Successful renal transplantation from a brain-dead deceased donor with head injury, disseminated intravascular coagulation and deranged renal functions
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 × 103/μl and platelet count was 2.08 × 105/ 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 2nd 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 . 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 × 104/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.\nRecipient 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 5th post-operative day to 1.22 mg/ dL and he was discharged on 7th 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.\nRecipient 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 × 105/μl to 9.5 × 104/μl. However, it recovered gradually and normalized on 4th post-operative day without any treatment. Coagulation profile performed performed on 1st and 4th post-operative day was normal and there was no evidence of bleeding diathesis. SCR normalized on 8th post-operative day to 1.27 mg/dL. She was discharged on 12th 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 . 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.