After Heart Surgery, Jehovah's Witnesses Fare as Well as or Better Than Those Who Get Blood

July 03, 2012

July 3, 2012 (Cleveland, Ohio) — New research coming out of the Cleveland Clinic shows that Jehovah's Witnesses--who refuse blood transfusions on grounds related to their religious beliefs--appear to fare better following cardiac surgery, at least in the short term, than matched controls who received transfusions [1]. Late outcomes, in the form of 20-year survival, were similar between the two groups, report Dr Gregory Pattakos (Cleveland Clinic, OH) and colleagues in a study published online July 2, 2012 in the Archives of Internal Medicine.

We do a really good job for our Jehovah's Witness patients of making sure they don't come to the OR anemic. Should we be doing this for all our patients?

Second author Dr Colleen G Koch (Cleveland Clinic) told heartwire : "We have a Jehovah's Witness Careplan, they are taken care of very differently from our routine cardiac-surgery patients--preoperatively, intraoperatively, and postoperatively--and there are certain processes of care that we implement for these patients." The new findings, she says, "show that we do a really good job for our Jehovah's Witness patients of making sure they don't come to the OR anemic. Should we be doing this for all our patients?"

In an accompanying editorial [2], Dr Victor A Ferraris (University of Kentucky Chandler Medical Center, Lexington) agrees with her conclusion: "The finding that the Witnesses who did not receive transfusions did at least as well as, if not better than, those who received a transfusion raises questions about whether more patients might benefit from surgical strategies that minimize transfusion of blood products."

EPO and Certain Other Tactics Employed to Conserve Blood in Witnesses

Koch explains that the religious beliefs of Jehovah's Witnesses disallow any blood; their hematocrit can get to any level and they will not receive blood, "so we go all out to try to conserve the patient's blood, hence the term 'extreme blood conservation.' "

She said they were unsure as to what they would discover in what they termed "a natural experiment with severe blood conservation. We know that blood causes complications and we know that anemia causes complications, and we know that erythropoietin [EPO] in patients with cardiovascular disease is associated with complications, so we didn’t really know what we would find in this study."

In the study, a total of 322 Jehovah's Witnesses who underwent cardiac surgery at the Cleveland Clinic between January 1, 1983 and January 1, 2011 and who prospectively refused blood transfusions were included. They were compared with the same number of propensity-matched controls, with similar comorbidities, taken from 48 986 patients who underwent cardiac surgery during that period and did receive blood.

She explains that use of EPO to prevent anemia in those with low hemoglobin is not employed routinely in CVD patients who will accept transfusions, because it has been associated with an increased risk of thromboembolism. But because they refuse transfusions, EPO is given routinely to Jehovah's Witnesses with low hemoglobin undergoing heart surgery, and there are also a number of other tactics employed in these patients to help conserve blood, she says.

These include: the use of smaller (pediatric) tubes to take blood; iron and complex vitamins given preoperatively; certain surgical techniques employed with the bypass to reduce blood loss; use of less crystalloid in the OR; and use of cell saver on all Jehovah's Witnesses. "We wanted to see if this unique process of care, for a specific group of patients, puts them at increased risk, and if it doesn't, perhaps we need to start using more of their extreme blood-conservation measures for our routine cardiac-surgery patients," she observes.

The results show that the extreme blood-management strategies do not appear to place patients at higher risk. In fact, the Witnesses had fewer acute complications and shorter length of stay than the matched patients who required transfusions. Long-term survival was similar.

Outcomes Following Cardiac Surgery Among Witnesses and Matched Controls

Outcomes Jehovah's Witnesses (n=322) Propensity-matched controls (n=322) p
Postop MI (%) 0.31 2.8 0.01
Additional operation for bleeding (%) 3.7 7.1 0.03
Prolonged ventilation (%) 6 16 <0.001
ICU length of stay (15th, 50th, and 95th percentiles, h) 24, 25, and 72 24, 48, and 162 <0.001
Hospital length of stay (15th, 50th and 95th percentiles, d) 5, 7, and 11 6, 8, and 16 <0.001
1-y survival (%) 95 89 0.07
20-y survival (%) 34 32 0.90


Treating Preoperative Anemia Is Key

Koch says prior work has shown that a patient's hematocrit in the perioperative state is dependent on preoperative values, so "treating preoperative anemia is probably where you get the biggest bang for your bucks, and more work needs to be done on treating anemia preoperatively, whether with EPO, iron therapy, or complex vitamins." However, she cautions that, with EPO, it will be vital to look at the thromboembolic type of events that might occur, to properly assess the risk/benefit ratio, she says.

In the Jehovah's Witnesses in their trial, use of EPO "did not come out as a signal for a thromboembolic event," she notes, but adds that the researchers did not have information on doses or duration of EPO given, and this would have changed over time during the course of the study.

It will also be important to look at using the other blood-conservation strategies in all patients, she says. "We are going to have aging baby boomers, a lot of older patients coming for surgery; many of them are anemic and are going to need blood products, but we have a very fine balance between supply and demand at this time; it's a precious resource."

She says they are not yet using the approach adopted in Jehovah's Witnesses for everyone coming to their center, "but it's something we are going to explore. We are starting to work with a research group developing a predictive model. Certainly some of these other things we do perioperatively that don't involve EPO we could certainly do better. We've got a big initiative right now of using smaller-volume tubes at the Cleveland Clinic, for example."

Ferraris agrees wholeheartedly: The new findings "add to the increasing data that more conservative use of blood transfusions would be in our patients' interests, in both Witnesses and non-Witnesses," he concludes.

What Are Jehovah's Witnesses Undergoing Cardiac Surgery Allowed to Receive?

Koch explained that there is a belief that "if you are a Jehovah's Witness, you don't take any blood products," but this isn't necessarily true and varies from person to person, depending on religious conviction. Some patients, for example, will accept certain clotting factors, she notes.

In his editorial, Ferraris details procedures and products permitted by Witnesses:

  • Transfusions of autologous blood.

  • Intraoperative blood salvage (autologous) or cell-saver scavenging.

  • Heart-lung machine, including extracorporeal membrane oxygenation and left ventricular assist device support.

  • Dialysis, where blood is cleaned and returned in continuity.

  • Plasmapheresis, where blood is withdrawn, plasma removed and replaced with nonblood solution, and then returned to patient.

  • Platelet gel.

  • Fractions from red blood cells: hemoglobin.

  • Fractions from white blood cells: interferon and interleukins.

  • Fractions from platelets: platelet factor 4.

  • Fractions from blood plasma: albumin, globulins, cryosupernatant, clotting factors (VIII and IX, and sometimes VII, IX and XIII).

  • Erythropoietin.

  • Homologous blood transfusion is accepted by a few Witnesses.

The authors and editorialist report no conflicts of interest


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