Advertisment
Indian Journal of Nephrology About us |  Subscription |  e-Alerts  | Feedback | Login   
  Print this page Email this page   Small font sizeDefault font sizeIncrease font size
 Home | Current Issue | Archives| Ahead of print | Search |Instructions |  Editorial Board  

Users Online:1212

Official publication of the Indian Society of Nephrology
  Search
 
  
 ~  Similar in PUBMED
 ~  Search Pubmed for
 ~  Search in Google Scholar for
 ~Related articles
 ~  Article in PDF (363 KB)
 ~  Citation Manager
 ~  Access Statistics
 ~  Reader Comments
 ~  Email Alert *
 ~  Add to My List *
* Registration required (free)  

 
   Abstract
  Introduction
  Case Report
  Discussion
  Conclusion
   References
   Article Tables

 Article Access Statistics
    Viewed1242    
    Printed36    
    Emailed1    
    PDF Downloaded88    
    Comments [Add]    

Recommend this journal

 


 
  Table of Contents  
CASE REPORT
Year : 2013  |  Volume : 23  |  Issue : 6  |  Page : 448-451
 

Successful renal transplantation from a brain-dead deceased donor with head injury, disseminated intravascular coagulation and deranged renal functions


1 Department of Nephrology and Clinical Transplantation, Institute of Kidney Diseases and Research Center, Dr. HL Trivedi Institute of Transplantation Sciences, Ahmedabad, India
2 Department of Pathology, Laboratory Medicine, Transfusion Services and Immunohematology, IKDRC-ITS, Ahmedabad, India
3 Department of Urology and Transplantation IKDRC-ITS, Ahmedabad, India
4 Department of Anesthesia, IKDRC-ITS, Ahmedabad, India

Date of Web Publication24-Oct-2013

Correspondence Address:
P P Ghuge
Department of Nephrology, Smt. G. R. Doshi and Smt. K. M. Mehta Institute of Kidney Diseases and Research Centre, Dr. H.L. Trivedi Institute of Transplantation Sciences, Ahmedabad - 380 001, Gujarat
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-4065.120344

Rights and Permissions

  Abstract 

Deceased donors (DDs) with the brain death due to head injury are the major source of organs for transplantation. The incidence of post-head injury disseminated intravascular coagulation (DIC) ranges from 24% to 50%. Many centers do not accept organs from donors with DIC due to increased risk of primary graft non-function and/or high chances of morbidity/mortality. We performed two successful renal transplants from a DD with head injury with DIC and deranged renal function. One of the recipients developed transient thrombocytopenia, but there was no evidence of DIC or delayed graft functions in either of the recipients. Over a follow-up of 1 month, both are doing well with stable graft function and hematological profile. Thus, a carefully selected DD with severe DIC even with deranged renal function is not a contraindication for organ donation if other risk factors for primary non-function are excluded. This approach will also help in overcoming organ shortage.


Keywords: Deceased donor, disseminated intravascular coagulation, renal transplant


How to cite this article:
Ghuge P P, Kute V B, Vanikar A V, Gumber M R, Gera D N, Patel H V, Shah P R, Modi P R, Shah V R, Trivedi H L. Successful renal transplantation from a brain-dead deceased donor with head injury, disseminated intravascular coagulation and deranged renal functions. Indian J Nephrol 2013;23:448-51

How to cite this URL:
Ghuge P P, Kute V B, Vanikar A V, Gumber M R, Gera D N, Patel H V, Shah P R, Modi P R, Shah V R, Trivedi H L. Successful renal transplantation from a brain-dead deceased donor with head injury, disseminated intravascular coagulation and deranged renal functions. Indian J Nephrol [serial online] 2013 [cited 2019 Nov 22];23:448-51. Available from: http://www.indianjnephrol.org/text.asp?2013/23/6/448/120344



  Introduction Top


Deceased donors (DDs) with the brain death due to head injury are the major source of organs for transplantation. Recent studies mention incidence of post-head injury disseminated intravascular coagulation (DIC) ranging from 24% to 50%. [1],[2],[3] Many centers hesitate in accepting organs from donors with DIC due to increased risk of primary graft non-function and/or high chances of morbidity/mortality.

In India, about 61% of stage V chronic kidney disease (CKD) patients are not on any form of renal replacement therapy and only 2% are prepared for renal transplantation. [4] There is a wide gap between the demand and supply of organs for patients with end organ failure and potential chances of getting a deceased donor (DD) organ in the present scenario are dismal. To reduce this disparity, various strategies are being implemented to expand the DD pool. An additional approach that could be considered is accepting DD with head injury with disseminated intravascular coagulation (DIC) for organ donation since, DD with traumatic head injury are the most common source of DD organ transplantation. Whether to consider a DD with DIC is controversial since some studies have shown increased incidence of primary non-function in transplanted kidneys while others have shown good long-term outcome, but initial delayed graft function. [5],[6],[7]

We present two successful renal transplants (RTx) from a brain-dead DD with head injury with extensive DIC and deranged renal function.


