Mother’s kidney donation provided son a second chance at life | Case study

PACE Hospitals' Kidney Transplantation team successfully performed a Living Donor Kidney Transplantation (LDKT) for a 32-year-old male from Bangladesh with chronic kidney disease due to suspected chronic glomerulonephritis.

A 32-year-old male patient (Abu Saleem) from Bangladesh with a history of suspected chronic glomerulonephritis was presented to the consultant nephrologist and renal transplant physician Dr. Kishore Kumar.

Medical History and Diagnosis

Delving deeper, it was understood that the Bangladeshi patient was a known case of chronic kidney disease progressing to end-stage renal disease (kidney failure). He had been dependent on haemodialysis for a considerable period to filter his blood. The treating nephrologist in Bangladesh ascertained the necessity of a kidney transplant, and the patient was advised to undergo Chronic Kidney Failure Treatment in Hyderabad, India, under the care of the Kidney Transplant Department, ensuring comprehensive management of the condition. Understanding the condition of her son, the mother of the patient came forward to donate her kidney.

Now that the question of donor had been solved, the patients started their quest for centres of renal transplantation which utilizes the state-of-the-art equipment to reap better prospects. In their search, they came across PACE Hospitals situated in Hyderabad, India. Compared to other renal transplantation centres, PACE Hospitals is equipped with a state-of-the-art kidney transplant facilities, centralized HIMS (Hospital Information System), round-the-clock guidance from highly qualified surgeons and physicians along with minimal waiting time for both inpatient and outpatient processes among other expertise facilities – all within affordable prices. 

Course in the PACE Hospitals

Upon being admitted to PACE Hospitals and undergoing necessary investigations (blood tests, kidney function tests, liver function tests and imaging tests such as abdominal ultrasonography), to evaluate the patient’s profile, the nephrology team in PACE Hospitals concurred with the Bangladeshi healthcare teams. He was found to be diagnosed with:

Kidney failure due to suspected chronic glomerulonephritis 

The increase levels of serum glutamic pyruvic transaminase (SGPT) and serum glutamic-oxaloacetic transaminase (SGOT) demonstrates liver injury. It can be concurred with hypoxia condition of the chronic kidney disease (CKD) which increased oxidative stress stimulating liver injury.

The patient was found with a slightly anaemic profile which can be traced to reduction of erythropoietin (an enzyme for the bone marrow to produce red blood cells) causing anaemia. 

The team of kidney transplant surgeons - Dr. Vishwambhar Nath, Dr. Abhik Debnath and Dr. K Ravichandra, concurred with the medical verdict of the Bangladeshi doctors. A renal transplant was necessary to save the patient.

Promptly, the patient was put on multiple lifesaving supports and was continued on haemodialysis. Both the donor and the patient were counselled about renal transplantation, the possible outcomes, complications, and the quality of life after transplantations. 

With necessary investigations done & clearances obtained, the patient underwent a Living Donor Kidney Transplant in Hyderabad at Pace hospitals, receiving the right kidney. The procedure was supervised by the consultant nephrologist & renal transplant physician Dr. A Kishore Kumar, and it was accomplished devoid of any accidental perforations during the transplantation surgery at the site.

Steroids and anti-human thymocyte immunoglobulin preparations were given as a prophylaxis to suppress any rejection.

The aftermath

Intraoperatively, the anastomosis was between internal iliac artery of recipient and donor renal artery. Venous anastomosis was done between the renal vein and external iliac artery.

The colour of kidney which was pale till then due to rinsing of blood turned pink after connecting with the recipient’s blood vessels showing the successful reperfusion. Associated with the pink colouration, diuresis (urine started to flow) is also witnessed. Both these milestones could be termed as early markers of a successful renal transplant. 

Nevertheless, within a few minutes the graft turgidity began to decrease. Turgidity can roughly be said as the tone of the organ (state of being swollen or firm due to fluid or pressure). Reduction of turgidity compelled the transplant surgeons to reopen the anastomosis to understand the cause of blocked blood reperfusion to the donated organ. 

The medical acumen of transplant surgeons did not fail them. Upon opening the anastomosis, they found a small clot in the renal artery which understandably was blocking the blood flow, reducing the turgidity. 

Upon physically removing the clot, the transplant surgeons performed re-anastomoses, the turgidity was restored. The second anastomosis reinstated the process of diuresis and the urine gradually started to improve. The pink colouration of the kidney was recorded.

Despite the development of an increased stenotic flow at graft rate, as depicted by the intraoperative graft vessel Doppler test, it was concluded that stenotic flow was developed due to the presence of discrepancy between the donor and recipient vessels and not necessarily a complication of the renal transplant. 

Since the urine output was good and due to the presence of discrepancy between the donor and recipient vessels encouraging stenotic flow, the renal transplant surgeons concurred to observe the repeat Doppler test and keeping an eye on creatinine levels post-surgery.

After surgery, the graft Doppler scan was done which revealed an increase in the velocity of the blood flow at anastomotic site but surprisingly the velocity of the blood flow distal to the anastomosis and inside the graft parenchyma was normal which suggests this might not be a complication case of transplant renal artery stenosis (TRAS). 

Post surgery the urine output was constantly evaluated which demonstrated good progress. Additionally, the creatinine levels are also checked which, although was high in the early days (suggestive of bad kidney functioning), gradually decreased to 1.5 mg/dl on the 6th day post transplantation. Similarly, the levels of immunosuppressive agents were monitored and gradually tapered off according to the necessity.

On 7th day, the creatinine levels were noted to be stabilised. Complete urine examination did not reveal any proteinuria (loss of protein through urine), but the presence of microscopic haematuria (blood in urine) was recorded, which was steadily improving as compared to the previous urine examination results. The graft Doppler test which was done at discharge did not reveal neither perinephric fluid collection nor obstructive features nor ineffective changes.

There was no fever or graft tenderness, which suggested the absence of infection or rejection. Upon achieving hemodynamic stabilisation, the patient was discharged with the necessary medications. He was advised to schedule a follow-up appointment with the Kidney Transplant Surgeons in Hyderabad at PACE Hospitals to assess his post-operative condition and ensure continued recovery.

The Kidney Transplant Doctor/Specialist concurred that it would be beneficial to regularly monitor the patient's creatinine levels on an outpatient basis and to perform a graft biopsy if there is a persistent or rising creatinine level in the later stages.

Conclusion

This case underscores the effectiveness of Living Donor Kidney Transplantation in managing End-Stage Renal Disease Treatment in Hyderabad, India, even when originating from chronic glomerulonephritis, highlighting the advanced capabilities of high-quality renal care.

The intensity and rarity of renal artery thrombosis

The renal artery thrombosis is a rare but dangerous complication which commonly develops in the early postoperative period, either due to hyperacute rejection or anastomotic occlusion etc. The common clinical signs include sudden oliguria (urinary output less than 400 ml per day or less than 20 ml per hour) or anuria (absence of urinary output) with the reduction of graft function. This results in segmental or global renal infarction (complete or partial occlusion of the main renal artery leading to ischemic renal necrosis) which can be identified by imaging diagnostic modalities.



Angiography (type of X-ray to check blood vessels) shows reduced or absent flow to the graft and an abrupt cutoff in the transplant renal artery. If graft arterial thrombosis is recognised early, it is usually treated with surgical thrombectomy to restore tissue perfusion or with catheter-guided fibrinolysis with better outcomes if performed within 24 hours.