When a Jehovah’s Witness With AML Refuses Blood Transfusions
Medscape, UK/October 20, 2025
By Wolfgang Paik
Key Takeaways
The refusal of blood transfusions by Jehovah’s Witnesses poses a major challenge in treating acute myeloid leukaemia (AML), particularly in patients presenting with severe anaemia.
A woman in her late twenties, presented with a haemoglobin of 6.7 g/dL, received azacitidine and venetoclax, but her haemoglobin fell to 3.7 g/dL during therapy. Despite completing three outpatient courses of azacitidine monotherapy, the patient continued to decline in blood products and died at home.
A case report by Rida Altaf, DO, and colleagues from the Department of Internal Medicine, Orlando Regional Healthcare System, Orlando, Florida, highlighted the clinical complexity of AML management without transfusions and underscored the need for alternative therapies and haematologic support strategies.
The Patient and Her History
The patient presented with palpitations, headaches, and fatigue for 4-8 weeks and was found to have a haemoglobin of 7.3 g/dL. The medication, family, social, drug, travel, and allergy history were unremarkable.
Findings and Diagnosis
On admission, her vital signs were as follows: blood pressure, 113/71 mm Hg; pulse, 77 beats/min; temperature, 36.9 °C (98.4 °F); respiratory rate, 23 breaths/min; and oxygen saturation, 100% on room air.
Physical examination revealed a pale woman with no bruising or skin lesions. Mucous membranes were intact, and there was no hepatomegaly. Iron stores showed severe iron deficiency, with normal vitamin B12 and folic acid.
Additional workup on her first admission for anaemia and leukopenia included a negative antinuclear antibody test, a negative hepatitis panel, a negative HIV test, and a normal thyroid-stimulating hormone level.
A peripheral blood smear showed an increased blast presence. Bone marrow aspiration and core biopsy were performed on day 3 of her first admission for confirmation of morphological diagnosis and for further molecular testing. The bone marrow results were positive for 70% blasts (95% cellularity), which is consistent with AML.
Immunohistochemistry was positive for CD2, CD7 (partial), CD13, CD15, CD33 (partial), CD34, CD38, CD45 (dim), CD117, and human leukocyte antigen-DR isotype (partial). Genetic testing revealed a deletion of chromosome 8q, and fluorescence in situ hybridization revealed atypical loss of NF1, located at chromosome 17q11.2. Given her low white blood cell count (< 10,000 cells per μL), she was diagnosed with low-risk acute promyelocytic leukaemia, a subtype of AML.
The patient refused blood products in accordance with her religious beliefs, treatment with IV iron infusions in addition to daily oral vitamin B12 and folic acid supplements, and a weekly erythropoietin injection.
Fourteen days into her treatment, her haemoglobin level was 3.9 g/dL, and her platelet count reached a nadir of 27,000 platelets per μL.
Treatment was interrupted for 1 week. During this time, the patient was instructed to take tranexamic acid and epoetin alfa.
A bone marrow biopsy was performed again on day 28. The patient was discharged on levofloxacin, voriconazole, and darbepoetin weekly on day 32.
During her 1-week follow-up appointment, the results of the second biopsy showed residual leukaemia with 10%-15% blasts. The patient’s haemoglobin had recovered to 9.5 g/dL.
Due to severe anaemia from venetoclax plus azacitidine and her continued refusal of all blood products, the patient proceeded with monotherapy using azacitidine 75 mg/m² intravenously for 5 days.
The patient was counselled extensively about the risk for disease persistence and relapse and recommended treatment options.
She understood the association between her condition and the high mortality caused by severe anaemia, lower rate of remission, and extremely low chance of sustained remission. Two outpatient cycles of 7 days of azacitidine with a 28-day rest were administered, but treatment was declined thereafter due to worsening fatigue.
Supportive care was provided by her family, including as-needed oxygen supplementation. Further treatment was refused for personal reasons, and the patient later died at home with severe anaemia, with her haemoglobin dropping to 2.1 g/dL.
Discussion
“In summary, this patient presented with severe anaemia and AML but refused to accept blood transfusions and refused to travel to a tertiary-level haematology/oncology care unit. This is the first reported case of its kind, which made counselling about treatment necessarily complicated. Similar cases treated in the future could include newer drug therapies with lower risks or even haematological support that does not require blood products,” the authors wrote.
- This story was translated from Univadis Germany.
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