How to Treat Anemia in a Patient Who Refuses Transfusions for Religious Reasons

Neil Zakai, MD
Associate Professor of Medicine, Hematology/Oncology Division, Department of Medicine, Associate Professor of Pathology & Laboratory Medicine, Larner College of Medicine, University of Vermont, Burlington, Vermont

This month, Neil A. Zakai, MD, discusses how to treat anemia in a patient who refuses packed red blood cells.

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I have a patient who is a Jehovah’s Witness with stage IV uterine cancer who was admitted to a community hospital with a uterine abscess. Her hemoglobin is low, and I am giving her epoetin alfa and intravenous iron. Are there any other options for treatment of anemia for patients who refuse packed red blood cell transfusions? Her son suggested PolyHeme (a human hemoglobin-based red cell substitute). Is it U.S. Food and Drug Administration (FDA)–approved?


Managing patients with religious objections to blood and blood products in need of a transfusion is a clinical challenge. Non-blood oxygen–carrying agents are currently not FDA-approved but can be obtained using an extended-access program, sometimes called “compassionate use.”

These are designed to be bridging agents until allogeneic blood can be given (such as for trauma patients or in war zones); using them as a complete blood replacement agent has not been wellstudied outside of case reports. The request for PolyHeme is somewhat surprising as this product is made from hemoglobin from expired allogeneic red blood cell units and so is not “blood-free,” but it may be acceptable for some Jehovah’s Witnesses.

Overall, your strategy is sound: ensuring the patient is iron replete and giving parenteral iron and erythropoiesis-stimulating agents. I would also suggest making sure her B12 and folate levels are normal and replete if needed as well as minimizing bleeding (both from her disease process as well as from iatrogenic blood draws).

You could try a blood alternative in an acute situation, but I would not rely on these for routine transfusion needs.

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