Massive haemorrhage and rupture of renal transplant from a donor who died of snake bite.

not suitable for transplantation because of a congenital Introduction anomaly. The recipient was a 40-year-old Saudi patient who A patient with chronic renal failure on haemodialysis had been on haemodialysis for over 7 years. He had was on the high urgency list for renal transplantation extensive problems with vascular access on dialysis. because of the multiple failures of vascular access. He He was placed on the national priority list for renal had a renal transplant from a donor who died following transplantation (RTx) once the cadaveric kidney had a snake bite. The course was complicated by massive become available, he was transplanted 18 h after haemorrhage and rupture of the graft. We conclude retrieval. He had a negative lymphocytic cross match that organ donation from a donor who died of snake and one A, B, DR, HLA match. Postoperatively he bite should be considered as absolute contraindication was put on broad spectrum antibiotics and triple for transplantation. immunosuppressive therapy. The graft had primary non-function. He was started on dopamine infusion Case history 5 mg/kg/min. Eight hours later he developed hypotension with BP 95/50. He was cold, clammy with profuse sweating and was afebrile. He had no reflex tachycardia The donor is a 31-year-old male Egyptian who went and clearly had signs of active bleeding with increasing on a picnic in the desert and was admitted with a pain, tenderness and swelling around the transplant history of collapse following a snake bite (type kidney. It is worth mentioning that at this stage, his unknown) [1–2] to a local hospital in Riyadh, he was preoperative, and up to 6 days post-RTx he had a given antivenom [9] on arrival to the Emergency Room. There was swelling at the site of the bite. His normal PT, APTT, negative FDP and his platelets condition rapidly deteriorated requiring ventilation. were 440 K/ml. His haemoglobin had decreased from His clinical picture was compatible with cerebrovascu9.9 to 7.6 g/dl. Ultrasound scan (U/S) showed haematlar accident. CT scan of his head showed massive oma around the graft. He was given four units of fresh intracerebral haemorrhage [3]. He had mild DIC, his frozen plasma (FFP) and two units of packed cells platelets dropped from normal to 114 K/ml. He had and was taken to theatre for exploration of his transmild deranged clotting, haemoglobin dropped but plant kidney, removal of the haematoma (600 ml ), remained stable at around 9 g/dl. Within 24 h of admisand haemostasis. There was no bleeding from either sion he was clinically brain dead which was confirmed the renal artery or vein. There was generalized oozing according to the recognized criteria. He had reactive from the raw muscle surface which could not be hyperglycaemia. His urine output and serum creatinine controlled. Two large drains were inserted. were normal throughout the hospital admission Postoperatively he continued oozing from the wound (97.8±6.8 mmol/l. His liver enzymes were normal and through the drain, and was given a further four except an elevation of bilirubin (39 mmol/l ). He was units of FFP and blood. He continued slowly but afebrile, maintained normal blood pressure without actively bleeding requiring daily at least two units of inotropes, except that he was on dopamine 3 mg/kg/min blood and FFP. On the sixth day there were more to maintain his renal perfusion. He was started on signs of acute bleeding and a large haematoma accumuceftriaxone empirically. Serological tests for hepatitis lated around the RTx as shown by U/S and clinically. B, C, HIV, CMV, VDRL were all negative, as well as He was taken to theatre and approximately 1200 ml blood and urine cultures. The other donor kidney was blood and blood clots were removed. There was no bleeding site found. We continued with active supportive treatment including FFP, blood transfusion, Correspondence and offprint requests to: H. Mansey, Department of inotropes and broad spectrum antibiotics, and was Renal Medicine, District & General Hospital, Kayll Road, Sunderland SR4 7TP, UK. dialysed without anticoagulants.