Successful living donor kidney transplantation in a patient with prothrombin gene mutation: Case report and literature review
A 69-year-old female with a history of prothrombin gene mutation was scheduled for living donor kidney transplantation. After developing spontaneous left subclavian and brachial artery thrombosis 17 years ago, patient underwent therapeutic anticoagulation and maintenance on warfarin for 1 year. With therapy, her thrombosis was found to have completely resolved; however, 8 years later following an arthroscopic procedure on her right knee, she developed venous thrombosis of her right lower extremity. She was subsequently found to have a heterozygous form of the prothrombin gene 20210 mutation and hence was maintained on chronic anticoagulation with warfarin. Over the past 2 years, patient developed end-stage renal disease in the setting of diabetes and hypertension.\nAfter careful discussion and institutional approval, patient and her son elected to undergo living donor kidney transplantation. Patient underwent general endotracheal anesthesia with smooth intravenous induction. She had a tunneled internal jugular double-lumen central venous catheter placed preoperatively and radial arterial line placed after induction. Access is sometimes difficult in renal transplant recipients and more so in our patient due to history of spontaneous subclavian and brachial artery thrombosis. As a routine practice in our institution, we place tunneled catheters preoperatively with interventional radiology for our scheduled kidney transplant recipients. There was no evidence of clots or thrombi in the internal jugular vein or vessels prior to placement of the line with ultrasound examination. A peripheral intravenous cannula was placed intra-operatively for additional access.\nShe received methylprednisolone and thymoglobulin for immunosuppression. In view of the patient's history of prothrombin gene mutation and history of prior thrombosis, she was maintained on a heparin infusion with a aim of maintaining the partial thromboplastin time (PTT) in the range of 70-75. To achieve this target PTT we gave a 2000 units bolus of heparin followed by an infusion of 1000 units/h. She remained stable throughout, maintaining a mean arterial pressure goal of > 80-85 mmHg after reperfusion. Trachea was extubated in the operating room and she was transported stable to the surgical intensive care unit. She received 2 l of albumin, 4.5 l of normal saline and 2 units of packed red blood cells during the case.\nOn the 3rd day post-operative, due to continued anticoagulation with heparin, patient developed retroperitoneal hematoma requiring re-exploration and washout. However, her allograft demonstrated good function and her creatinine remained stable post-operatively. She was transitioned to warfarin for anticoagulation and discharged home. Her continued immunosuppressive regimens include prednisone, tacrolimus and mycophenolate. Patient subsequently developed ureteral calculus, hydronephrosis and acute renal failure requiring nephrostomy tube placement. She has since had the nephrostomy tube removed and to date, her allograft continues to function well fifteen months later.