  Case Report Top


A 19-year-old male patient with head injury following a road traffic accident was brought in emergency to a private trauma care hospital. On admission, he was found to be comatose, had fractured right tibia and left femur. On day of admission, his renal function and liver function tests were normal with serum creatinine (SCr), 1.40 mg/dL. However, he had deranged coagulation profile with activated partial thromboplastin time: 32.7 s, (control: 27.9 s), Prothrombin time: 20 s (control: 10.6 s) and international normalized ratio was 1.89. His hemoglobin was 7.21 g/dL, total leukocyte count 1.52 × 10 3 /μl and platelet count was 2.08 × 10 5 / μl. He had hypotension and fall in hemoglobin level; hence, he was transfused 4 units of whole blood and started on vasopressors dopamine at 10 μg/kg/min and noradrenaline at 10 μg/ min. Blood pressure was maintained around 110-120 systolic and 80-90 mm of Hg diastolic. On 2 nd day, he developed extensive petechiae and purpura all over the body and oozing of blood through wounds hence 6 units of fresh frozen plasma were transfused. However, he further deteriorated with increase in purpuric spots, further derangement in coagulation profile, decreasing platelet count and Hemoglobin level, low Serum fibrinogen level and D-DIMER >4000 ng/ml suggestive of extensive DIC. Detaillaboratory parameters of the donor are shown in [Table 1]. Computed tomography brain was suggestive of changes of diffuse hypoxia. Electroencephalogram was suggestive of alpha alpha coma. Patient was declared brain-dead by neurophysician and neurosurgeon at the interval of 6 h. Ultrasonography of the abdomen showed normal sized kidneys. Blood and urine culture were sterile. The relatives were explained about organ donation. Since, they agreed he was shifted to our institute. His renal function was deranged with SCr, 3.57 mg/dL and blood urea 92 mg/dL. His hemoglobin had dropped to 7.3 g/ dL and platelet count was 5.5 × 10 4 /μl. Blood pressure was 100/70 mmHg on dopamine and noradrenalin support. Both kidneys were harvested and transplanted in two recipients with favorable complement-dependent lymphocytotoxicity cross-match.
Table 1: Laboratory parameters of donor

Click here to view


Recipient 1-was a 25-year-old male on maintenance hemodialysis for, 55 months. He received induction therapy with rabbit anti-thymocyte globulin (r-ATG) 1.5 mg/kg and 3 doses of methyl prednisolone 500 mg/ day. His hematological, coagulation and renal function profile remained within normal range throughout the post-operative period and follow-up period of 1 month. SCR normalized on 5 th post-operative day to 1.22 mg/ dL and he was discharged on 7 th post-operative day with SCR, 1.18 mg/dL on maintenance immunosuppression of Tacrolimus 0.08 mg/day, Mycophenolate sodium 720 mg twice daily and Prednisolone, 20 mg/day. There was no evidence of graft dysfunction throughout the follow-up period of 1 month.

Recipient 2 was a 30-year-old female with post-partum cortical necrosis. She was on maintenance hemodialysis since 44 months. She received the same induction and maintenance immunosuppression therapy as recipient 1. On first post-operative day, her platelet count decreased from 1.44 × 10 5 /μl to 9.5 × 10 4 /μl. However, it recovered gradually and normalized on 4 th post-operative day without any treatment. Coagulation profile performed performed on 1 st and 4 th post-operative day was normal and there was no evidence of bleeding diathesis. SCR normalized on 8 th post-operative day to 1.27 mg/dL. She was discharged on 12 th post-operative day with SCR of 0.87 mg/dL with same maintenance immunosuppression as that of recipient 1. Demographic profile and laboratory parameters of both recipients are shown in [Table 2]. Sr. Tacrolimus level of both transplant recipients in immediate post-transplant period and throughout the follow-up period of 1 month was maintained in the range of 7-10 ng/ml.
Table 2: Demographic data and post-transplantation follow-up of allograft recipients

