View source for Severe anemia in Jehovah's Witness patients

==Background==
Jehovah's Witness paients traditionally refuse allogenic blood and whole blood products.  
*This includes:  RBCs, plasma, platelets, white cells) <ref>https://www.jw.org/en/jehovahs-witnesses/faq/jehovahs-witnesses-why-no-blood-transfusions/</ref>
*HOWEVER, they are able to choose to accept BLOOD COMPONENT FRACTIONS (includes recombinant factor VII, PCC), though this decision may still vary per individual. <ref>https://wol.jw.org/en/wol/d/r1/lp-e/2004448#h=4</ref>

This can make cases of life threatening bleeding difficult to address.  However, multiple options exist to temporize and treat bleeding which are acceptable to Jehovah's Witness patients. These include:<ref>Gannon CJ, Napolitano LM. Severe anemia after gastrointestinal hemorrhage in a Jehovah’s Witness: new treatment strategies. Crit Care Med 2002;30:1893-5.</ref>
*Erythropoesis stimulation  
*Iron supplementation
*Oxygen carriers
*Whole blood conservation

It is important to note that individual Jehovah's Witnesses may not strictly adhere to this doctrine; up to 49% of Jehovah's Witness patients in one study would be willing to accept blood products in certain circumstances. <ref>Gyamfi C, Berkowitz RL. Responses by pregnant Jehovah's Witnesses on health care proxies. Obstet Gynecol. 2004;104(3):541-4.</ref> It's worth carefully discussing the risks/benefits with the patient (without visitors present), especially if the need is truly critical.

==Control Bleeding==
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.<ref>Waters J, Potter, P. Cell Salvage in the Jehovah’s Witness Patient. Anesth Analg. 2000 Jan;90(1):229-30. [http://journals.lww.com/anesthesia-analgesia/Fulltext/2000/01000/Cell_Salvage_in_the_Jehovah_s_Witness_Patient.53.aspx Full Text]</ref>
*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)

==Erythropoesis Stimulation==
High dose epoetin has a multimodal mechanism of action that includes  an increase in reticulocyte count, decrease in plasma volume and increase in hemoglobin levels<ref>Lundby C, Olsen NV. Effects of recombinant human erythropoietin in normal humans. J Physiol 2011;589(Patient 6):1265- 71.</ref>

===Epoetin Alfa (Epogen)===
*Dose: 40,000 units IV daily until hemoglobin > 7g/dL then 40,000 units per week<ref name="JW">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.</ref>
*Onset of Action: 3 days
*Patients must have sufficient iron supplementation or max erythropoesis will not occur

==Iron Supplementation==
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<ref>Barsun A et al. Reducing postburn injury anemia in a Jehovah’s Witness patient. J Burn Care Res 2014;35:e258-61.</ref>
*Iron supplementation to keep serum iron 100-400mg/dl
*IV iron sucrose 100mg daily for 10 days<ref name="JW"></ref>
**For first dose, test dose 25mg slow push over 15 min
**Wait 2 hrs, if no anaphylactoid reaction, give rest of 75mg
*Oral [[Iron Supplementation]] afterwards

==Vitamin Supplementation==
Should be provided to all patients
*Vitamin C: 500mg TID( q24hrs daily in renal failure)
*[[Folate]]: 1mg PO or IV daily (q24hrs)
*[[Vitamin B12]] multivitamin PO or IV

==Decrease Phlebotomy==
*Use pediatric tubes for blood draws and limit daily volume to 1mL

==hemoglobin-Based Oxygen Carriers (Hemapure)==
In the US, Hemapure requires individual patient IRB and institutional FDA approval and is experimental. 
*May be able to use this on a US patient by requesting "Expanded Access/Compassionate Care" protocol from FDA (see:  https://www.fda.gov/NewsEvents/PublicHealthFocus/ExpandedAccessCompassionateUse/)

Hemopure is approved in South Africa and Russia and is a purifiec acellular bovine hemoglobin in lactated ringer's solution<ref>ClinicalTrials.gov. Expanded access study of HBOC-201
(Hemopure) for the treatment of life-threatening anemia. 2014. [http:// clinicaltrials.gov/ct2/show/NCT01881503]</ref>
*Dosing: 1 unit (225 mL) administered IV over 4 hours if bleeding
**If patient develops hypertension slow infusion rate

==See Also==
*[[Anemia]]
*[[Massive transfusion]]
*[[Transfusion reaction]]
*[[Blood products]]

==External Links==


==References==
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[[Category:Trauma]]
[[Category:Heme/Onc]]