VCUDEATH AND COMPLICATIONS CONFERENCE

Introduction

Complication Post operative bleeding, reoperation

Procedure Deceased donor kidney transplant

Primary Diagnosis Hypertension

Clinical History HPI: 44 yo f with renal failure due to severe HTN

since childhood. She has had 3 previous kidney transplants.

PMH/PSH: 1989, 1999, 2007 kidney transplant 1999 AV and MV mechanical St. Jude valves, on

Coumadin 2007 Left transplant nephrectomy 2008 Right femoral AVG Hyperparathyroidism, OSA, infectious

endocarditis

Hospital Course

INR 2.4 on admission INR 4.8 on POD #2

2mg Vitamin K INR 1.5 Heparin gtt with goal ptt 60-70

POD#4, Coumadin restarted POD#6: 2g drop in Hgb, hypotension,

tenderness over incision, left flank pain, INR 2.3, PTT 79 US: large collection of blood in left

retroperitoneum, obscuring and compressing transplant kidney; flow present in renal vein and artery

Hospital Course

Return to OR for exploration ~250 mL of blood surrounding the

transplant kidney. Good flow in artery and vein, kidney slightly mottled, but viable. No active bleeding.

Biopsy: mild tubulitis, not clearly rejection POD#8, Hgb drop 8.9 7.1

CT scan: large collection of blood in retroperitoneum, no mass effect on kidney; hematocrit effect with layering

2 U PRBC, 2 U FFP

transplant kidney, JP drain

superior to transplant kidney

just inferior to spleen

Hospital Course

POD#11 2g hgb drop, hypotension, INR 1.5, PTT 30’s Repeat US with large collection of blood

around transplant kidney (400mL) Second return to OR 1L blood evacuated, no focal areas of

active bleeding POD#14 Current Hgb stable 9.1, 8.9,

hemodynamically stable, INR 1.4

Analysis of Complication

• Was the complication potentially avoidable?• Yes, could have held anticoagulation or could

have avoided surgery

• Would avoiding the complication change the outcome for the patient?– Most likely, yes. No transfusions, no reoperation,

no compression of transplant kidney.

• What factors contributed the complication?– Anticoagulation, surgical dissection

Discussion points

Mechanical valves Anticoagulation Management of post operative bleeding Perinephric hematoma, transplant

kidney

Highest risk of stroke/embolism/valve thrombosis Mitral position Caged-ball valve Two or more prosthetic valves

Overall risk of valve thrombosis per year 0.7 - 1% on coumadin 2.2% on ASA 9-22% no anticoagulation (lower in some studies)

0.17-0.42% calculated absolute risk for 6-8 day post op warfarin interruption

Mechanical valve thrombosis

Douketis, James D. Perioperative anticoagulation management in patients who are receiving oral anticoagulant therapy: a practical guide for clinicians., Thrombosis research 2009

Recommendations: Coumadin discontinued 5 days prior to surgery,

with reversal of INR to 1.5 or less FFP and low dose vitamin K for emergency

reversal Good intraoperative hemostasis Coumadin restarted 12-24 hours after surgery

Anticipated partial effect within 48 hours In high risk cases, heparin bridge recommended

several strategies with 24-72 hours, therapeutic vs. low dose depending on bleeding risk

Chest 2008;133;299S-339S

28 patients with prosthetic heart valves hospitalized for major bleeding

Anticoagulation held, mean of 15 +/- 4 days 24 Mechanical valves

20 patients with St. Jude valves 12 mitral valves (11 St Jude) 12 aortic valves (5 St Jude) 4 both aortic and mitral (all St. Jude)

Thromboembolic events: zero at 6 month follow up One patient sudden death at 4 months, no post

Page kidney Described by Irvine Page in 1939

Compression of animal kidneys with cellophane Seen with subcapsular/perinepheric

hematoma, uroma Renal hypoperfusion Microvascular ischemia Hypertension due to activation of renin angiotensin

system AKI, renal failure Evaluate by US, duplex US, CT scan Reversible by evacuation of hematoma,

decapsulation, nephrectomyAcute Renal Failure and Severe Hypertension from a Page Kidney Post-Transplant Biopsy Division of Nephrology, Feinberg School of Medicine, Northwestern University, Chicago TheScientificWorldJOURNAL August 3, 2010

Learning points

Mechanical valve type and location important for risk of thrombosis and need for anticoagulation. Anticoagulation may be held for life

threatening bleed, but must be continually re-evaluated.

Perinepheric hematoma that is compressing or obstructing transplant kidney should be evacuated to prevent ischemia and graft failure.