|Year : 2020 | Volume
| Issue : 3 | Page : 266-268
Liver retrieval from brain-dead kidney transplant recipient – Expanding the organ pool - case report
Aniruddha V Bhosale, Bipin B Vibhute, Dinesh K Zirpe, Shailesh Sable
Department of Liver Transplant and HPB SurgerySahyadri Centre for Organ Transplant, Sahaydri Specialty Hospitals, Pune, Maharashtra, India
|Date of Submission||12-Nov-2019|
|Date of Acceptance||28-Mar-2020|
|Date of Web Publication||30-Sep-2020|
Dr. Aniruddha V Bhosale
Flat No 16, Takshak Apartment, Nagala Park, Kolhapur - 416 003, Maharashtra
Source of Support: None, Conflict of Interest: None
Organ shortage is the leading cause of mortality while on the waiting list for an organ. There is a huge difference between the number of organs required for transplants and the number of organs and organ donations available for transplants. In Asian countries such as India, with a high prevalence of decompensated chronic liver disease requiring organ transplantations, organ shortage is one of the most important issues. Various modifications in donor criteria have been done in the past few decades to expand the organ pool. Organ donation from a brain stem dead person, who was a living donor organ recipient, is a novel and attractive option for expanding the organ pool. Few noteworthy cases have been reported from the west. There are no reports from Asian countries, especially from India. Here, we report a case where liver retrieval was performed from a renal transplant recipient after brain stem death.
Keywords: Extended donor criteria, India, liver transplant, organ donor, organ shortage
|How to cite this article:|
Bhosale AV, Vibhute BB, Zirpe DK, Sable S. Liver retrieval from brain-dead kidney transplant recipient – Expanding the organ pool - case report. Indian J Transplant 2020;14:266-8
|How to cite this URL:|
Bhosale AV, Vibhute BB, Zirpe DK, Sable S. Liver retrieval from brain-dead kidney transplant recipient – Expanding the organ pool - case report. Indian J Transplant [serial online] 2020 [cited 2021 May 18];14:266-8. Available from: https://www.ijtonline.in/text.asp?2020/14/3/266/296900
| Introduction|| |
The first report of the reuse of transplanted organs came in 1991 from Spain. Since then till the past decade, there are such 22 reports, but none of the reports came from India. Reuse of transplanted organs, including the liver, heart, and kidneys, are mentioned in the literature, including the reuse of auxiliary partial grafts. Furthermore, a few reports regarding the use of multiple organs from the transplant recipient. Although most retrievals took place within the first few weeks after transplantation. We report the first case from India where liver retrieval was done from kidney recipient after 3 years of initial transplant, who was on immunosuppression.
| Case Report|| |
A 48-year- female, a renal transplant recipient on regular immunosuppression and follow-up was admitted to our institute with complaints of headache and dyspnea. She had a living donor renal transplant 3 years back. Her brother had donated the kidney. She also had diabetes mellitus and hypertension. She was on triple immunosuppression with tacrolimus, mycophenolate mofetil, and steroids. Despite regular immunosuppression, she had developed graft dysfunction 2 years after the transplant. She developed chronic rejection. She was treated with thymoglobulin twice, but rejection persisted, and she required dialysis for the past 1 year. Hence, she had been advised a second renal transplant. She was admitted to the intensive care unit. Persistent hypertension had complicated her clinical status. She had neurological deteriorations, and hence urgent neuroimaging was ordered. On neuroimaging, she had massive subarachnoid hemorrhage, leading to brain stem dysfunction. Neurosurgical opinion was taken for the possibility of any surgical intervention, but it was not feasible. She rapidly deteriorated clinically and was declared brain dead. Brain death was confirmed by two clinical examinations registered at 6 h intervals according to the medicolegal protocol.
