• Diego Costanzo, Maria Bindi, Davide Ghinolfi, Massimo Esposito, Francesco Corradi, Francesco Forfori, Paolo De Simone, De Gasperi Andrea A Anesthesia and Critical Care Unit, Ospedale Niguarda Ca' Granda, Milan, Italy., and Gianni Biancofiore.
• Transplant Anesthesia and Critical Care Unit, University School of Medicine, Azienda Ospedaliera-Universitaria Pisana, Pisa, Italy.
• BMC Anesthesiol. 2020 Jan 30; 20 (1): 31.

BackgroundJehovah's Witnesses represent a tremendous clinical challenge when indicated to liver transplantation because they refuse blood transfusion on religious grounds and the procedure is historically associated with potential massive peri-operative blood loss. We herein describe a peri-operative management pathway with strategies toward a transfusion-free environment with the aim not only of offering liver transplant to selected Jehovah's Witnesses patients but also, ultimately, of translating this practice to all general surgical procedures.MethodsThis is a retrospective review of prospective medical records of JW patients who underwent LT at our Institution. The peri-operative multimodal strategy to liver transplantation in Jehovah's Witnesses includes a pre-operative red cell mass optimization package and the intra-operative use of normovolemic haemodilution, veno-venous bypass and low central venous pressure.ResultsIn a 9-year period, 13 Jehovah's Witness patients received liver transplantation at our centre representing the largest liver transplant program from deceased donors in Jehovah's Witnesses patients reported so far. No patient received blood bank products but 3 had fibrinogen concentrate and one tranexamic acid to correct ongoing hyper-fibrinolysis. There were 4 cases of acute kidney injury (one required extracorporeal renal replacement treatment) and one patient needed vasoactive medications to support blood pressure for the first 2 postoperative days. Two patients underwent re-laparotomy. Finally, of the 13 recipients, 12 were alive at the 1 year follow-up interview and 1 died due to septic complications.ConclusionsOur experience confirms that liver transplantation in selected Jehovah's Witnesses patients can be feasible and safe provided that it is carried out at a very experienced centre and according to a multidisciplinary approach.

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