Lessons learned from transfusion refusal

By Sarah Guy

Jehovah's Witness patients (Witnesses) who refuse blood transfusions during cardiac surgery are not at risk for surgical complications or long-term mortality compared with non-Witnesses who receive transfusions, report US researchers.

Witnesses had fewer postoperative myocardial infarctions, fewer additional operations for bleeding, and a lower hazard for in-hospital death, says the team.

The findings indicate that the severe blood-conserving management strategies used in Witness patients could benefit other patient groups, suggest Colleen Koch (Cleveland Clinic, Ohio) and co-investigators.

"Witnesses hold beliefs that disallow blood product transfusion and therefore offer a natural experiment in severe blood conservation," they explain in the Archives of Internal Medicine, adding that blood conservation practices include preoperative use of erythropoietin, iron, and B-complex vitamins, and intraoperative use of antifibrinolytics.

The study cohort included 322 Witness and 48,986 non-Witness cardiac surgery patients, the latter of whom received transfusions, who were followed up for a respective mean 9.6 and 8.6 years.

The researchers report that the two groups showed similar rates of in-hospital mortality, at 3.1% of Witnesses and 4.5% of non-Witnesses, but Witnesses had significantly lower rates of additional operations for bleeding (3.7 vs 7.3%), myocardial infarction (0.3 vs 2.8%), and prolonged ventilation (6.0 vs 16.0%), than non-Witnesses.

There was a trend toward a lower risk for death/improved survival after 1 year among Witnesses (95% survival vs 89%); however, by 20 years' follow up, mortality rates did not differ significantly from those for non-Witnesses (66 vs 68%).

One important potential limitation of the study is highlighted in an accompanying commentary, by Victor Ferraris (University of Kentucky Chandler Medical Center, Lexington).

"Witnesses who undergo cardiac surgery are likely a healthier subgroup of Witnesses because those who are believed by their surgeons to require blood transfusion to survive cardiac surgery presumably never go to the operating room," he wrote.

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