Gelatin-thrombin hemostatic matrix injection to salvage refractory post-renal graft biopsy bleed
A 47-year-old man received a renal allograft from his wife in December 2010 using prednisolone, tacrolimus, and mycophenolate mofetil, without any induction. In the immediate post-transplant period, his urine output was just 30 ml. Graft Doppler study showed reversal of diastolic flow in renal artery at hilum, segmental, and interlobar arteries and loss of diastolic flow in arcuate arteries. The patient was dialyzed. The next day, his total urine output was 60 ml and serum creatinine level was 3.6 mg/dl. He received another hemodialysis and underwent graft biopsy. Biopsy was unremarkable. There was no evidence of rejection or calcineurin inhibitors (CNI) toxicity. His creatinine showed a steady rise over the next few days to 7.7 mg/dl. His tacrolimus levels (C0) on Post-operative days four and seven were 7.4 ng/ml and 17.1 ng/ml, respectively, and tacrolimus dose adjustment was done accordingly. After ensuring a normal coagulation profile, a repeat biopsy was done on ninth post-transplant day using 18-gauge automated gun under real-time ultrasound guidance. Post-biopsy, the patient had progressive abdominal distension and drop in his hematocrit. Ultrasonography (USG) disclosed a large upper polar hematoma of approximately 650 ml. He developed hypotension and a total of 17 units of blood transfusions were given. This did not help, so emergency angiographic embolization was attempted. Angiography revealed an upper polar arterio-venous fistula for which the metallic clips were deployed. Even after this, he continued to bleed necessitating exploration. Having obtained the consent for graft nephrectomy, he was taken for exploration. Under general anesthesia, graft kidney was approached by opening the previous incision. On exploration, there was a large perinephric hematoma at the upper pole, which was evacuated and biopsy needle tract was identified. There was continuous bleeding from the tract, which continued even after applying local pressure. Hemostatic sutures also failed to stop the bleeding. So, 5 ml of Gelatin-thrombin hemostatic matrix was prepared as per the manufacturer's instructions. It was injected in the biopsy needle tract using 20 G intravenous cannula []. The bleeding stopped within a few minutes. Patient was hemodynamically stable and did not require any more transfusions after the exploration. Graft biopsy revealed features of ATN. He required four more sessions of hemodialysis after this. He started passing urine 16 days after the transplantation. The creatinine levels started declining and reached a nadir level of 1.1 mg/dl, four weeks after the transplant. He was discharged in a stable condition. He was last followed-up in Jan 2012 and maintained a stable graft function and well-being.