of Surgery; University of Auckland; Auckland; New Zealand
| |
Collapse
|