Bloodless medicine refers to a set of strategies and products that may serve as alternatives to allogenic blood transfusion or other blood-based products such as platelets or plasma.
Who might need bloodless medicine?
Bloodless medicine has often been colloquially equated with the Jehovah's Witnesses religion, a faith that prohibits the acceptance of blood products while permitting other medical treatment (1). However, patients refuse blood transfusion for many reasons, from fear of infectious or allergic reactions to concerns about the vaccination status of blood donors (2). Furthermore, blood transfusion may be contraindicated in certain clinical scenarios, such as among patients with severe transfusion reactions, with a significant antibody load, or those at risk of severe volume overload. In other cases, bloodless medicine may not be a choice. Last year, the American Red Cross experienced the lowest number of blood donations in 20 years, prompting declarations of emergency blood shortages across the United States (3). With health care costs on the rise, and blood donations on the decline, widespread availability and accessibility of blood products may not be guaranteed in years to come.
What are bloodless alternatives?
The paradigm of bloodless medicine includes both strategies to prophylactically reduce the need for blood transfusion as well as nonblood-based products that assist management. Such “blood conservation” methods include minimizing iatrogenic blood loss for laboratory testing; tolerating lower hemoglobin levels; treating preoperative anemia with iron, vitamin B12, and folate as indicated; salvaging intraoperative blood (e.g., “cell saver” technology); performing autologous hemodilution; and optimizing surgical hemostasis such as with new electrocautery methods, antifibrinolytics, and hemostatic agents (4). Anemia tolerance can be maximized with supplemental oxygen and reduction of oxygen demand with bed rest, sedation, and strict fever control (5). Products such as epoetin alfa and darbepoetin alfa are staples in bloodless medicine, thanks to their ability to promote erythropoiesis, whereas newer products such as perfluorocarbon emulsion, hemoglobin-based oxygen carriers (e.g., Hemopure), oxygen-releasing microparticles, and artificially engineered erythrocytes remain under keen investigation (6).
How does bloodless medicine compare?
While studies on outcomes of bloodless medicine are mainly limited to case studies and series, some larger retrospective case-control and cohort studies demonstrate similar patient outcomes in adult patients receiving bloodless medicine compared with standard care (7, 8). In fact, some studies go so far as to suggest that bloodless medicine results in superior care, although a more robust subgroup analysis is needed to support this claim (9). Studies that examine the safety and efficacy of bloodless medicine in nephrology are especially lacking.
However, several case series of kidney transplants among members of Jehovah's Witnesses demonstrate that the procedure can be performed safely and is tolerated well (10–12). More recently, a large 2021 case-control study compared a variety of hematologic and transplantation-specific endpoints in 143 members of Jehovah's Witnesses who had received kidney transplants with matched controls and found no differences in the mean estimated glomerular filtration rate and in the incidences of treated acute rejections, death, and graft loss at 12 months (13).
While allogenic blood transfusion has long been taken for granted as a safe and reliable therapy, recent blood shortages and a growing culture of patient refusal are ushering in an era in which blood transfusions may not always be an option. In light of these changing tides, nephrologists must be prepared to incorporate bloodless medicine into their practice to ensure optimal patient care in all situations.
Footnotes
References
- 1.↑
Watch Tower Bible and Tract Society of Pennsylvania. Why don't Jehovah's Witnesses accept blood transfusions? JW.ORG®. Accessed March 5, 2025. https://www.jw.org/en/jehovahs-witnesses/faq/jehovahs-witnesses-why-no-blood-transfusions/
- 2.↑
Cho DJ, et al. Shared decision-making for patients with vaccine-related concerns of blood transfusion: A single institution experience. Transfusion 2024; 64:2247–2251. doi: 10.1111/trf.18052
- 3.↑
American Red Cross. Red Cross declares emergency blood shortage, calls for donations during National Blood Donor Month. January 7, 2024. Accessed March 5, 2025. https://www.redcross.org/about-us/news-and-events/press-release/2024/red-cross-declares-emergency-blood-shortage-calls-for-donations-during-national-blood-donor-month.html
- 4.↑
Resar LMS, Frank SM. Bloodless medicine: What to do when you can't transfuse. Hematology Am Soc Hematol Educ Program 2014; 2014:553–558. doi: 10.1182/asheducation-2014.1.553
- 5.↑
Rogers DM, Crookston KP. The approach to the patient who refuses blood transfusion. Transfusion 2006; 46:1471–1477. doi: 10.1111/j.1537-2995.2006.00947.x
- 6.↑
Gomes FL, et al. Engineering synthetic erythrocytes as next-generation blood substitutes. Adv Funct Mater 2024; 34:2315879. doi: 10.1002/adfm.202315879
- 7.↑
Frank SM, et al. Risk-adjusted clinical outcomes in patients enrolled in a bloodless program. Transfusion 2014; 54:2668–2677. doi: 10.1111/trf.12752
- 8.↑
Frank SM, et al. Methods of bloodless care, clinical outcomes, and costs for adult patients who decline allogeneic transfusions. Anesth Analg 2022; 135:576–585. doi: 10.1213/ANE.0000000000006114
- 9.↑
Lee S, Choi JH. Does bloodless care significantly improve patient outcomes? Anesth Analg 2023; 136:e8–e9. doi: 10.1213/ANE.0000000000006296
- 10.↑
Boggi U, et al. Kidney and pancreas transplants in Jehovah's Witnesses: Ethical and practical implications. Transplant Proc 2004; 36:601–602. doi: 10.1016/j.transproceed.2004.02.045
- 11.
Kaufman DB, et al. A single-center experience of renal transplantation in thirteen Jehovah's Witnesses. Transplantation 1988; 45:1045–1049. doi: 10.1097/00007890-198806000-00009
- 12.↑
Figueiro J, et al. Simultaneous pancreas-kidney transplantation in Jehovah's Witness patients. Clin Transplant 2003; 17:140–143. doi: 10.1034/j.1399-0012.2003.00035.x
- 13.↑
Carvalho Fiel D, et al. Is there sufficient evidence justifying limited access of Jehovah's Witness patients to kidney transplantation? Transplantation 2021; 105:249–254. doi: 10.1097/TP.0000000000003227
