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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 12  |  Issue : 2  |  Page : 84-86

Organ donation: Saga of an 18-month-old lifesaver


1 Department of Nephrology, Institute of Renal Science, Sir Gangaram Hospital, New Delhi, India
2 Department of Nephrology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
3 Department of Urology, Sir Gangaram Hospital, New Delhi, India
4 Department of Hospital Administration, Sir Gangaram Hospital, New Delhi, India
5 Department of Surgical Gastroenterology and Liver Transplantation, Sir Gangaram Hospital, New Delhi, India

Date of Submission20-Dec-2021
Date of Decision28-Feb-2022
Date of Acceptance07-Mar-2022
Date of Web Publication26-Apr-2022

Correspondence Address:
Dr. Priti Meena
Department of Nephrology, All India Institute of Medical Sciences, Bhubaneswar - 171 019, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cmrp.cmrp_122_21

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  Abstract 


There is a huge gap between organ donation and the current demand for organ transplantation. With a very low donation rate of 0.26 per million in India, a high number of patients die due to lack of organ transplantation. Strategies such as increasing organ donation from the paediatric population can improve the void in the national donor pool. Increasing awareness among the general population, propitious support for families during the donation process, more dedicated clinical staff, development of better screening and assessment processes are some multifaceted methods to improve organ donation. We herein report a case of an 18-month-old girl child who donated her heart, liver, kidneys and cornea to five patients following her demise. This case emphasises that with advanced surgical techniques and meticulous organ procurement even from a very young donor, results can be rewarding.

Keywords: En-bloc kidney transplant, heart transplant, organ transplantation


How to cite this article:
Bhargava V, Meena P, Chadha S, Bhalla AK, Gupta A, Bhoiyar A, Malik M, Gupta A, Tiwari V, Rana DS, Prakash V, Dhir U. Organ donation: Saga of an 18-month-old lifesaver. Curr Med Res Pract 2022;12:84-6

How to cite this URL:
Bhargava V, Meena P, Chadha S, Bhalla AK, Gupta A, Bhoiyar A, Malik M, Gupta A, Tiwari V, Rana DS, Prakash V, Dhir U. Organ donation: Saga of an 18-month-old lifesaver. Curr Med Res Pract [serial online] 2022 [cited 2022 May 19];12:84-6. Available from: http://www.cmrpjournal.org/text.asp?2022/12/2/84/343931




  Introduction Top


Organ transplantation offers superior survival and a better quality of life to patients suffering from end-stage organ damage.[1] There is no doubt that practice and advancement in the field of solid organ transplantation have been unwavering over the past decades. According to the United Network for Organ Sharing data, around 107,000 candidates are on the national waiting list and approximately 17 patients die per day waiting for organ transplantation.[2] There is an ever-expanding requirement for organ donors globally that creates a huge mismatch in supply and demand. In India, organ donation rate is merely 0.26 per million.[3] Strategies such as paediatric organ transplantation to an adult recipient are a few of the well-established techniques to widen the donor pool. Herein, we report a case of organ transplantation from an 18-month girl child into five patients with a review of literature pertaining to the difficulties and challenges accounted for during the processes.


  Donor Characteristics Top


The index patient, an organ donor, was an 18-month-old female child who was declared brain dead following a head injury. The parents displayed truly altruistic behaviour and decided to donate her organs. She weighed 15 kg and had a body surface area of 0.38 m2. Her blood group was O +ve. After ethical and authorisation committee clearance, an informed consent from the parents was taken. She was haemodynamically stable, maintaining euthermia and her urine output was 30–35 ml/h.

It was decided to procure five organs which were the cornea, both kidneys, heart, and liver. Prior to the transplantation, all the recipients were informed regarding the potential risks and complications of organ transplantation from a child.


  Heart Transplant Top


The recipient of the heart was a 5-month-old boy child. He weighed 6 kg and had O +ve blood group. The child was suffering from cardiomyopathy. The 2D echocardiogram of the donor was within normal limits, and cardiac volume was 75 ml. The surgical team first recovered the donor's heart after inspecting for any structural abnormalities. The heart was preserved using 2 L of custodial solution (Bretschneider's solution). The total aortic cross-clamp time was 75 min. The patient was discharged on the 17th day of surgery. At his outpatient department (OPD) visit after discharge at 8 weeks, the child was in good health without any evidence of cardiac allograft rejection or any other complications. He is on triple-drug maintenance immunosuppression (tacrolimus, mycophenolate mofetil and prednisone).


  Liver Transplant Top


The liver recipient was a 10-month-old male child, and his blood group was similar to that of the donor. He weighed 7 kg with a height of 67 cm. He was suffering from biliary atresia. The cold ischaemia time was 4 h and 30 min, and the warm ischaemia time was 16 min. The hospital course was uneventful and on OPD follow-up after 2 months, the recipient was maintaining normal liver functions with no evidence of liver allograft rejection on dual immunosuppression (tacrolimus, prednisone).


  Kidney Transplant Top


The recipient was a 38-year-old adult male patient on twice-weekly maintenance haemodialysis for 18 months. His native kidney disease was unknown. His weight and body mass indexes were 54 kg and 23.5 kg/m2, respectively. His blood group was AB +ve. The pre-operative complement-dependent cytotoxic crossmatch was negative.

The measurements of donor right and left kidneys were 5.4 cm × 2.5 cm and 5.3 cm × 2.6 cm, respectively. We decided to transplant both the kidneys into the adult male recipient. The surgical team transected the aorta and vena cava above the origin of renal arteries and renal veins and thereafter proceeded to procure the liver. After this, en-bloc dual kidneys were recovered along with the aorta and vena cava. Both ureters were dissected and traced to their entrance into the bladder. Other branches from the aorta and vena cava were ligated, leaving behind the kidney blood supply intact. The en bloc graft was then perfused through the aorta and no leakage was observed. There was no evidence of any injury to kidney tissue. The warm ischaemia time was 6 min and the cold ischaemia time was 280 min. The pre-operative immunosuppression was induction with thymoglobulin (1 mg/kg) and methylprednisolone (1000 mg).

