Severe anemia in Jehovah's Witness patients
Jehovah's Witness patients refuse allogenic blood and blood products. The major clinical complication due to their religious beliefs is life threatening bleeding. Multiple options exist to temporize and treat bleeding, which include:
- Erythropoesis stimulation
- Iron supplementation
- Oxygen carriers
- Whole blood conservation
The use of advanced treatments are generally reserved for patients with severe anemia < 7g/dL
Early control of bleeding and coordination with the family or patient is the only means of managing an severely bleeding Jehovah's Witness patient. Most patients will accept autotransfusion.
- Early surgical or hemostatic control
- Tranexamic Acid administration for major trauma < 3 hrs
- Prothrombin complex concentrates
- Recombinant factor VIIa
- Autotransfusion (ie Cell Saver, CATS, or Fresenius cell salvage)
High dose epoetin have a multimodal mechanism of action that includes an increase in reticulocyte count, decrease in plasma volume and increase in Hb levels
Epoetin alfa (Epogen)
- Dose: 40,000 units IV daily until Hb > 7g/dL then 40,000 units per week
- Onset of Action: 3 days
- Patients must have sufficient iron supplementation or max erythropoesis will not occur
Supplementation will allow for full RBC production but will not correct anemia immediately. Most useful for preparing for scheduled surgical procedures or in burn patients
- Iron supplementation to keep serum iron 100-400 mg/dl
- IV iron sucrose 100 mg daily for 10 days
- For first dose, test dose 25 mg slow push over 15 min
- Wait 2 hrs, if no anaphylactoid reaction, give rest of 75 mg
- Oral Iron Supplementation afterwards
Should be provided to all patients
- Vitamin C: 500 mg TID( q24hrs daily in renal failure)
- Folate: 1 mg PO or IV daily (q24hrs)
- Vitamin B12 multivitamin PO or IV
- Use pediatric tubes for blood draws and limit daily volume to 1mL
Hb-based oxygen carriers (Hemapure)
Hemapure require individual patient IRB and institutional FDA approval and is experimental. Hemopure is approved in South Africa and Russia and is a purifiec acellular bovine Hb in lactated ringer's solution
- Dosing: 1 unit (225 mL) administered IV over 4 hours if bleeding
- If patient develops hypertension slow infusion rate
- Gannon CJ, Napolitano LM. Severe anemia after gastrointestinal hemorrhage in a Jehovah’s Witness: new treatment strategies. Crit Care Med 2002;30:1893-5.
- Waters J, Potter, P. Cell Salvage in the Jehovah’s Witness Patient. Anesth Analg. 2000 Jan;90(1):229-30. Full Text
- Lundby C, Olsen NV. Effects of recombinant human erythropoietin in normal humans. J Physiol 2011;589(Pt 6):1265- 71.
- Posluszny JA Jr, Napolitano LM. How do we treat life-threatening anemia in a Jehovah's Witness patient? Transfusion. 2014;54(12):3026-3034. doi:10.1111/trf.12888.
- Barsun A et al. Reducing postburn injury anemia in a Jehovah’s Witness patient. J Burn Care Res 2014;35:e258-61.
- ClinicalTrials.gov. Expanded access study of HBOC-201 (Hemopure) for the treatment of life-threatening anemia. 2014. [http:// clinicaltrials.gov/ct2/show/NCT01881503]