By Yushkov, Yuriy Hoffman, Allison; Giudice, Anthony
Background-Approximately one-third of organ donors in the United States are trauma victims. In general, kidneys with large subcapsular hematomas are not used for transplant because of the possibility of significant parenchymal injury. A large subcapsular renal hematoma may cause scarring resulting in renal parenchymal compression and development of the Page syndrome. Objective-To elucidate a successful method of evaluating kidneys subject to trauma, while also possibly preventing further damage and improving their function.
Design-Data were collected from the donor kidney pool of the New York Organ Donor Network from January 2006 through July 2007. Four kidneys during that period were determined to have significant subcapsular hematomas. Surgical intervention was undertaken and outcomes after transplantation were reviewed.
Main Outcome Measures-Four of the kidneys underwent a surgical procedure to drain the subcapsular hematoma allowing assessment of the underlying renal parenchyma. All 4 of these kidneys were deemed transplantable. After transplantation, 3 of the 4 kidneys had immediate function and did not require dialysis. The remaining kidney was removed as a result of primary nonfunction.
Conclusion-The described surgical intervention allows the transplant surgeon to accurately assess the extent of damage to a traumatized kidney while possibly preventing further damage to the kidney. (Progress in Transplantation. 2008;18:6-9)
According to the 2006 Annual Report of the Organ Procurement and Transplantation Network and the Scientific Registry of Transplant Recipient, the number of kidney transplants is growing at an annual rate of 5.9%.’ This is a substantial increase except when compared with the 8.9% growth rate of the patient waiting line.1 The mounting gap between the organs available for transplantation and the rising number of people on the waiting list prompts the transplant community to reevaluate the existing criteria for kidney acceptance to increase the number of transplants and shorten the demand.2,3
Studies4-6 have shown that a large subcapsular hematoma may lead to scarring that results in renal parenchyma compression, which in turn may result in arterial hypertension and then, possibly, renal failure. This phenomenon was demonstrated in the animal model by Irwin Page in 1939 and has been supported by subsequent clinical findings, becoming known as Page syndrome.4-7 Page syndrome is defined as the compression of the transplanted kidney by a subcapsular hematoma leading to renal hypertension.4,3,9 These subcapsular hematomas have resulted from renal allograft trauma or posttransplant biopsy.10-4 The evacuation of a subcapsular hematoma has been used as the method of treatment to prevent renal failure.10- 3
A significant percentage of organ donors in the United States have resulted from trauma fatalities (in 2006, 35.47%; in 2005, 34.70%).1 In general, kidneys with large subcapsular hematomas are not used for transplantation because of the possibility of significant parenchymal injury. In most cases, these kidneys are discarded. From January 1,2006, to July 31, 2007, the New York Organ Donor Network handled and evaluated 1722 kidneys, of which 20.4% (352) were kidneys from trauma victims. Of these kidneys, 17 (4.8%) showed physical signs of injury evidenced by hematomas in perirenal adipose tissue, and 9 of those had subcapsular hematomas. Five of the 9 had hematomas that were not clinically significant (we defined significant subcapsular hematomas as encompassing 20% of the kidney’s surface).
Evacuation of the subcapsular hematomas was performed with the goal of better assessment of the renal parenchymal injury and a prophylactic against scarring of the subcapsular hematoma and development of Page syndrome.
Methods
In order to better assess the possible damage to the graft kidney and to prevent the formation of Page kidney, the Preservation Unit of the New York Organ Donor Network began opening the renal capsule above the hematoma to evacuate blood clots beginning in June 2006.
From June 2006 to July 31,2007,4 kidneys were identified as having significant subcapsular hematomas, covering 33% to 50% of the kidney surface area. Two senior renal preservation staff members and 1 surgeon performed 4 capsular decompressions to better evaluate the tissue beneath the capsule. In each case the subcapsular hematoma that was close to the hylum or covered an entire kidney’s pole was opened and relieved. In order to assess a kidney with a subcapsular hematoma and possible parenchymal trauma, it had to be completely cleaned of perirenal adipose tissue and blood clots. Occasionally, trauma affects the surrounding perirenal tissue, giving the appearance that the kidney may not be transplantable; however, after complete kidney dissection, the kidney itself may still be determined to be viable (Figures 1 and 2).
The subcapsular hematoma evacuation technique was performed as follows: the renal capsule was opened with an incision of 1 to 2 cm (Figures 3 and 4) and the hematoma was “massaged out” (Figure 5). The hematoma’s remnants were removed using a mosquito clamp (Figure 6) and rinsed out using a syringe with preservation solution. After the hematoma was removed, the kidney’s parenchyma was observed for the possible rupture (Figure 7).
The renal artery with aortic patch was dissected and cannulated using a Seal Ring. The kidney was placed on the renal pulsatile preservation machine to better preserve the kidney and to evaluate vascular resistance and flow. The continuous preservation also allowed us to assess if parenchymal leakage existed from the location where the hematoma had been evacuated. In each of the 4 cases, no leakage was observed by the preservation technician for the several hours that the kidney was on the pulsatile perfusion pump.
Pictures were taken before and after decompression and sent to a local transplant center for evaluation. All 4 kidneys were placed on the pulsatile perfusion pump after decompression and parameters were within acceptable ranges. Without this intervention it is likely that these kidneys would have been discarded rather than being used for transplantation.
In one case the kidney was placed on a pulsatile perfusion pump before its decompression. The flows were in a range that reflected a poor impression of its potential for transplantation. In the other 3 cases, the hematoma was evacuated from the kidney before it was placed on the pulsatile perfusion machine.
Three of 4 kidneys had immediate function after transplantation, and the recipients were discharged, free from dialysis. One kidney was a primary nonfunctioning kidney and was subsequently removed.
Conclusion
Kidneys from trauma donors should be completely dissected from adipose tissue and blood clots before clinicians make a decision regarding their suitability for transplantation. The dissection should be performed by staff trained in evaluating trauma kidneys.
The evacuation technique permits a better assessment of the underlying renal parenchyma. It also allows the renal capsule to adhere back to kidney tissue instead of developing scar tissue or a cyst, possibly preventing the development of Page syndrome. The accumulation of blood and fluid in the hematoma may lead to venous outflow obstruction, kidney edema, and eventual kidney discard. The evacuations of subcapsular clots were performed on 4 kidneys. Each of these kidneys had hematomas covering more than 20% of their surface.
Evacuation of subcapsular hematomas appears to allow successful transplantation of renal allografts. In this small cohort, 3 of the 4 kidneys have performed well after transplantation.
References
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11. Mohammed EP, Venkat-Raman G, Marley N. Is trauma associated with acute resection of a renal transplant? case report. Neprol Dial Transplant. 2002;17(2):283-284. 12. Rea R, Anderson K, Mitchell D, Harper R, Williams T. Subcapsular hematoma: a cause of post biopsy oliguria in renal allografts. Neprol Dial Transplant. 2000;15(1):1104-1105.
13. Abutaleb N, Obaideen A. Renal tamponade secondary to subcapsular hematoma. Saudi J Kidney Dis Transplant. 2007; 18(3):426- 429.
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Yuriy Yushkov, PhD, CTBS, MBA, Allison Hoffman, BS, Anthony Giudice, BS
New York Organ Donor Network,
New York
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