Click here to view



  Discussion Top


DIC is common in DD with head injury with incidence of 59% in open head trauma, 43% in combined open and closed head trauma and 37% in closed head trauma. [8] Mechanisms responsible for DIC are activation of the coagulation cascade through release of brain tissue thromboplastin, inflammatory cytokines, tissue factor activation and exposure of phospholipids to circulating blood. [9],[10] DIC causes occlusion of small and medium sized vessels due to the formation of fibrin thrombi. [11] Many centers still hesitate to accept organs from DD with DIC due to reported incidence of primary non-function. In one study, fibrin thrombi present in renal biopsy at 1 h post-transplant was not present in biopsy done at 7 days and 6months post-transplant. This suggested that fibrin thrombi can be lysed by recipient fibrinolytic system. [12],[13],[14],[15],[16] Recipients of grafts with donor thrombi were more likely to exhibit delayed graft function; however, graft function and survival at 1 and 2 years post-transplant was good suggesting that the presence of donor microvascular thrombosis doesn't n't portend poor outcome in RTx. [17]

Some studies suggest that the presence of good renal function and renal biopsy is necessary prior to transplantation to exclude renal cortical necrosis due to microvascular thrombosis in DIC, but other reports negate this view. [18],[19],[20] Pre-transplant renal biopsy is not a good method to guide organ allocation in cases of donor DIC because of false positive and false negative results and also inability of renal biopsy to predict reversibility of fibrin thrombi by glomerular fibrinolytic system after transplantation. [21],[22],[23],[24],[25],[26],[27] One study reported increased incidence of post-transplant thrombocytopenia in recipients of kidney from DIC positive donors. It also noted that there was increased incidence of delayed graft function in recipients who had post-transplant thrombocytopenia, but long-term graft survival was good. [28] Recipient thrombocytopenia may be an early sign of intrarenal clotting due to DIC; thus, may contribute to delayed graft function or slow graft function. [28],[29],[30] There are some case reports, which showed that even presence of severe DIC with thrombotic microangiopathy on renal biopsy and renal function impairment in DD is not a reason for excluding organ from DIC positive donor. [31]

We selected this donor for organ donation because of his young age and since, there was no any major illness in the past; also he had good urine output prior to transplant. We proceeded without performing pre-transplant renal biopsy. One of our recipients developed transient thrombocytopenia, but there was no clinical or laboratory evidence of DIC and also there was no evidence of delayed graft function or slow graft functions in either recipient. We attribute this transient thrombocytopenia to r-ATG given for induction.


  Conclusion Top


To conclude, a carefully selected DD with head injury and DIC even with deranged renal function may not be a contraindication for organ donation if other risk factors for primary non-function are excluded.

 
  References Top

1.Sun Y, Wang J, Wu X, Xi C, Gai Y, Liu H, et al. Validating the incidence of coagulopathy and disseminated intravascular coagulation in patients with traumatic brain injury: Analysis of 242 cases. Br J Neurosurg 2011;25:363-8.  Back to cited text no. 1
    
2.Selladurai BM, Vickneswaran M, Duraisamy S, Atan M. Coagulopathy in acute head injury: A study of its role as a prognostic indicator. Br J Neurosurg 1997;11:398-404.  Back to cited text no. 2
    
3.Talving P, Lustenberger T, Lam L, Inaba K, Mohseni S, Plurad D, et al. Coagulopathy after isolated severe traumatic brain injury in children. J Trauma 2011;71:1205-10.  Back to cited text no. 3
    
4.Rajapurkar MM, John GT, Kirpalani AL, Abraham G, Agarwal SK, Almeida AF, et al. What do we know about chronic kidney disease in India: First report of the Indian CKD registry. BMC Nephrol 2012;13:10.  Back to cited text no. 4
    
5.Meyers JL, Disler PB, Milne FJ, Hyde P, Abrahams C, Myburgh JA. Donor disseminated intravascular coagulation (DIC), intraglomerular fibrin deposition and subsequent graft function. Kidney Int 1978;13:432.  Back to cited text no. 5
    
6.Leunissen KM, RuersTh JM, Bosman F, Kootstra G, Van Hooff JP. Intravascular coagulation and kidney donation. Transplantation 1986;18:469.  Back to cited text no. 6
    
7.Hull D, Karlson CG, Lucier JS, Bradley JW, Cho SI. Disseminated intravascular coagulation in cadaver kidney donors. Transplant Proc 1986;18:469.  Back to cited text no. 7
    
8.Hefty TR, Cotterell LW, Fraser SC, Goodnight SH, Hatch TR. Disseminated intravascular coagulation in cadaveric organ doners, incidence and effect on renal transplantation. Transplantation 1993;55:2-442.  Back to cited text no. 8
    
9.Toh CH, Dennis M. Disseminated intravascular coagulation: Old disease, new hope. BMJ 2003;327:974-7.  Back to cited text no. 9
    
10.Takada M, Nadeau KC, Hancock WW, Mackenzie HS, Shaw GD, Waaga AM, et al. Effects of explosive brain death on cytokine activation of peripheral organs in the rat. Transplantation 1998;65:1533-42.  Back to cited text no. 10
    
