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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
CASE REPORT  
Year : 2016  |  Volume : 27  |  Issue : 3  |  Page : 581-584
Severe hemorrhage complicating early transplant nephrectomy due to sepsis


South West Transplant Center, Plymouth Hospitals NHS Trust, Derriford Hospital, Plymouth PL6 8DH, United Kingdom

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Date of Web Publication13-May-2016
 

   Abstract 

Compared to the general population, transplant patients receiving immuno- suppression have an increased risk of wound and systemic infection that might lead to hemorrhage. We present a case of severe bleeding from the external iliac artery secondary to a pelvic abscess following renal transplantation and transplant nephrectomy. A 73-year-old man received an extended criteria donor organ from a 49-year-old person who died from systemic sepsis. The patient bled from the Carrel's patch while awaiting a computed tomographic scan- guided drainage of an infected peritransplant collection. At exploration, a nonviable allograft surrounded by about 1 L of thick pus was removed. Bleeding from a 2 mm hole in the Carrel's patch was repaired by prolene suture as the external iliac vessels could not be mobilized due to a frozen pelvis. The patient died 72 h later from a massive bleed confirmed at postmortem to have originated from the external iliac artery distal to the anastomosis. Diversion of blood flow away from an affected area (with or without excision of the infected vessels) through a bypass procedure probably represents the best option in avoiding such sequelae.

How to cite this article:
Akoh JA, Rana T. Severe hemorrhage complicating early transplant nephrectomy due to sepsis. Saudi J Kidney Dis Transpl 2016;27:581-4

How to cite this URL:
Akoh JA, Rana T. Severe hemorrhage complicating early transplant nephrectomy due to sepsis. Saudi J Kidney Dis Transpl [serial online] 2016 [cited 2019 Jul 23];27:581-4. Available from: http://www.sjkdt.org/text.asp?2016/27/3/581/182411

   Introduction Top


Compared to the general population, trans- plant patients receiving immunosuppression have an increased risk of wound and systemic infection. Sepsis in the donor further increases this risk by introducing the pathogen with the allograft. Local infection is a well-known cause of the breakdown of vascular anastomoses. We present a case of severe bleeding from the external iliac artery secondary to a pelvic abscess following renal transplantation and transplant nephrectomy. This case highlights the risk of bleeding from major vessels as a result of local infection and suggests possible ways of preventing such a complication.


   Case Report Top


DH, a 73-year-old male approaching end-stage renal failure due to obstructive nephropathy underwent a preemptive renal transplantation. His past medical history was minimal but included secondary hypertension and gastric ulcer. The donor's kidney was retrieved from a 49-year-old deceased donor who died from systemic sepsis (unknown organism). The do- nor creatinine was 230 µmol/L. A preimplan- tation biopsy showed mild vessel disease and features compatible with acute tubular necrosis. The less than the optimum quality of the kid- ney with an increased risk of infection and failure was explained to the patient who elected to continue with transplantation.

The transplant procedure involved using the Carrel's patch for the arterial anastomosis to the external iliac artery. Immunosuppression comprised basiliximab and prednisolone for induction and tacrolimus (trough level main- tained between 7 and 10 µg/L), mycophenolate mofetil, and prednisolone for maintenance. A routine ultrasound scan performed on the 1st postoperative day showed a well-perfused kid- ney with no collection or hydronephrosis. The patient continued to improve but his creatinine plateaued at 350 µmol/L even though he continued to maintain a good urine output. He had a spike in temperature with rigors and breathlessness on the 8th postoperative day and was treated empirically with intravenous teico- planin and tazocin for an assumed hospital acquired pneumonia (based on chest X-ray fin- dings). Blood cultures were negative. He also manifested a urinary tract infection due to Escherichia coli treated by tazocin (piperacillin/ tazobactam) and superficial wound infection/ dehiscence requiring treatment in the form of vacuum-assisted closure dressing and teico- planin for Enterococcus species and coliforms grown from the pus swabs.

A renal biopsy performed on the 11th post- operative day revealed features compatible

with acute tubular necrosis and thrombotic microangiopathy, thus pointing to a likely diagnosis of calcineurin toxicity. Following the biopsy, the patient developed abdominal dis- comfort, a low blood pressure (85/55 mm Hg) and his hemoglobin fell from 10.0 to 5.7 g/dL. He was transfused 3 units of blood and under- went a further ultrasound scan that showed a large hematoma. This was managed conser- vatively. Following discharge, the patient was readmitted with further bleeding from the wound site, and again the ultrasound showed a hematoma with a small amount of intra-abdo- minal fluid but with a well-perfused kidney. He was discharged from hospital and followed- up regularly at the transplant clinic. One month postoperatively, he was noted to have an infec-tion in the transplant wound and readmitted.

While arrangements were being made for a computed tomographic scan-guided drainage, the patient suffered an acute bleed from the wound and was taken for emergency re-explo- ration. The findings were an infected hema- toma in the subcutaneous wound plane, a shrunken transplant kidney lying in a pool of pus estimated to measure about 1 L, no flow in the renal artery (undetectable by an ultrasound Doppler), a thrombosed renal vein, and active bleeding through a blowout hole of about 2 mm in the Carrel's patch. A transplant neph- rectomy was performed and the necrotic patch was repaired using 3/0 prolene after obtaining specialist vascular advice. Postoperatively, the patient was started on intravenous meropenem and his immunosuppression was stopped, with the exception of prednisolone.

