How do we treat life-threatening anemia in a Jehovah's Witness patient?

Jehovah's Witness Needing Critical Care: A Narrative Review on the Expanding Arsenal

Present day Jehovah's Witness (JW) religion accounts for 8.5 million followers. A tenant feature of the JW faith is religious objection to transfusions of blood and blood products. Interpatient variability, as it pertains to blood and blood products may occur; hence, a confidential interview will determine which products individual may consent to (Marsh and Bevan, 2002). This belief and practice place great restrictions on treating medical professionals in scenarios of life-threatening anaemia and active haemorrhage. The review to follow explores the physiological and pathophysiological consequences of severe anaemia. Non-blood transfusion practices are explored, many of which are potentially lifesaving. Particular attention is drawn to the evolving science involving artificial oxygen carriers and their use in emergency situations. A greater safety profile ensures its future use amongst religious objectors to be greatly beneficial. Intravenous iron supplementation has enjoyed a lively debate within the critical care community. A review of recent systematic and meta-analysis supports its use in the ICU; however, more investigation is needed into the complementary use of hepcidin.

Consensus of the Brazilian association of hematology, hemotherapy and cellular therapy on patient blood management: Anemia tolerance mechanisms

Understanding the physiological concepts of oxygen delivery is essential to discern the mechanisms that influence its increase, reduction or maintenance in the body. This text explores the different mechanisms that help maintain oxygen delivery even in the face of reduced hemoglobin levels. Adequate oxygen delivery ensures tissue and metabolic balance, which is crucial to avoid harmful consequences such as metabolic acidosis and cellular dysoxia. The complex interaction between variables such as cardiac output, hemoglobin and heart rate (HR) plays a fundamental role in maintaining oxygen delivery, allowing the body to temporarily adjust to situations of anemia or high metabolic demand. It is important to emphasize that blood transfusions should not be based on fixed values, but rather on individual metabolic needs. Strategies to reduce myocardial consumption and monitor macro and micro hemodynamics help in making rational decisions. Individualizing treatment and considering factors such as blood viscosity in relation to the benefits of transfusion are increasingly relevant to optimize therapy and minimize risks, especially in complex clinical scenarios, such as neurocritical patients and trauma victims.

Management of Severe Anemia in a Jehovah's Witness Patient With Lung Abscess Secondary to Malpositioned Laparoscopic Adjustable Gastric Band: A Case Report

Jehovah's Witnesses is a Christian denomination widely recognized for their steadfast refusal of blood transfusions, even when facing severe anemia. We describe a unique case of a 42-year-old Jehovah's Witness woman with severe iron deficiency anemia. She necessitated surgical correction of a malpositioned gastric band within the context of a complex necrotizing aspiration pneumonia secondary to esophageal obstruction. Medical management of this severe anemia has been a challenge as traditional approaches, like a blood transfusion, are not possible. Instead, a multifaceted approach has been described with intravenous iron infusions, recombinant human erythropoietin, vitamin B12, folate, and vitamin C administration. We emphasize the lack of consensus on guideline protocols regarding management of severe anemia for Jehovah's Witness patients and the subsequent need for more investigation into that matter. It also underscores the significance of respecting patient autonomy through close collaboration between patients and their health care providers to ensure effective patient-centered care.

Management and clinical outcomes for patients with gastrointestinal bleeding who decline transfusion

BACKGROUND

The national blood shortage and growing patient population who decline blood transfusions have created the need for bloodless medicine initiatives. This case series describes the management of gastrointestinal bleed patients who declined allogeneic blood transfusion. Understanding the effectiveness of bloodless techniques may improve treatment for future patients while avoiding the risks and cost associated with transfusion.

STUDY DESIGN AND METHODS

A retrospective chart review identified 30 inpatient encounters admitted between 2016 to 2022 for gastrointestinal hemorrhage who declined transfusion due to religious or personal reasons. Clinical characteristics and patient blood management methods utilized during hospitalization were analyzed. Hemoglobin concentrations and clinical outcomes are reported.

