Gelatin-thrombin hemostatic matrix injection to salvage refractory post-renal graft biopsy bleed
A 41-year-old gentleman underwent renal transplant with his wife as the donor on 17th July 2011. He received basiliximab as induction and maintained on triple immunosuppression (prednisolone, tacrolimus, and mycophenolate mofetil). He continued to have good urine output through fourth post-operative day and his creatinine declined to 1.7 mg/dl. His tacrolimus levels (C0) on days two and five were 7.8 ng/ml and 9.3 ng/ml respectively. On fifth post-operative day, his serum creatinine level increased to 2.2 mg/dl with a decline in urine output. Laboratory investigations revealed hemoglobin of 9.6 mg/dl, a total count of 7100/mm2, a normal platelet count, coagulation and electrolyte profiles. Graft Doppler showed high resistive indices throughout the arterial tree beginning from renal artery at hilum. On sixth post-operative day, the creatinine rose to 2.6 mg/dl. USG-guided biopsy was done from the upper pole of the graft. Post-biopsy, he developed hematuria, which was initially managed with bed-rest, hydration, and other conservative measures. In the evening, his hemoglobin was found to be 7.2 mg/dl (a drop of 2.7 mg/dl in 8 h). He received two units of blood transfusions. He continued to have hematuria and developed hypotension. Repeat hemoglobin level after two units of transfusion was 6.9 mg/dl. He underwent angiography and transarterial embolization of upper polar pseudoaneurysm using metallic coils was attempted. In spite of this, his hematuria did not subside and there was a further drop in hematocrit. He was explored on the morning of 24th July. By this time, he had received five units of blood. Under general anesthesia, graft was approached by opening the previous incision. There was a small hematoma at the upper pole. After evacuating hematoma, a 2-cm superficial laceration apart from the tract site bleeding was identified. Attempts to close the laceration using prolene sutures in the capsule failed as the sutures cut through the edematous graft. Based on our previous successful experience with Gelatin-thrombin hemostatic matrix, we decided to use it in this case also. A total of 5 ml of the sealant was injected into the tract, in a manner similar to the previous case, and an additional 5 ml was used over the laceration site. In addition, the laceration site was covered with Surgicel. Bleeding was successfully controlled in this case as well. The patient became hemodynamically stable and his graft function improved after receiving anti-rejection therapy as his biopsy revealed C4d-negative acute cellular rejection (Banff 1A). He was discharged after two weeks with a serum creatinine level of 1.2 mg/dl. This patient has been on regular follow-up. He was admitted in April 2012 with culture-positive urinary tract infection with transient graft dysfunction.