Ethical and clinical management of a jehovah’s witness patient undergoing deceased donor renal transplantation

Ethical and clinical management of a jehovah’s witness patient undergoing deceased donor renal transplantation: A case presentation (jehovah’s witness renal transplant)

Deepa. S¹, Subathra Devi. M², Maha Lakshmi³

¹Nursing Supervisor, Kauvery Hospital, Cantonment, Trichy, Tamil Nadu

²Nurse Educator, Kauvery Hospital, Cantonment, Trichy, Tamil Nadu

³Nursing Superintendent, Kauvery Hospital, Cantonment, Trichy, Tamil Nadu

Abstract

Jehovah’s Witness patients present unique clinical and ethical challenges in intensive care, particularly following high-risk surgeries such as renal transplantation. Their refusal to accept blood transfusions and blood products based on deeply held religious beliefs complicates postoperative management in the presence of bleeding or hemodynamic instability.

Renal transplantation remains the gold-standard treatment for end-stage renal disease (ESRD), offering improved survival and quality of life compared to dialysis. Optimal management requires a multidisciplinary approach encompassing pre-transplant evaluation, perioperative stabilization, and post-transplant immunosuppressive care. This case highlights the complex perioperative and ethical considerations in managing a Jehovah’s Witness renal transplant recipient with multiple comorbidities.

Background

Chronic kidney disease (CKD) is a global health burden that often progresses to ESRD, necessitating renal replacement therapy. While dialysis offers life-sustaining support, renal transplantation provides superior long-term outcomes in terms of survival, metabolic balance, and quality of life.

CKD patients often present with multiple comorbidities such as hypertension, diabetes, and anemia, which complicate transplant candidacy and postoperative recovery. A comprehensive evaluation, optimization of comorbidities, and individualized perioperative care are essential to maximize graft survival and patient well-being.

Introduction

Renal transplantation is a life-saving intervention for patients with ESRD. However, in Jehovah’s Witness patients, the refusal to receive allogenic blood transfusions introduces significant complexity. The risk of intraoperative and postoperative bleeding is heightened due to fragile vasculature, pre-existing anemia, and the use of anticoagulants or antiplatelet therapy.

In the ICU, nurses play a pivotal role in balancing patient safety, ethical respect for autonomy, and adherence to clinical protocols. Understanding the religious, ethical, and physiological aspects is vital for achieving optimal outcomes. As a nurse, witnessing the emotional and physical transformation of both patient and family during the transplant journey underscores the significance of holistic nursing care.

Religious and Ethical context

Jehovah’s Witnesses decline transfusion of whole blood and major components (red cells, white cells, platelets, plasma). However, they may individually consent to specific blood fractions such as albumin, clotting factors, or immunoglobulins.

Ethical and legal considerations

Respect for patient autonomy and informed consent is paramount.
Ensure a signed refusal of blood form is documented in the case sheet.
Obtain informed consent for permissible alternatives such as cell salvage, erythropoietin, or volume expanders.

Pre-operative management

General Principles:

Minimize blood loss and determine acceptable interventions.
Anticipate and plan for emergency scenarios.
Optimize medications affecting coagulation.
Maintain meticulous documentation and close hemodynamic monitoring.
Limit unnecessary phlebotomy.

Aims of Management:

Minimize intraoperative and postoperative blood loss.
Optimize oxygen delivery and erythropoiesis.
Correct coagulopathies and maintain hemostasis.
Prevent hypothermia and hypotension.
Maintain adequate volume and circulation.

Case Presentation

A 50-year-old Jehovah’s Witness male with ESRD was admitted for deceased donor renal transplantation.

Comorbidities: Hypertension, Obstructive Sleep Apnea, Anemia of CKD (on erythropoietin therapy), Severe Pulmonary Arterial Hypertension (PAH) with moderate left ventricular dysfunction and coronary artery disease (CAD), history of bilateral renal cell carcinoma (post bilateral nephrectomy), appendectomy, and old pulmonary tuberculosis.

Social history: Non-smoker, non-alcoholic.

Allergies: None known.

Physical Examinations

Parameter	Finding
Temperature	98.6°F
HR	84/min
RR	24/min
BP	150/90 mmHg
SpO₂	98% on room air

Initial Evaluation

POCUS:

Mild LVD, Concentric LVH, Mild RA dilatation, Severe PAH

IVC collapsing on breathing.

Lung-No B lines

Abdomen -Free fluid present.

Investigations:

Hemoglobin:8 → 5.9 g/dL
WBC: 5660 → 12,520 /cumm
Urea: 102 mg/dL
Creatinine:6 → 5.2 mg/dL
ABG: pH 7.2 (Metabolic acidosis)
Ferritin: 4000 ng/mL (Iron overload)
Platelet count:29 → 1.37 lakh /mm³

Imaging examination (CT Chest on 26.08.25)

Cardiomegaly with dilated pulmonary artery
Multiple lung secondaries
Multiple lytic lesions in L1 vertebral body
? Secondaries

Imaging examination (CT Chest on 31.08.25)

Cardiomegaly with dilated pulmonary artery
Bilateral pleural effusion with collapse consolidation of bilateral lower lobe
Patchy ground glass density in superior segment of left lingular lobe
Multiple lung secondaries
Multiple lytic lesion in L1 vertebral body

Perioperative Management

Induction immunosuppression: IV Methylprednisolone (Solumedrol) and Anti-Thymocyte Globulin (ATLG).
Immediate postoperative period: moderate urine output, less than typically expected in live donor transplants.
Developed delayed graft function (DGF) requiring one session of hemodialysis via AVF

Intra operative Management

Minimize blood loss: Utilize minimally invasive surgical techniques and hemostatic agents to reduce bleeding. Inj.Tranaxemic acid 1gm IV given.