RESULTS

The most common therapy was intravenous iron (n = 25, 83.3%), followed by erythropoietin (n = 18, 60.0%). Endoscopy was the most common procedure performed (n = 23, 76.7%), and surgical intervention was less common (n = 4, 13.3%). Pre-procedure hemoglobin was <6 g/dL in 7 patients, and <5 g/dL in 4 patients. The median nadir hemoglobin was 5.6 (IQR 4.5, 7.0) g/dL, which increased post-treatment to 7.3 (IQR 6.2, 8.4) g/dL upon discharge. One patient (3.3%) with a nadir Hb of 3.7 g/dL died during hospitalization from sepsis. Nine other patients with nadir Hb <5 g/dL survived hospitalization.

CONCLUSIONS

Gastrointestinal bleed patients can be successfully managed with optimal bloodless medicine techniques. Even patients with a nadir Hb <5-6 g/dL can be stabilized with aggressive anemia treatment and may safely undergo anesthesia and endoscopy or surgery for diagnostic or therapeutic purposes. Methods used for treating bloodless medicine patients may be used to improve clinical care for all patients.

When blood is not an option: Optimal bloodless management of severe anemia in pregnancy

Standard treatment for severe anemia in pregnancy is allogeneic blood transfusion, but this is not acceptable to all patients. Options for alternative anemia treatment are available. In this case report, a 32-year-old G2P1 woman who was a Jehovah's Witness presented at 27 weeks gestation with dyspnea, palpitations, and severe anemia (hemoglobin 2.8 g/dL) related to chronic rectal bleeding. She declined blood transfusion. An anemia management protocol (high-dose erythropoietin-stimulating agent, iron, vitamin D, vitamin C, folate, vitamin B12) rapidly increased endogenous erythropoiesis. After 12 days, hemoglobin increased to 8 g/dL. A bovine hemoglobin-based oxygen carrier was available for acute bleeding but was not used. This case highlights that early initiation of multimodal therapy can adequately increase endogenous erythropoiesis to treat life-threatening anemia in antepartum patients who do not accept blood transfusion.

Jehovah’s Witness survives severe favism complications: Advance provisions of treatment and new challenges for the physicians

The management of an acute hemolytic event in a patient suffering from favism is based on transfusion support to ensure adequate tissue oxygenation. If this measure could not be pursued, in case of severe anemia the risk of death from multiorgan failure would be relevant. Most of Jehovah’s Witness decline transfusion of whole blood and its main components, even in life-threatening situations. In this context, the treatment of severe anemia in these patients still represents a challenge from both medical and legal stand points. Authors report a case of a Jehovah’s Witness suffering from favism who refused blood transfusion, surviving a severe event of critical anemia associated with acute renal failure, thanks to the application of alternative therapies. It is essential that clinicians know the medico-legal aspects in such situations and are able to act promptly to support the patient’s vital functions, by complying with his/her wishes.

Evans Syndrome in a Jehovah's Witness

Evans syndrome (ES) is a rare hematologic disorder characterized by the development of autoimmune hemolytic anemia (AIHA), idiopathic thrombocytopenia, and occasionally immune-mediated neutropenia. Jehovah's Witnesses (JW) often decline blood product transfusion on the grounds of a scriptural stand based on biblical texts. The acute management of ES often consists of blood product transfusion in addition to high-dose steroids and intravenous immunoglobulin. We describe the case of a JW female presenting with new-onset, acutely worsening AIHA and thrombocytopenia with concern for hemodynamic compromise who was successfully treated with erythropoietin-stimulating agents, parenteral iron, folic acid, and high-dose steroids.

Physician autonomy and patient rights: lessons from an enforced blood transfusion and the role of patient blood management

This article provides an ethical and medico-legal analysis of ruling no. 465 of 30 May 2018 issued by the Court of Termini Imerese (Palermo) and confirmed on appeal on 11 November 2020, which, in the absence of similar historical precedents in Europe, convicted a medical doctor of a crime of violent assault for having ordered the administration of a blood transfusion to a patient specifically declining blood transfusion on religious grounds. We analyse the Court's decision regarding the identification of assault in performing the blood transfusion and its decision not to accept exculpatory urgent 'necessity' as a defence. In addition, we present an updated revision of the current standard of care in transfusion medicine as well as the ethical principles governing the patient's declining of transfusion. In doing so, we highlight that respect for the patient's self-determination in declining transfusions and respect for the professional autonomy of the doctor protecting the safety and life of the patient could be equally satisfied by applying the current peer-reviewed evidence.

