BTS 2014 Report: A case I wish I never did

Maria Dalby reporting on the presentation by Dorry Segev, Johns Hopkins University, Baltimore, USA – Every transplant surgeon has had his/her share of cases that turned out less than successful and with the benefit of hindsight should not have been attempted. However, in the midst of disappointment and gloom, there are always lessons that can be learned for the future. Dorry Segev holds the vice chair of research in the department of surgery at Johns Hopkins University in Baltimore and was this year’s invited guest at the BTS Congress; in a session during the BTS Transplant Surgeons Chapter entitled ‘The case I wish I never did’ he shared his experience of a fraught case which illustrates the importance of efficient organ allocation and careful matching of marginal organs with suitable recipients.

To begin with there was nothing to suggest that the case was going to be anything other than a success. The candidate was a 42 year-old African-American lady with end-stage renal disease caused by hypertension and a panel reactive antibodies (PRA) level of 45% from pregnancy and blood transfusions. She had been on haemodialysis for six years and had been waiting for an organ for a year. The donor, on the other hand, was a 52 year-old Caucasian lady who was a DCD donor with a terminal creatinine value of 1.1 and 25 minutes of warm ischaemia time. The biopsy indicated mild pathological changes. However, the donor came from an area of the United States with exceptionally good organ supply and both kidneys were therefore declined locally. By the time the offer was accepted by the Johns Hopkins centre, the cold ischaemia time (CIT) was already 26 hours, but since the median CIT for all DCD donors in the centre is 30 hours Dorry Segev and his team were unfazed. There was a negative cross-match with no donor-specific antibodies and everything was ready to go – including the recipient who was very excited at the prospect of receiving a kidney after a long wait.

However, delays in transporting the organ and getting the cross-match result had mounted up and by the time the patient was ready for surgery, the CIT had risen to 47 hours. Dorry Segev’s own personal record with a successful outcome is 58 hours – with a DBD organ. With hindsight, this was the moment when the surgeon should have asked himself whether this transplantation really ought to go ahead. But the patient and the team were all ready to go and at the time it seemed the best option to go ahead with the procedure. The operation took two hours skin-to-skin with 19 minutes of warm time. Reasonable reperfusion was achieved and antithymocyte globulin (ATG) induction was commenced. The patient was anuric immediately post-transplantation, but there was good flow on duplex and a biopsy on day 10 revealed no signs of rejection and moderate donor disease. The patient was discharged on dialysis.

In the second week post-transplant urine output slowly gained; by week 4 creatinine began to fall and stalled at 2.7 by week 6. A new biopsy showed still no signs of rejection and moderate donor disease – more than had been anticipated from the original biopsy. The creatinine level never improved beyond this level and after the first year post-transplant it was in the 3 range. Graft function slowly deteriorated and by year 3 post-transplant the patient was back on dialysis with a PRA of 85%. She remained grateful for the operation, but sceptical as to whether it had been right for her in the first place – a view that was shared by Dorry Segev. In contrast, the recipient of the second kidney from this donor, who was aged 75 years at the time of transplantation, died with a functioning graft and thus had a very successful outcome. The most important learnings for Dorry Segev and the team from this case, apart from how inefficient the US organ allocation system can be, was that prolonged CIT does not mix well with a DCD organ and that it is acceptable to send a patient home even if he or she is really excited, since questionable organs are best suited for questionable candidates.