S Yoshikawa

A clinical renal-transplant case from a non-heart-beating donor using percutaneous cardiopulmonary support.

Organ procurement from non–heart-beating donors (NHBDs) has been considered as one technique to expand door pools. Experimental and clinical renal transplantation from NHBDs has been reported (1–3). Percutaneous cardiopulmonary support (PCPS) used in cardiopulmonary resuscitation can possibly maintain organ viability (4). We reported a renal transplant from a NHBD using PCPS. A 48-year-old man with cardiopulmonary arrest was admitted to our emergency department. An electrocardiogram (ECG) showed ventricular fibrillation, which was resistant to defibrillation and subsequent standstill and arrest. Fortynine minutes with cardiac massage after arrival, PCPS for rescuing the patient was indicated and performed successfully within 10 minutes. We used PCPS (CAPIOX EBS, TERUMO Corporation, Tokyo, Japan), consisting of oxygenator and centrifugal pump system, after insertion of arterial (16.5 F [5.5 mm] diameter) and venous (21 Fr [7 mm] diameter) catheters into the right femoral artery and vein using a percutaneous centesis method. ECG recovered to a normal sinus rhythm after the initiation of PCPS. The patient was admitted to intensive care unit (ICU) with dobutamine and dopamine. Bilateral pupils were 5.5 mm without light reflex. Spontaneous breathing was observed. However, 8 hours after admission to the ICU, a significant increase of urine output was observed (Fig. 1). However, serum creatinine and blood urea nitrogen (BUN) increased during PCPS and was affected by cardiac massage. Spontaneous breathing was disappeared and noradrenalin was required. Echocardiography showed severe hypokinetic wall motion of 15% ejection fraction that was suspicious for heart trouble such as coronary artery disease. The pupils were dilated to the size of 7.0 mm. Twenty-four hours later, clinical brain death was diagnosed. Blood pressure of the patient during PCPS was maintained at approximately 90 mm Hg at systole. Core temperature was maintained at 37°C during PCPS. Catecholamines were discontinued after the family’s agreement to donate the kidneys and cornea. Because Japanese law did not permit organ procurement under the criteria of brain death without a donor card that provided consent by both the donor and his family. After cardiac arrest, the bilateral kidneys and corneas were harvested. Through median laparotomy, topical cooling was performed with an ice slush. After clamping the descending thoracic aorta through the left diaphragm, abdominal organs were successfully perfused with 4°C cold lactate Ringer’s solution through the arterial canula of PCPS, with drainage through the venous canula. The duration from cardiac arrest to initiation of cold perfusion was 35 minutes. After harvesting, both kidneys were immersed in Euro-Collins’ solution for preservation. Two male recipients who were a 51 and 38 years old were selected. Kidney cold ischemic times were 17 hours, 58 min and 20 hours, 55 min, respectively. Histologic findings of specimens 1 hour postperfusion showed slight acute tubular necrosis. Both kidneys produced urine immediately after reperfusion. Initially, the amount of the urine at 1 day posttransplant was 650 mL; however, it increased to up to 1,000 mL/day at 3 days posttransplant. Finally, dialysis for both recipients was discontinued 15 days posttransplant. Weber et al. (1) reported significantly higher incidence of delayed graft function of the kidneys from NHBDs than those from donors with a heartbeat. However, long-term graft survival rates were similar. Sufficient blood perfusion of organs with PCPS in donors with insufficient cardiac output is an important issue for keeping organs viable. Warm ischemic time (WIT) is defined as the duration from the cardiac arrest to the perfusion with cold preservation solution. In our case, there was no WIT because of the use of PCPS after cardiac arrest. Kidneys were perfused with warm oxygenated blood during PCPS immediately before the perfusion with a cold preservation solution. Arterial and venous catheters of PCPS were useful for the cold perfusion and drainage. Fukushima et al. (5) reported a renal-transplant case from an NHBD using PCPS. They demonstrated that a donor with a single ventricle and massive pulmonary arterial venous shunt developed hypoxemic shock during their treatment. Our case was a patient case with cardiopulmonary arrest at