Blood transfusion and alternatives in Jehovah's Witness patients

PURPOSE OF REVIEW

More than 8.5 million people in the world observe the Jehovah's Witness faith, and require unique consideration for perioperative blood management as they generally refuse transfusion of blood and blood products. This review addresses a collaborative approach to each patient throughout the perioperative arena. The principles of this approach include optimization of hemoglobin levels preoperatively, attention to blood-salvaging methods intraoperatively, and minimization of blood draws postoperatively. In addition, we review the technologies currently in development as transfusion alternatives, including hemoglobin-based oxygen carriers.

RECENT FINDINGS

Progress has been made recently in the field of synthetic blood alternatives and hemoglobin-based oxygen carriers, which may lead to improved outcomes in this patient population.

SUMMARY

Utilization of multiple prevention and mitigation strategies to optimize oxygen supply and decrease oxygen demand will lead to decreased incidence of critical anemia and subsequent improved mortality in Jehovah's Witness patients.

How I treat cancer-associated anemia

Despite increasing use of targeted therapies to treat cancer, anemia remains a common complication of cancer therapy. Physician concerns about the safety of intravenous (IV) iron products and erythropoiesis-stimulating agents (ESAs) have resulted in many patients with cancer receiving no or suboptimal anemia therapy. In this article, we present 4 patient cases that illustrate both common and complex clinical scenarios. We first present a review of erythropoiesis and then describe our approach to cancer-associated anemia by identifying the contributing causes before selecting specific treatments. We summarize clinical trial data affirming the safety and efficacy of currently available IV iron products used to treat cancer-associated anemia and illustrate how we use commonly available laboratory tests to assess iron status during routine patient management. We compare adverse event rates associated with IV iron vs red cell transfusion and discuss using first-line IV iron monotherapy to treat anemic patients with cancer, which decreases the need for ESAs. A possible mechanism behind ESA-induced tumor progression is discussed. Finally, we review the potential of novel therapies such as ascorbic acid, prolyl hydroxylase inhibitors, activin traps, hepcidin, and bone morphogenetic protein antagonists in treating cancer-associated anemia.

Stepping stones to the future of haemoglobin-based blood products: clinical, preclinical and innovative examples

Critical overview of the different oxygen therapeutics developed so far to be used when donor blood is not available.

Hip Fracture Surgery without Transfusion in Patients with Hemoglobin Less Than 10 g/dL

Backgroud

Hip fracture surgery is associated with blood loss, which may lead to adverse patient outcomes. The hemoglobin level declines gradually in most hip fracture cases involving femoral neck fractures and intertrochanteric fractures. It decreases further after hip fracture surgery due to perioperative bleeding. We developed a protocol, which avoids transfusion in hip fracture surgery, and reviewed the hemodynamic outcomes of patients with hemoglobin less than 10 g/dL without transfusion.

Methods

From 2014 to 2019, we retrospectively recruited 34 patients with hip fractures and a hemoglobin level less than 10 g/dL, who refused to undergo transfusion. There were 19 patients with femoral neck fractures and 15 patients with intertrochanteric fractures. Our patient blood management (PBM) protocol involving 4,000 U erythropoietin (3 times a week) and 100 mg iron supplement (every day) was applied to all included patients. Intraoperatively, a cell saver and tranexamic acid were used. Postoperatively, the protocol was maintained until the patients' hemoglobin level reached 10 g/dL. We evaluated the feasibility of our protocol, perioperative complications, and hemodynamic changes.