11.Levi M, Cate HT. Disseminated intravascular coagulation. N Engl J Med 1999;341:586-92.  Back to cited text no. 11
    
12.Gil-Vernet S, Martinez-Brotons F, Gonzalez C, Domenech P, Carreras M. Disseminated intravascular coagulation in multiorgan donors. Transplant Proc 1992;24:33.  Back to cited text no. 12
    
13.Faulk WP, Gargiulo P, McIntyre JA, Bang NU. Hemostasis and fibrinolysis in renal transplantation. Semin Thromb Hemost 1989;15:88-9.  Back to cited text no. 13
    
14.Levin RD, Kwaan HC, Ing TS, Miller AW, Merkel FK. Return of function in the thrombosed kidney after transplantation. Nephron 1977;19:146-52.  Back to cited text no. 14
    
15.Ruers TJ, Bosman F, Kootstra G, van Hooff JP. Intravascular coagulation and kidney donation. Transplantation 1986;42:307-8.  Back to cited text no. 15
    
16.Shamash FS, Oh HK, Lee MW, Dienst SG. Kidney retrieval from cadaver donors with disseminated intravascular coagulopathy. Curr Surg 1989;46:6-9.  Back to cited text no. 16
    
17.McCall SJ, Tuttle-Newhall JE, Howell DN, Fields TA. Prognostic significance of microvascular thrombosis in donor kidney allograft biopsies. Transplantation 2003;75:1847-52.  Back to cited text no. 17
    
18.Matlin RA, Gary NE. Acute cortical necrosis. Case report and review of the literature. Am J Med 1974;56:110-8.  Back to cited text no. 18
    
19.Colman RW, Robboy SJ, Minna JD. Disseminated intravascular coagulation (DIC): An approach. Am J Med 1972;52:679-89.  Back to cited text no. 19
    
20.Robboy SJ, Major MC, Colman RW, Minna JD. Pathology of disseminated intravascular coagulation (DIC). Analysis of 26 cases. Hum Pathol 1972;3:327-43.  Back to cited text no. 20
    
21.Kaufman HH, Hui KS, Mattson JC, Borit A, Childs TL, Hoots WK, et al. Clinicopathological correlations of disseminated intravascular coagulation in patients with head injury. Neurosurgery 1984;15:34-42.  Back to cited text no. 21
    
22.Caig JM, Gitlin D, Janeway JA. Studies on the nature of fibrinoid in the collagen diseases. Am J Pathol 1957;33:55-77.  Back to cited text no. 22
    
23.Davison AM, Thomson D, Macdonald MK, Rae JK, Uttley WS, Clarkson AR. Identification of intrarenal fibrin deposition. J ClinPathol 1973;26:102-12.  Back to cited text no. 23
    
24.Gitlin D, Craig JM. Variations in the staining characteristics of human fibrin. Am J Pathol 1957;33:267-83.  Back to cited text no. 24
    
25.Guarrera JV, Nasr SH, Reverte CM, Samstein B, Brown T, Balachandran V, et al. Microscopic intrarenal particles after pulsatile machine preservation do not adversely affect outcomes after renal transplantation. Transplant Proc 2006;38:3384-7.  Back to cited text no. 25
    
26.Bergstein JM. Glomerular fibrin deposition and removal. Pediatr Nephrol 1990;4:78-87.  Back to cited text no. 26
    
27.Wardle EN. Fibrin in renal disease: Functional considerations. Clin Nephrol 1974;2:85-92.  Back to cited text no. 27
    
28.Wang CJ, Shafique S, McCullagh J, Diederich DA, Winklhofer FT, Wetmore JB. Implications of donor disseminated intravascular coagulation on kidney allograft recipients. Clin J Am Soc Nephrol 2011;6:1160-7.  Back to cited text no. 28
    
29.Saba HI, Morelli GA. The pathogenesis and management of disseminated intravascular coagulation. Clin Adv Hematol Oncol 2006;4:919-26.  Back to cited text no. 29
    
30.Vincent JL, De Backer D. Does disseminated intravascular coagulation lead to multiple organ failure? Crit Care Clin 2005;21:469-77.  Back to cited text no. 30
    
31.Keeris LM, Bergmans DC, van der Sande FM, Wind TJ, van Suylen RJ, van Mook WN. Kidney donor with severe disseminated intravascular coagulation: Transplantation however successful. Ned Tijdschr Geneeskd 2009;153:B418.  Back to cited text no. 31
    



 
 
    Tables

  [Table 1], [Table 2]



 

Top
Print this article  Email this article
 

    

Indian Journal of Nephrology
Published by Wolters Kluwer - Medknow
Online since 20th Sept '07