You Make the Call
Each month in “You Make the Call,” we pick a challenging clinical question submitted through the Consult a Colleague program
and post the expert’s response, but we also want to know what you would do. Send in your response to next month’s clinical
dilemma and see how your answer matches up to the expert’s in the next print issue.
This month, Neil Zakai, MD, discusses how to treat anemia in a patient who refuses packed red blood cells.
Clinical Dilemma:
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?
Expert Opinion
Consult a Colleague
Through ASH
Neil A. 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
Managing patients with religious objections to
blood and blood products in need of a transfu-
sion is a clinical challenge. Non-blood
oxygen–carrying agents are currently
not FDA-approved but can be ob-
tained 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 well-
studied 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: en-
suring 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 situa-
tion, but I would not rely on these for routine transfu-
sion needs.
REFERENCE
Apte SS. Blood substitutes - the polyheme trials. Mcgill J Med. 2008;11:59-65.
Consult a Colleague is a service for ASH
members that helps facilitate the exchange
of information between hematologists
and their peers. ASH members can seek
consultation on clinical cases from qualified
experts in 11 categories:
• Anemias
• Hematopoietic cell
transplantation
• Hemoglobinopathies
• Hemostasis/thrombosis
• Lymphomas
• Lymphoproliferative disorders
• Leukemias
• Multiple myeloma & Waldenström
macroglobulinemia
• Myeloproliferative neoplasms
• Myelodysplastic syndromes
• Thrombocytopenias
Assigned volunteers (“colleagues”) will
respond to inquiries within two business
days (either by email or phone).
Have a puzzling clinical dilemma?
Submit a question, and read more
about Consult a Colleague volunteers at
hematology.org/Clinicians/Consult.aspx
or scan the QR code.
Next Month’s Clinical Dilemma:
What induction regimen would you choose for a patient
with Philadelphia chromosome–negative precursor B-cell
acute lymphocytic leukemia and ischemic cardiomyopa-
thy with a left ventricular ejection fraction of 35 percent?
How would you respond? Email us at
[email protected] ●
*If you have a request related to a
hematologic disorder not listed here,
please email your recommendation to
[email protected] so it can be
considered for addition in the future.
DISCLAIMER: ASH does not recommend
or endorse any specific tests, physicians,
products, procedures, or opinions, and
disclaims any representation, warranty, or
guaranty as to the same. Reliance on any
information provided in this article is solely
at your own risk.
48
ASH Clinical News
November 2018