Results

Nineteen patients with femoral neck fractures underwent bipolar hemiarthroplasty and 15 patients with intertrochanteric fractures underwent internal fixation with a cephalomedullary nail. The mean hemoglobin level was 8.9 g/dL (range, 7.3–9.9 g/dL) preoperatively, 7.9 g/dL (range, 6.5–9.3 g/dL) immediately postoperatively, 7.7 g/dL (range, 4.3–9.5 g/dL) on postoperative day 1, 7.4 g/dL (range, 4.2–9.4 g/dL) on postoperative day 3, 8.1 g/dL (range, 4.4–9.7 g/dL) on postoperative day 5, 8.5 g/dL (range, 4.5–9.9 g/dL) on postoperative day 7, and 9.9 g/dL (range, 5.7–11.1 g/dL) on postoperative day 14. The average intraoperative bleeding was 206.2 ± 78.7 mL. There was no case associated with complications of anemia.

Conclusions

Hip fracture surgery in patients with hemoglobin less than 10 g/dL was feasible without the need for transfusion using our PBM protocol in 34 patients. Using this protocol, the operation was conducted safely despite the anemic condition of patients with fractures whose hemoglobin was less than 10 g/dL.

Management of thymoma-associated pure red cell aplasia: A novel use of blood substitute HBOC-201 in a Jehovah's Witness

Pure red cell aplasia (PRCA) is a rare paraneoplastic syndrome occasionally associated with thymomas. Here, we report on the first ever use of a bovine hemoglobin-based oxygen carrier, HBOC-201 (HbO2 Therapeutics LLC; Hemopure®, Waltham, MA) for the supportive management of pure red cell aplasia in a Jehovah Witness patient.

Artificial Oxygen Carriers-Past, Present, and Future-a Review of the Most Innovative and Clinically Relevant Concepts

Blood transfusions are a daily practice in hospitals. Since these products are limited in availability and have various, harmful side effects, researchers have pursued the goal to develop artificial blood components for about 40 years. Development of oxygen therapeutics and stem cells are more recent goals. Medline (https://www.ncbi.nlm.nih.gov/pubmed/?holding=ideudelib), ClinicalTrials.gov (https://clinicaltrials.gov), EU Clinical Trials Register (https://www.clinicaltrialsregister.eu), and Australian New Zealand Clinical Trials Registry (http://www.anzctr.org.au) were searched up to July 2018 using search terms related to artificial blood products in order to identify new and ongoing research over the last 5 years. However, for products that are already well known and important to or relevant in gaining a better understanding of this field of research, the reader is punctually referred to some important articles published over 5 years ago. This review includes not only clinically relevant substances such as heme-oxygenating carriers, perfluorocarbon-based oxygen carriers, stem cells, and organ conservation, but also includes interesting preclinically advanced compounds depicting the pipeline of potential new products. In- depth insights into specific benefits and limitations of each substance, including the biochemical and physiologic background are included. "Fancy" ideas such as iron-based substances, O₂ microbubbles, cyclodextranes, or lugworms are also elucidated. To conclude, this systematic up-to-date review includes all actual achievements and ongoing clinical trials in the field of artificial blood products to pursue the dream of artificial oxygen carrier supply. Research is on the right track, but the task is demanding and challenging.

Early Experiences With PEGylated Carboxyhemoglobin Bovine in Anemic Jehovah’s Witnesses: A Case Series and Review of the Literature

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.

Investigational use of PEGylated carboxyhemoglobin bovine in a Jehovah's Witness with hemorrhagic shock

BACKGROUND

Jehovah's Witnesses pose a clinical challenge in the setting of critical anemia. Most do not accept transfusions, but some accept hemoglobin-based oxygen carriers on a compassionate-use basis. PEGylated carboxyhemoglobin bovine (PCHB) is an acellular dual-action carbon monoxide (CO)-releasing and oxygen transfer agent currently being investigated in Phase II clinical trials.

CASE REPORT

We present the case of a 42-year-old Jehovah's Witness with an acute upper gastrointestinal bleed and hemorrhagic shock who required emergent PCHB for stabilization during lifesaving interventions. After PCHB infusion, the patient's shock and encephalopathy improved with decreased vasopressor requirement. Through gastroenterology and interventional radiology procedures, the patient's bleeding stabilized. While receiving five additional doses of PCHB and other supportive therapies (iron, folate, vitamin B12, darbepoetin alfa), the patient was extubated and weaned off vasopressors.

