Blood product transfusions for pediatric Jehovah's witness patients: Management recommendations and considerations

Abstract The Jehovah's witness faith precludes patients from consenting to blood transfusions. This presents a therapeutic challenge for pediatric patients with hematologic and oncologic disorders that routinely require transfusion support due to disease or treatment toxicity. For most patients, hemoglobin (Hgb) levels of < 7 g/dL and platelet (plt) counts of < 10k/µL are generally accepted transfusion thresholds. In some patients who refuse blood products, adjunct supportive care interventions like erythropoietic or thrombopoietic agents can be used to minimize transfusion burden. This case series reviews management and clinical decision-making for three pediatric patients of Jehovah's witness faith at our institution. Note: All patients described were of the Jehovah's witness faith and their parents declined consent for blood product transfusion. Case 1 A 6-year-old female was diagnosed with large B-cell lymphoma without bone marrow involvement. Her treatment consisted of 6 cycles of intensive chemotherapy with anticipated periods of bone marrow suppression and recovery. Her individualized management plan included administration of a weekly erythropoietin agonist, thrombopoietin agonists, and monthly ferritin monitoring. In her fourth and fifth cycles of chemotherapy, she developed severe anemia (lowest Hgb 5.2 g/dL) and severe thrombocytopenia (lowest Plt 8k/µL). She did not have clinical symptoms of anemia except mild tachycardia. She was admitted to the inpatient unit for close clinical monitoring in an effort to avoid transfusions. She developed mild nosebleeds in the setting of thrombocytopenia, for which she was treated with an antifibrinolytic agent. During this time an ethics consult was requested, and a court order was obtained for transfusions if needed. Ultimately, she completed chemotherapy without requiring any transfusions. Case 2 An 11-month-old male was diagnosed with infant acute lymphoblastic leukemia. On initial presentation, he displayed severe symptomatic anemia (Hgb 3.3 g/dL) and thrombocytopenia (Plt 7k/µL) due to leukemic replacement of his bone marrow. His clinical status necessitated pRBC and platelet transfusions shortly after admission. The ethics team was consulted, and a court order was obtained to proceed with pRBC and platelet transfusions. Treatment for his disease requires intensive chemotherapy up to 3 years with intervals of bone marrow suppression and recovery. Given concerns for possible induction of leukemogenesis related to erythropoietin and thrombopoietin agonists, these adjunct therapies were carefully considered. His initial care plan included weekly erythropoietin agonist and, after induction of remission, a thrombopoietin agonist was added to his regimen. Three months into therapy, he continues to require intermittent transfusions of pRBCs and/or platelets related to chemotherapy. Case 3 A 10-year-old male was diagnosed with severe aplastic anemia. On initial presentation, he had severe anemia (Hgb 4.9 g/dL) and thrombocytopenia (Plt 9k/µL). His clinical status necessitated pRBC and platelet transfusions on presentation. The ethics team was consulted, and a court order was obtained to proceed with transfusions. After diagnosis of aplastic anemia, stem cell transplant was considered but immunosuppressive therapy (IST) was chosen as upfront therapy. His care plan included a trial of weekly erythropoietic agents and thrombopoietic agents, but they were discontinued due to minimal effect. Additional supportive care interventions included antifibrinolytic agents and chlorhexidine mouthwash rinses for oral mucosal bleeding. Despite these interventions, he still requires frequent transfusion of blood products related to his severe aplastic anemia. Conclusion:Jehovah's witness patients are a unique patient population that warrant careful clinical and ethical decision-making. Based on our experience, we advocate for individualized therapy plans based on patient needs and disease processes. Our case series highlights that supportive care interventions can be enacted to minimize transfusion burden in some clinical scenarios. We advocate for early involvement of an ethics team and Jehovah's Witness liaisons. Finally, court orders can be a useful tool to reduce uncertainty in management and eliminate the need for families to provide consent against their religious beliefs.