In the recipient, a modified Gibson incision was performed to prepare the right iliac fossa. Preparation for transplantation was done by creating an extraperitoneal space. Simultaneously, the external iliac vessels were made ready for anastomosis. The en bloc graft was placed on the right psoas muscle. Furthermore, the anastomosis of graft vena cava to the recipient external iliac vein was done using 6-0 polypropylene suture and then graft aorta was anastomosed to the right external iliac artery using a 7-0 polypropylene suture. The procedure was later followed by anastomosis of both ureters separately to the bladder using the modified Lich‒Gregoir technique and placement of double-J stent in the ureter. Total blood loss during the surgery was approximately 120 ml. On declamping, the kidneys were noted to be pink and turgid. They were well perfused and produced brisk diuresis.

During the initial 1–4 days, urine output remained approximately 200–300 ml. During this period, the creatinine was 4–6 mg/dl. Multiple sessions of haemodialysis were given. Ultrasonography Doppler showed a normal graft flow pattern with a resistive index value of 0.6–0.7 in both the transplanted kidneys. On post-operative day 7, his graft biopsy was performed which showed features of acute tubular injury. His serum creatinine gradually started declining and stabilised to 1.5–1.6 mg/dl. He was discharged on post-operative day 14 on creatinine of 1.8 mg/dl with adequate urine output. On his last follow-up at 2 months, his serum creatinine is 1. 2 mg/dL with no evidence of rejection or any other complication.


  Corneal Transplant Top


A healthy corneal graft tissue was obtained from the deceased. Applied surgical techniques included full-thickness penetrating keratoplasty. One cornea was transplanted to a 70-year-old male patient who was suffering from corneal scarring. Till the last follow-up 2-month post-transplant, there were no signs of graft rejection or other complications. The second cornea could not be transplanted due to tissue damage during procurement.


  Discussion Top


Organ transplantation is one of the greatest triumphs of modern medicine that saves the lives of many individuals who are suffering from end-organ damage. Owing to the existence of multiple myths and the lack of awareness, a large number of people failed to opt for the noble cause of organ donation. In India annually, there is a need for at least 2 lakh kidney organs, 50,000 livers and a minimum of 50,000 hearts for transplantation.[4] Literature regarding the practice of using paediatric organs in the adult population is scarce. According to worldwide data, the overall rate of paediatric donation rate under 18 years is markedly less than adults. Yet, deceased paediatric donors contribute to approximately 3%–6% of deceased donors in various countries.[5] One of the most important reasons for low numbers may be attributed to late referrals, unsuitability for donation and an undiagnosed or undefined leading cause of death.

Moreover, paediatric transplantation is a complex surgical undertaking which is challenging. The disparity in the size of the child donor and recipient and lesser familiarity with paediatric physiology further adds to complexities.[6]

Pre-donation counselling of the parents of the donor is most crucial. Once death is declared, it is of utmost importance to sustain organ viability and lessen the loss of potentially transplantable organs. Nationalised protocols by the transplantation centres using national or international resources will thwart the organ donation program, thereby augmenting the number of organs recovered for transplantation.[7] The arena of paediatric organ donation needs further development to shorten the air for transplantation.

In conclusion, this index case shows that advanced surgical techniques and meticulous procurement of organs from a deceased donor, even at a very young age can result in favourable outcomes and lifesaving for many listed recipients. Paediatric organ transplantation into an adult recipient offers an excellent option to expand the insufficient donor pool and to optimise available organ utilisation.

Consent

All authors declare that all appropriate written consent was obtained from the donor's parents as well as from the recipients to publish this case.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Black CK, Termanini KM, Aguirre O, Hawksworth JS, Sosin M. Solid organ transplantation in the 21st century. Ann Transl Med 2018;6:409.  Back to cited text no. 1
    
2.
Brennan C, Husain SA, King KL, Tsapepas D, Ratner LE, Jin Z, et al. A donor utilization index to assess the utilization and discard of deceased donor kidneys perceived as high risk. Clin J Am Soc Nephrol 2019;14:1634-41.  Back to cited text no. 2
    
3.
Nallusamy S, Shyamalapriya, Balaji, Ranjan, Yogendran. Organ donation – Current Indian scenario. J Pract Cardiovasc Sci 2018;4:177-9.  Back to cited text no. 3
  [Full text]  
4.
Shroff S. Legal and ethical aspects of organ donation and transplantation. Indian J Urol 2009;25:348-55.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Weiss MJ, Domínguez-Gil B, Lahaie N, Nakagawa TA, Scales A, Hornby L, et al. Development of a multinational registry of pediatric deceased organ donation activity. Pediatr Transplant 2019;23:e13345.  Back to cited text no. 5
    
6.
Brierley J, Hasan A. Aspects of deceased organ donation in paediatrics. Br J Anaesth 2012;108:i92-5.  Back to cited text no. 6
    
7.
Martin DE, Nakagawa TA, Siebelink MJ, Bramstedt KA, Brierley J, Dobbels F, et al. Pediatric deceased donation – A report of the transplantation society meeting in Geneva. Transplantation 2015;99:1403-9.  Back to cited text no. 7
    




 

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  In this article
Abstract
Introduction
Donor Characteri...
Heart Transplant
Liver Transplant
Kidney Transplant
Corneal Transplant
Discussion
References

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