Safety of bloodless autologous stem cell transplantation in Jehovah's Witness patients

Abstract

Due to the curative potential and improvement in progression-free survival (PFS), high-dose chemotherapy followed by autologous stem cell transplantation (ASCT) is considered the standard of care for several hematologic malignancies, such as multiple myeloma, and lymphomas. ASCT typically involves support with blood product transfusion. Thus, difficulties arise when Jehovah's Witness patients refuse blood transfusions. In order to demonstrate the safety of performing "bloodless" ASCT (BL-ASCT), we performed a retrospective analysis of 66 Jehovah's Witnesses patients who underwent BL-ASCT and 1114 non-Jehovah's Witness patients who underwent transfusion-supported ASCT (TF-ASCT) at Cedars-Sinai Medical Center between January 2000 and September 2018. Survival was compared between the two groups. Transplant-related complications, mortality, engraftment time, length of hospital stay, and number of ICU transfers were characterized for the BL-ASCT group. One year survival was found to be 87.9% for both groups (P = 0.92). In the BL-ASCT group, there was one death prior to the 30 days post transplant due to CNS hemorrhage, and one death prior to 100 days due to sepsis. Based on our data, BL-ASCT can be safely performed with appropriate supportive measures, and we encourage community oncologists to promptly refer JW patients for transplant evaluation when ASCT is indicated.

NCCN Guidelines Insights: Acute Myeloid Leukemia, Version 2.2021

“…To mobilize peripheral blood stem cells and/or raise hemoglobin levels prior to peripheral blood stem cell transplantation, some treatment centers have used erythropoietin-stimulating agents, G-CSF, and thrombopoietin mimetics. [49][50][51] However, before using this strategy, the potential risks, benefits, and uncertainties of using these agents in this context should be thoroughly discussed. Consider referring patients to centers with expertise in bloodless autologous transplant.…”

“…Consider referring patients to centers with expertise in bloodless autologous transplant. 50,51 In addition, for patients who are Jehovah's Witnesses and therefore refuse blood transfusions, the United States branch of the Christian Congregation of Jehovah's Witness has Hospital Liaison Committees that may provide helpful information about bloodless medicine.…”

“…55 During treatment, measures should be taken to minimize blood loss and decrease the risk of bleeding, including use of pediatric collection tubes, avoiding concomitant medications or procedures that increase the risk of bleeding or myelosuppression, use of oral contraceptive pills or medroxyprogesterone acetate in menstruating women, or administration of proton pump inhibitors, as indicated. 50,57 Vitamin K may be considered as an adjuvant to improve coagulopathy. 50,57 In patients at risk for bleeding (eg, when platelet counts decrease to ,30,000/mcL), aminocaproic or tranexamic acid may be considered to manage bleeding.…”

“…50,57 Vitamin K may be considered as an adjuvant to improve coagulopathy. 50,57 In patients at risk for bleeding (eg, when platelet counts decrease to ,30,000/mcL), aminocaproic or tranexamic acid may be considered to manage bleeding. 50,57 In patients with elemental or vitamin deficiencies, iron, folate, and vitamin B12 supplementation should be considered.…”

“…50,57 In patients at risk for bleeding (eg, when platelet counts decrease to ,30,000/mcL), aminocaproic or tranexamic acid may be considered to manage bleeding. 50,57 In patients with elemental or vitamin deficiencies, iron, folate, and vitamin B12 supplementation should be considered. 50,57 In patients with severe anemia, bed rest and supplemental oxygenation should be considered.…”