Family and keen were ready for organ donation. Due to comorbidities, only liver retrieval was planned. Her liver functions were normal, and sonography showed near-normal liver, which was confirmed by liver biopsy. Biopsy showed well-preserved portal architecture, with no fibrosis, no neutrophilic infiltration, no interface hepatitis, no portal tract expansion, or any apoptotic bodies. The presence of 20% micro steatosis was noted. Deceased donor liver transplantation was performed at our institute by our team. Her liver was transplanted to 66-year-old male suffering from decompensated chronic liver disease. There were no significant surgical or medical challenges faced during the intra or postoperative period. Postoperative recovery was uneventful, and the patient got discharged on the 6th postoperative day. He was started on regular immunosuppression. He is clinically stable, and his liver function tests are good at the end of 6 months post-liver transplant.
| Discussion|| |
Organ shortage for transplantation and waiting list mortality of patients requiring organ transplantation is one of the biggest hurdles faced by the transplant community all across the globe. The same is the situation in India, where the number of transplants taking place annually is gradual increasing but is far from the requirement of organs. Due to a lack of awareness and sociocultural reasons in Indian society, the organ donation rate after brain death remains very low as compared to the Western world and developed nations. The organ donation rate is 0.26 per million in India, while that in the Western world is >25 per million, with the USA having 26 per million, Spain >35 per million, and Croatia 36.5 per million. If there is 1 per million rates of organ donation rate in India, it will fulfill the current requirement of organs for transplantation, while 2 per million organ donation rates will virtually eliminate the need of living donor organ transplants. In India, there is a rough annual need of two lakhs kidneys, 50,000 hearts, and 50,000 livers for transplantation. The total number of brain deaths due to accidents is nearly 1.5 lakhs annually, even if 5%–10% of all brain deaths are harvested properly for organ donation, technically, there would be no requirement for a living person to donate organs.
Social awareness and public education, along with government efforts have led to some increase in organ donations. Hence, the transplant community has been forced to find other ways to increase the organ pool. This has led to the development of extended donor criteria (EDC), with the liberalization of organ acceptance criteria. EDC must be applied carefully, making sure it does not reduce patient or graft survival. In the case of liver transplantations, EDC may include acceptance of organs with following – (1) Age >59 years (2) body mass index >39.5 kg/m2 (3) transaminase activity up to 500 (4) serum sodium levels >70 mmol/dL (5) cold ischemia time >2 h (6) history of alcohol abuse (7) hepatitis B or C reactive donor (8) active bacteriemia (8) three or more vasoactive drugs (9) graft macrovesicular steatosis >30% (10) history of nonskin malignancy.,
Donation after cardiac death (DCD) is another method used to increase the organ pool. DCD organ retrieval involves the withdrawal of life support and procurement 5 min after the asystole. Variable warm ischemia period in DCD makes it prone to biliary complications (29%) and ischemic cholangiopathy (16%), which are much higher than in the case of donation after brain death (17% and 7%, respectively)., The careful selection of DCD donors is important for reducing complications. Donors younger than 50 years of age, <30 min duration between asystole and cross-clamp, less cold ischemia time are crucial.
Split-liver transplantation is another method for increasing organ pool and currently accounts for approximately 4% of liver transplantations. It typically involves the splitting of the graft into the left lateral segment, which is donated to the pediatric recipient, while the remaining graft is donated to adults. Splitting into right and left grafts with a donation of each to adults is also reported.
The reuse of transplanted organs is also reported in the literature. Although one must remember that these donors are immunosuppressed. First, such a case of the reuse of the liver from brain dead organ recipient came from Spain in 1991. In 2007, two extraordinary cases were reported where orthotropic reuse of hypertrophied partial liver grafts from surviving recipients of partial auxiliary liver transplant. The reuse of the transplanted heart is also reported.
Concerns regarding the potential hepatotoxic effects are the most important hurdles in the reuse of transplanted organs. Cyclosporine is known to cause cholestasis, while steroids can induce steatosis. In I ndex case, a formal liver biopsy was performed to rule this out. Although cases have been reported in the past regarding the reuse of transplanted organs, ours is the first case reported with the use of the liver from a patient of renal transplant who was on all three immunosuppressants. Furthermore, it is the first reported case from India.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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