Surgery Notes:

Cadaver renal transplantation done under General anesthesia
Under SAP, Under GA patient in supine position parts painted and draped

Through modified right Gibson’s incision
Layers opened, retroperitoneum entered
Right external iliac artery + right external iliac vein skeletonized
Right common iliac artery + Right internal iliac artery completely calcified
Bed prepared in RIF
Cadaver kidney (Right kidney received after adequate perfusion & bench dissection) ( Single renal artery with aortic cuff, single renal vein with IVC cuff and single ureter)
Renal vein anastomosed to right external iliac vein with 6-0 prolapse in end to side fashion
Renal artery anastomosed to urinary bladder with 5-0 PDS after keeping 5 Fr 16 cm DJ stent
Right frank DT kept
Hemostasis achieved
Wound cleared in layers
Sterile dressing done

Post Operative Period

Hematological Course:

Postoperative hematuria resolved gradually. He experienced a fall in hemoglobin levels, but in view of his Jehovah’s Witness status, blood or blood products were not administered. Managed with erythropoietin and deciduate supplementation. Ferritin and iron studies showed marked iron overload; hence, further iron supplementation was avoided.

Pulmonary Evaluation:

Complaints of cough and snoring at night prompted a pulmonology consultation. Workup for obstructive sleep apnea has been initiated; follow-up advised.

Hepatic Function:

Developed transient hyperbilirubinemia and worsening renal parameters, suspected drug-induced versus secondary hemosiderosis.

Medical gastroenterology (MGE) opinion obtained; N-acetylcysteine started, following which bilirubin and renal parameters improved. Fibroscan planned in the near future to assess for possible liver fibrosis secondary to iron overload.

Immunosuppression:

Tacrolimus dosing titrated based on trough levels. Foley catheter removed on POD 5 and surgical drain on POD 6.

Graft Evaluation: In view of persistently slow creatinine decline, a graft renal biopsy was performed successfully.

Nursing Management

Respect the patient religious belief (Refusal of blood and blood products)
Obtained informed consent clearly documenting refusal of transfusions
Collaborate with medical team to plan bloodless surgery
Erythropoietin therapy to stimulate red cell production
Encourage high protein and iron rich diet
Educate the patient and family about surgical procedures, anesthesia and recovery
Provide emotional and spiritual support in accordance with beliefs
Check availability of hemostatic agents
Maintain strict aseptic precaution during the procedure
Monitor vital signs, urine output, blood loss continuously
Ensure iv fluid and volume expanders are ready
Monitor hemoglobin level regularly
Observe the signs of bleeding
Avoid unnecessary blood withdrawal.

Discharge Medications:

S.No	Drug Name	Strength	Frequency				Route of admin	Relationship with meal
			M	A	E	N
1	TAB. VINGRAF	3.5 MG	1(7AM)	0	0	1(7PM)	Oral	Before Food
2	TAB. MOFECON- S	360 MG	1	0	0	1	Oral	After Food
3	TAB. WYSOLONE	20 MG	1	0	0	0	Oral	After Food
4	TAB. VALGAN	450 MG	0	1	0	0	Oral	After Food
5	TAB. SEPTRAN - DS		0	0	0	1	Oral	After Food
6	TAB. ECOSPRIN AV	75/20	0	1	0	0	Oral	After Food
7	CANDID MOUTH PAINT		1	1	1	1	L/A
8	SYP. LACTIHEP	15 ML	0	0	0	1	Oral	After Food
9	TAB. OXEMIA	100 MG	1	0	0	0	Oral	After Food
10	TAB. BENIDIPINE	8 MG	1	1	0	1	Oral	After Food
11	TAB. ISOLAZINE	20/375	1	1	0	1	Oral	After Food
12	TAB. CONCOR	2.5 MG	0	0	0	1	Oral	After Food
13	INJ. EPO	40000 U					S/C
14	TAB. DYTOR	80 MG	1	1	1	1	ORAL	AFTER FOOD
15	CAP. SILODAL	4MG	0	0		1	ORAL	BEFORE FOOD
16	TAB. MONDESLOR	10MG	0	0		1	ORAL	AFTER FOOD
17	DUONASE NASAL SPRAY	1PUFF	1	0		1	ORAL
18	SYP. PIRITON CS	10ML	1	1		1	ORAL	AFTER FOOD

Following a cadaveric renal transplant his perioperative management course was successful with notable improvements in his hematological and pulmonary evaluations. At the time of discharge, his general condition was good, and his vitals were stable.

Health Education

Adhere strictly to immunosuppressive therapy
Report decreased urine output immediately.
Maintain follow-up for creatinine, tacrolimus levels, and liver evaluation (Fibroscan).
Continue erythropoietin therapy as advised.
Maintain hand hygiene, avoid crowds, and wear masks.
Follow renal transplant diet and fluid restrictions.

Conclusion

This case demonstrates the clinical and ethical complexity of managing a renal transplant recipient with multiple comorbidities and religious restrictions on transfusion. It highlights the importance of multidisciplinary collaboration, careful planning, and culturally sensitive nursing care to achieve optimal outcomes in high-risk transplant patients.

Ethical and clinical management of a jehovah’s witness patient undergoing deceased donor renal transplantation