Liver transplantation in Jehovah's witnesses

Introduction: Liver transplantation (LT) is a major surgical procedure with large dissections and sutures of large vessels in patients with high portal hypertension and low levels of platelets and coagulation factors. In consequence, LT often requires large amounts of blood products. For religious reasons, most Jehovah's witnesses (JW) refuse infusions of any blood product, including autologous or homologous pre-donated blood, platelets, fresh frozen plasma, coagulation factor concentrates, or human albumin. However, they may accept solid organ transplantation, including LT.
Aim: The authors developed experience in abdominal and oncological surgery in JW and present here their results with LT in JW patients.
Methods: Over a 20-year period, 22 LT (16 DBD, 2DCD, and 4 LRLT with JW living donors) were performed in 21 JW patients and were analyzed retrospectively. All patients received perioperative iron supplementation and erythropoietin. Two patients had percutaneous spleen embolization to increase platelet level. Anti-fibrinolytic (aprotinin or tranexamic acid) was administrated during LT and meticulous surgical hemostasis was achieved, helped by argon beam coagulation. Continuous circuit cell salvage and reinfusion whereby scavenged blood was maintained in continuity with the patient's circulation, was used in all patients. Veno-venous bypass was avoided during LT to minimize the coagulation disorders.
Results: There were 10 male and 11 female patients whose mean age was 48 years (ranges: 6-70). Indications for LT were HCV with (3) or without (1) HCC, PBC (2), PSC (1), HBV (2), autoimmune hepatitis (1), antitrypsin deficiency (1), sarcoidosis (2), amyloidosis (3), polycystic liver disease (1), alcoholic cirrhosis with HCC (1), cryptogenic (3), hepatic artery thrombosis (1). At transplant, mean pre-operative hematocrit was 41% (ranges: 22-50), mean platelet level was 140x103/mm3 (ranges: 33-355), and mean INR was 1.25 (ranges: 0.84- 2.18).One LRLT recipient died at day 11 from aspergillosis and anemia, and another DBD recipient at day 28 due to complications after hepatic artery thrombosis. One patient finally accepted to be transfused for severe anemia. The mean hospital stay was 31 days (10-137). Kaplan-Maier patient survival was 85%, 72%, 72% at 5, 10 and 15 years, respectively Conclusions: According to the authors' experience, LT may be successful in selected and prepared JW patients who should not be a priori excluded from this life saving procedure. The indications for LT in JW were quite different from the common indications for LT, with a low rate of alcoholic cirrhosis. The experience with this particular group of patients helped the team to reduce transfusion needs in the non-JW patients.