He appeared to be recovering well and eno- xaparin was restarted on the day following transplant nephrectomy. However, on the 3rd day posttransplant nephrectomy, he developed cardiac arrest due to a massive hemorrhage and died despite 30 min of cardiopulmonary resuscitation. At postmortem, the pathologist reported the cause of death as hemorrhage secondary to necrosis of the external iliac arterial wall just distal to the infected renal transplant site. The arterial patch that was initially thought to be the source of bleeding was intact and showed inflammatory changes only.


   Discussion Top


This case highlights the dangers associated with the use of organs of less than optimum quality. The major risk factors with this parti- cular donor kidney were septic arthritis in the donor, acute kidney injury with a creatinine of

230 mmol/L, and a cold ischemia time of about 21 h. Factors that might have encou- raged the use of the kidney included a donor age of 49, donation after brain death, and a preimplantation biopsy revealing only mild vessel disease.

Patients with a heightened risk of infection need prolonged antibiotic cover following transplantation. Though a single peroperative dose of antibiotics is routinely administered followed by the use of oral cotrimoxazole (mainly to prevent Pneumocystis carinii pneu- monia) in the authors center, this may not suffice when there is evidence of infection in the donor. As the organism causing infection in the donor was not identified, the usual anti- microbial protocol for the unit was followed. However, as soon as there was evidence of infection, appropriate antibiotics were admi- nistered. In retrospect, a longer course of anti- biotics should have been considered and started empirically and then altered according to yield from various cultures. Our center now routinely culture organ preservation fluid and donor ureter tips obtained at the time of bench preparation of the organ. In retrospect, a large hematoma such as present in this case with a significant risk of sepsis should have been drained early to prevent morbidity and mortality.

The masking effect of immunosuppression is clearly demonstrated in this case. Apart from a raised white cell count, there was no sign of serious infection until the precipitate hemor- rhage from the anastomotic patch. The patient felt well and even resisted admission to hospital. Of particular interest is the fact that the first bleed was from the Carrel's patch which was repaired at the time of the explo- ration of the wound, which included drainage of 1 L of pus from around the allograft. The second (and fatal) bleed was from a previously unaffected site on the external iliac artery distal to the anastomosis. No areas of necrosis in the vessel wall were noted at the time of exploration and clamps were not applied to the external iliac artery as the external iliac vessels could not be dissected due to a frozen pelvis.

As borne out by subsequent events, closure of bleeding point in the Carrel's patch, though sufficient to arrest hemorrhage, did not prevent further hemorrhage in the region. Even though subsequent (fatal) bleeding did not occur from the repaired Carrel's patch, it can be argued that the diseased patch should have been replaced by an autologous vein patch. Long- term infection in the pelvis had probably damaged the wall of the external iliac artery though it was not clinically apparent at the time of exploration, as there was neither slough nor aneurysmal dilatation. Though wound exploration and transplant nephrec- tomy were carried out as a life-saving proce- dure and dissection of the external iliac vessels was not possible at the time, perhaps an early/urgent planned ligation of the external iliac artery and an extra-anastomotic bypass procedure would have avoided a recurrent hemorrhage, while preserving flow to the lo- wer limb. A femorofemoral or ipsilateral ilio- femoral bypass procedure could also be considered. Kim et al[1]have used embolization with a coil and a vascular plug combined with femorofemoral bypass for iliac artery aneu- rysms, though there was no active infection present. Nakai et al[2]described a case which developed graft infection from an iliac artery to urinary bladder fistula, where they employed a similar technique with success. However, it may be argued that the presence of active infection in an immunosuppressed patient warrants removal of the affected blood vessels.[3]The severity of adhesions in this case made such an option unworkable.


   Conclusion Top


Immunosuppression can mask the features of posttransplant infection, which increases the risk of complications with conservative manage- ment of hematomas. A vascular bypass avoi- ding the infected area (with or without exci- sion of the infected vessels) may represent an option to avoid potentially drastic vascular complications.

Conflict of interest: None

 
   References Top

1.
Kim MD, Lee do Y, Lee M, et al. Single-center experience in the endovascular management of isolated iliac artery aneurysm. Acta Radiol 2014;55:195-200.  Back to cited text no. 1
    
2.
Nakai M, Sato H, Sato M, et al. Successful endo-vascular treatment of iliac arteriovesical fistula with secondary stent-graft infection. J Vasc Interv Radiol 2013;24:1409-12.  Back to cited text no. 2
    
3.
Bonardelli S, Nodari F, De Lucia M, Cervi E, Giulini SM. Crossover ilio-iliac bypass and removal of femoro-femoral graft as first treat- ment for the infection of crossover bypass in aorto-uni-iliac endovascular aneurysm repair. Vascular 2012;20:306-10.  Back to cited text no. 3
    

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Correspondence Address:
Jacob A Akoh
South West Transplant Center, Plymouth Hospitals NHS Trust, Derriford Hospital, Plymouth PL6 8DH
United Kingdom
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DOI: 10.4103/1319-2442.182411

PMID: 27215254

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    Abstract
   Introduction
   Case Report
   Discussion
   Conclusion
    References
 

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