A Fatal Course After Combined Pancreas Kidney Transplantation From a Donor with HELLP-syndrome

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Abstract

Introduction

An increasing disproportion between waiting list patients and the available number of donor organs makes it necessary to expand the donor pool. Although there were some reports of successful transplantations of livers and kidneys from donors with HELLP-syndrome, the acceptance of these organs is still controversial.

Case

A 41 years old man with diabetic-related terminal kidney failure underwent a combined pancreas and kidney transplantation. The donor was a 38 years old woman with HELLP-syndrome with acute kidney failure and good pancreatic function. Also at the moment of procurement there were no morphologic or laboratory changes suggesting pancreatitis. The immunosuppressive induction consisted of thymoglobuline and prednisolone. The ischemia time for the pancreas was 12,5h. There were no macroscopic abnormalities during the back-table preparation. Directly after the reperfusion we saw signs of pancreatitis. Despite a significant elevation of pancreatic enzymes and progressive abdominal pain in the first postoperative days the endocrine function of the graft was excellent. The kidney graft showed a primary non function. On the third postoperative day laparotomy with removal of necrotic areas of the pancreas was performed. Eventually, due to the progression of the pancreatitis and arrosion of the splenic artery, graft pancreatectomy (6th postop. day) was necessary. The histology specimen showed a severe hemorrhagic and necrotizing pancreatitis. The further course was as characterized by heavy complications. Due to an abscess, severe generalised peritonitis and sepsis we performed relaparotomies every 2nd day. Broad spectrum antibiotics were given but still there was no significant improvement. The kidney never regained function. CT scans showed large infarctions of the kidney and on the 24th day after the transplantation a transplant nephrectomy was performed. Histologically a diffuse ischemia and endured glomerular thrombotic microangiopathy were described. The patient died of a multi-organ failure 2 months after the transplantation.

Discussion

The results of transplantation of other organs from donors with HELLP-syndrome are promising. The criteria for acceptance of a pancreas were always stricter and to the best of our knowledge there are no reports about a transplantation of a pancreas from this donor group. The pathophysiological processes in HELLP-syndrome like microvascular abnormalities, vasospasm, edema and DIC can cause damage to any organ including the pancreas. Although very rare, in the literature we find some cases of an eclampsia related pancreatitis. However mostly without any obvious symptoms, presumably pancreas of every affected patient suffers a certain damage. Possibly HELLP syndrome related preexisting endothelial injury combined with the unavoidable ischemia reperfusion injury were the reason for this regrettable course.

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