Liver transplantation in a Jehovah’s Witness with ankylosing spondylitis

Abstract

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 features: 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·L -1 compared with 120 g·L -1 baseline). Intraoperatively, strategies for reducing risk of blood product transfusion included avoidance of hypothermia (T>35°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·hr -1 ), and return of blood (1,500 ml) scavenged from the operative field. Estimated blood loss was 2,200 ml. The preoperative and postoperative hemoglobin concentration was 147 g·L -1 (hematocrit 0.45) and 123 g·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.Objectif : La transplantation du foie orthotopique est typiquement associée à une perte de sang importante. Les progrès technologiques et pharmacologiques permettent de réaliser une transplantation hépatique chez des patients qui n'auraient pu subir cette opération auparavant à cause de limitations rigoureuses d'administration des produits sanguins. Nous décrivons une greffe hépatique chez un témoin de Jéhovah qui présente une spondylarthrite ankylosante.Éléments cliniques : Un témoin de Jéhovah de 49 ans souffrant de spondylarthrite ankylosante et d'une maladie hépatique terminale secondaire à une cholangite sclérosante a subi une greffe hépatique. L'administration d'érythropoïétine recombinante humaine (4 000 UI sc aux deux jours pendant quatre semaines, puis 4 000 UI sc chaque semaine) a établi une concentration d'hémoglobine préopératoire normale (>140 g·L -1 comparée à 120 g·L -1 au départ). Les stratégies peropératoires adoptées pour réduire le risque lié à la transfusion de produit sanguin comprenaient l'absence d'hypothermie (T >35 o C), le prélèvement minimal de sang (quatre échantillons de 1 ml), l'hémodilution normovolémique (deux unités), l'administration d'aprotinine (des bolus de deux millions d'unités suivis de perfusion de 500 000 u·h -1 ) et le retour du sang épuré (1 500 ml) provenant du champ opéra-toire. La perte sanguine a été de 2 200 ml. La concentration préopératoire et postopératoire d'hémoglobine a ét...

Effect of low central venous pressure and phlebotomy on blood product transfusion requirements during liver transplantations

“…As previously stated, logistic regression analysis yielded that three independent variables were linked to liver transplantation without RBC transfusion: avoidance of plasma, phlebotomy, and the starting Hb value. The higher the starting Hb value, the least chance of blood transfusion during a liver transplant suggests that in some cases, human recombinant erythropoietin might be useful to raise the starting Hb value before undertaking a liver transplantation 17. In the logistic regression model, the CVP value just before clamping did not emerge as a significant variable, probably because it did not reflect the CVP during the whole dissection during the pre‐anhepatic phase.…”

A quantitative model to predict blood use in adult orthotopic liver transplantation

“…The hemoglobin level can potentially be modified preoperatively. Recombinant erythropoietin has been administered to Jehovah's Witnesses in case reports to increase the red cell mass to minimize blood transfusion during OLT [8,15,16]. In a series of 9 Jehovah's Witnesses, medical preparation consisting of high-dose erythropoietin, iron and folic acid supplementation allowed these patients to tolerate the transplantation with no blood transfusion [10].…”

“…With the improvement of surgical techniques and anesthesia practices, the amount of blood transfused has been dramatically reduced [1][2][3]. Some centers achieved avoidance of RBC transfusion in up to 40% of liver recipients [4][5][6][7], and bloodless OLT has been reported in single cases and case series [8][9][10][11][12][13][14][15][16]. Also contributing to this trend is the increasing awareness of the hazards associated with blood transfusion in OLT [4,17,18], which have been observed in patients receiving red blood cells, platelets and plasma products [17,19,20].…”

“…The former presents a unique ethical dilemma in Jehovah's Witnesses patients, who on the basis of religious beliefs refuse transfusion of blood products [8][9][10][11][12][13][14][15][16]21]. The reliance on blood transfusion may also delay OLT in patients with numerous red blood cell alloantibodies or with deficiencies in IgA or haptoglobin [22,23].…”

Blood Transfusions and the Jehovah's Witness Patient

“…This sometimes puts anesthesiologists in highly unusual clinical situations. [12][13][14][15] JEHOVAH'S WITNESSES Jehovah's Witnesses base their religious beliefs on a strict literal interpretation of the Bible and hold that eternal life may be forfeited if they do not follow biblical commands. [16][17][18] The determination that blood transfusions were a violation of God's law was made in 1945 and is primarily based on the following three biblical passages 19 : Genesis 9:3-4, Leviticus 17:10-16, and Acts 15:28-29.…”