Hydroxyethylstarch as a replacement fluid in therapeutic plasma exchange for lupus nephritis in a Jehovah’s Witness

To the editor 

The restoration of the blood volume is fundamental in order to achieve adequate tissue perfusion when therapeutic plasma exchange (TPE) is performed. The most widely used colloid solutions are blood-derived products [1], [2]. Since a 1945 decision, Jehovah’s Witnesses have refused blood transfusions. As a result, physicians need to be aware of alternative therapeutic options for these patients [3], [4].

We report on the use of a hydroxyethylstarch (HES) [5], Elohes®, as a TPE non-blood-derived colloid replacement solution while treating a Jehovah’s Witness with pulmonary hemorrhage due to systemic lupus erythematosus (SLE).

A 21-year-old white female Jehovah’s Witness was admitted to the hospital in January 2002 because of acute renal failure. She suffered from SLE since 1996 and corticosteroids were administered. In January 2001, a renal biopsy showed a diffuse proliferative glomerulonephritis (WHO Class IV) and immunosuppressive therapy with cyclophosphamide and azathioprine was initiated. At admission, a pulse of methylprednisolone was administered and daily dialysis was initiated. Despite this treatment, the patient worsened and a pulmonary hemorrhage was diagnosed. The patient was placed on a respirator and TPE was indicated. Her religious belief did not approve the use of blood and derivatives. Thus, an artificial colloid named Elohes® was elected as the replacement fluid for the TPE.

A total of three procedures were performed over a two-day interval using HES replacement. The TPEs were performed using standard techniques on the Spectra™ Apheresis System (Gambro BCT, Lakewood, CO, USA). The total blood volume processed was 14,304 ml and the total plasma removed was 7,006 ml. The ratio of replacement HES/plasma volume removed was 1, thus, a total of 7,006 ml of HES was given over the six day treatment period. Of note, prior to treatment with HES, the total protein and albumin levels were 43 and 23 g/l and the posttreatment levels were 21 and 14 g/l, respectively. The protein loss is the most important limitation when HES is used as a replacement solution in TPE [6], [7]. In our case, we discontinued TPE because the pulmonary hemorrhage stopped after the first session of TPE and generalized edema appeared. The young patient survived the acute situation and is now regularly seen at our dialysis center.

In summary, we found that HES provided an effective replacement solution in plasma exchange in a patient who had previously refused blood derivatives because of religious belief.