CONCLUSIONS

PCHB was used to stabilize (bridge) a critically ill anemic patient for lifesaving interventions without adverse effects. Additional studies are warranted to explore the drug's safety profile and efficacy in patients declining blood products.

Pharmacotherapy in Acutely Anemic Jehovah’s Witnesses: An Evidence-Based Review

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.

Thrombolytic therapy for critical limb ischemia in a Jehovah's Witness with severe anemia

A patient's refusal to receive blood products can pose both clinical and ethical challenges to the surgeon. In this report, we review the case of a Jehovah's Witness presenting with critical lower limb ischemia and severe anemia for whom the decision of whether to perform thrombolytic therapy was complicated by his refusal to accept blood products. The case demonstrates that thrombolytic therapy can produce favorable results in severely anemic patients even when transfusion is not an option. We conclude that offering thrombolytic therapy in this context is a reasonable therapeutic option from both a clinical and ethical perspective.

Feasibility of Hip Fracture Surgery Using a No Transfusion Protocol in Elderly Patients: A Propensity Score-Matched Cohort Study

OBJECTIVES

To determine whether hip fracture surgery (HFS) without transfusion affects postoperative mortality and complications in elderly patients.

DESIGN

Retrospective comparative study.

PATIENTS

Three hundred fourteen patients ≥65 years of age who underwent HFS between May 2003 and December 2014. Patients were divided into 2 groups: those who consented to blood transfusion if needed and those who did not. One-to-one propensity score matching generated 50 matched pairs of patients.

INTERVENTION

Patients underwent HFS with or without blood transfusion. In the no transfusion group, simultaneous administration of erythropoietin and iron was used as an alternative.

MAIN OUTCOME MEASUREMENTS

The primary outcome was postoperative mortality (90-day, 1-year, overall). The secondary outcomes were hemoglobin change and the incidence of postoperative complications.

RESULTS

HFS using a no transfusion protocol was not associated with increased mortality at any time point. Mean hemoglobin levels were significantly different between the 2 groups on postoperative day 1 (11.0 ± 1.3 vs. 10.5 ± 1.6, P = 0.002) but levels completely recovered within 2 weeks in both groups. There was also no difference in postoperative complication rates between the 2 groups, and overall hospital stays and charges were similar.

CONCLUSIONS

An HFS protocol without blood transfusion was not associated with increased mortality or complications in elderly patients.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Low-dose erythropoietin treatment is not associated with clinical benefits in severely anaemic Jehovah's Witnesses: a plea for a change

BACKGROUND

Jehovah's Witnesses who refuse blood transfusion have high mortality. Erythropoietin (EPO) has been used as an alternative to blood transfusion. The optimal dosing of EPO in anaemic Jehovah's Witnesses is unknown. The aim of our study was to evaluate the clinical benefits of treatment with a low dose (<600 IU/kg/week) of epoietin beta (EPO-β).

MATERIALS AND METHODS

This was an observational study, retrospectively considering a 10-year period during which 3,529 adult Jehovah's Witnesses with a total of 10,786 hospital admissions were identified from databases of four major public hospitals in New Zealand. Patients with severe symptomatic anaemia (haemoglobin <80 g/L) who were unable to tolerate physical activity were included in the study. Patients treated without EPO were assigned to the conventional therapy group and those treated with EPO to the EPO treatment group.

RESULTS

Ninety-one Jehovah's Witnesses met the eligibility criteria. Propensity score matching yielded a total of 57 patients. Patients treated with conventional therapy and those treated with EPO had similar durations of severe anaemia (average difference 6.25 days, 95% confidence interval [CI]: -3.77-16.27 days; p=0.221). The mortality rate among Jehovah's Witnesses treated with conventional therapy was 4.68 per year (95% CI: 2.23-9.82), while that in those treated with EPO was 2.77 per year (95% CI: 0.89-8.60). Treatment with EPO was associated with a mortality ratio of 0.59 (95% CI: 0.1-2.6; p=0.236). Both groups of patients had similar in-hospital survival (p=0.703).

