Wednesday, March 10, 2010
Lack of respect for the beans
Despite a list of absolute contraindications which include donors with active malignancy, untreated sepsis or active intravenous drug abuse, I have found that the limits are a little more subjective than expected, and with the organ shortage, transplant services are even more aggressive of using organs labeled as expanded criteria donor (ECD).
We had an interesting donor offer recently, in which a young female had died after a closed head trauma complicated by disseminated intravascular coagulation. The creatinine was normal and urine output was around 40cc/hour. Our transplant service decided to accept both kidneys. Not sure if you guys know, but the kidneys are actually the last organ to be removed from the deceased donor!? Liver, heart and lungs have preference!!! We had to wait almost 2 hours for another team to take out the liver before we were able to get to the beans… The concern was: could the DIC had damaged the kidneys?
DIC is associated with histopathological evidence of microthrombi in several organs, particularly in the brain, liver, lung, kidney and pancreas. A combination of mechanisms, including release of fat, phospholipids and thromboplastin from tissue—especially brain tissue—into the circulation, hemolysis and endothelial damage may promote systemic activation of coagulation. Cytokines also may have a role in the development of DIC.
The two recipients demonstrated a very slow increase in urine output postop associated with also small downtrending of the creatinine. A time zero biopsy showed multiple fibrin thrombi in the glomerular capillaries. As an important learning point, these allografts are usually associated with delayed graft function. Moreover, it is essential to ensure no significant necrosis is present on biopsy at time zero, before transplantation. It is believed that the recipient's own fibrinolytic system is able to slowly breakdown the thrombi and reestablish the renal function. Still, I was disappointed that the kidneys were last…