Live donor liver transplantation without blood products: strategies developed for Jehovah's Witnesses offer broad application.

Since first performed by Thomas Starzl in 1963, liver transplantation has become mainstream surgical therapy for patients with end-stage liver disease, with an operative mortality of less than 5% and 1- and 5-year survivals of 85% and 65%.1–5 Despite the successes of liver transplantation, however, end-stage liver disease from hepatitis C has led to a disproportionate increase in patients awaiting transplantation in relation to available organs.6,7 The resultant medical consequences for transplant candidates include longer waiting times, frequent hospitalizations with increased costs of care, transplantation during a state of higher medical acuity, and increased mortality risk. Responses by the transplant community to this need have included expanding organ utilization to include older donors, splitting of cadaveric livers for two recipients, living donor liver transplantation (LDLT) for children and adults, and remodeling of the organ allocation system for maximal utilization. Because the current allocation system gives preference to sicker patients, cadaveric transplantation is usually performed within the physiologic context of various system failures. Renal insufficiency, hypersplenism, portal hypertension, lowered production of pro-coagulant factors, and heightened fibrinolysis are proportionate to the severity of liver disease, contribute to bleeding during transplantation, and make transfusion of blood products likely. These factors have made liver transplantation prohibitive in Jehovah's Witness (JW) patients who refuse the transfusion of blood and blood products for religious reasons. We report successful LDLT in 8 adult JW patients. This group was compared with non-JW patients who underwent LDLT during the same period of time. Although live donation from JW patients may raise some ethical issues, several lessons may be learned from the management of these patients and applied to non-JW patients. We have successfully combined the technique of LDLT with transfusion-free strategies to accomplish LDLT in JW recipients. Based on our experience with blood augmentation and conservation practice, we elaborate an algorithm for elective LDLT in JW patients and report a comparative hematologic record in transfusion-eligible LDLT recipients. Our approach provides broad possibilities for LDLT timing and blood resource conservation with applications for all surgical patients.