DISCUSSION

Treatment with low-dose EPO-β was not associated with either shorter duration of severe anaemia or a reduction in mortality.

Major abdominal surgery in Jehovah's Witnesses

Introduction Patients who are Jehovah's Witnesses pose difficult ethical and moral dilemmas for surgeons because of their refusal to receive blood and blood products. This article outlines the personal experiences of six Jehovah's Witnesses who underwent major abdominal surgery at a single institution and also summarises the literature on the perioperative care of these patients. Methods The patients recorded their thoughts and the dilemmas they faced during their surgical journey. We also reviewed the recent literature on the ethical principles involved in treating such patients and strategies recommended to make surgery safer. Results All patients were supported in their decision making by the clinical team and the Hospital Liaison Committee for Jehovah's Witnesses. The patients recognised the ethical and moral difficulties experienced by clinicians in this setting. However, they described taking strength from their belief in Jehovah. A multitude of techniques are available to minimise the risk associated with major surgery in Jehovah's Witness patients, many of which have been adopted to minimise unnecessary use of blood products in general. Nevertheless, the risks of catastrophic haemorrhage and consequent mortality remain an unresolved issue for the treating team. Conclusions Respect for a patient's autonomy in this setting is the overriding ethical principle, with detailed discussion forming an important part of the preparation of a Jehovah's Witness for major abdominal surgery. Clinicians must be diligent in the documentation of the patient's wishes to ensure all members of the team can abide by these.

Bloodless medicine: current strategies and emerging treatment paradigms

BACKGROUND

Advances in our understanding of the risks associated with allogeneic blood transfusions (ABTs) and the growing number of patients who wish to avoid ABTs have led to the emergence of new treatment paradigms for "bloodless" medicine and surgery.

STUDY DESIGN AND METHODS

Here, we review prior studies and summarize current strategies for bloodless care used at our institution. We advocate three basic principles: 1) diagnosing and aggressively treating anemia, 2) minimizing blood loss from laboratory testing and invasive procedures, and 3) identifying and managing bleeding diatheses. Anemia is treated with erythropoiesis-stimulating agents as well as iron, folate, and B12 when indicated. Low-volume phlebotomy tubes are used for laboratory testing. Autologous blood salvage is used for childbirth and surgical patients who have the potential for substantial bleeding.

RESULTS

Although there have been few retrospective studies and no prospective studies to guide management, prior studies suggest that outcomes for surgical patients managed without ABTs are comparable to those of historic controls.

CONCLUSIONS

Given the emerging evidence that patients who avoid ABTs do as well if not better than patients who accept ABTs, further efforts are needed to determine whether all patients could benefit from bloodless strategies. Bloodless approaches in selected patients could reduce risks, improve outcomes, and decrease costs for all patients.

Severe Acute Anemia After Liver Transplantation in an Elderly Jehovah's Witness Treated With High-dose Erythropoietin and Ferric Carboxymaltose: A Case Report

BACKGROUND

There is no standard treatment for patients with severe anemia who refuse blood transfusion or cannot receive red blood cells.

CASE REPORT

After an orthotopic liver transplantation, an elderly Jehovah's Witness who refused blood transfusion presented with severe acute anemia with hemorrhagic shock. The calculated red blood cell loss was near 70%. Associated with surgical treatment and supportive measures, the patient was treated with high-dose erythropoietin and ferric carboxymaltose.

RESULTS

The patient presented a rapid increase in hemoglobin concentration and reticulocyte count with resolution of hemorrhagic shock after the proposed pharmacologic treatment combined with local hemostatic measures. She was transferred to a low-risk unit 4 days after transplantation and was discharged from the hospital on day 10. The hemoglobin concentration was normal 35 days after the bleeding event.

CONCLUSION

This case demonstrated that a protocol with high-dose erythropoietin and ferric carboxymaltose may be an option for patients with severe anemia who refuse blood transfusion or cannot receive red blood cells.