Transplant of Kidneys from a Small Pediatric Donor with Severe Rhabdomyolysis

Acute Rhabdomyolysis in a Child with Multiple Suspicious Gene Variants

Rhabdomyolysis is diagnosed with creatinine kinase (CK) elevation beyond 1000 U/L or ten times above the normal upper limit. Severe episodes can be fatal from electrolyte imbalance, acute renal failure, and disseminated intravascular coagulation. A 13-month-old child was admitted with a CK of 82,090 U/L in the setting of respiratory tract infection-related hyperthermia of 106.9° farenheit. His medical history was significant for prematurity, dystonia, and recurrent rhabdomyolysis. His home medications clonazepam, clonidine, and baclofen were continued upon admission. He exhibited uncontrolled dystonia despite treatment for dystonia. Therefore, sedative infusions and forced alkaline diuresis were begun to prevent heme pigment-induced renal injury. Despite these interventions, his CK peaked at 145,920 U/L, which is rarely reported in this age group. The patient also developed pulmonary edema despite diuresis and required mechanical ventilation. Sedative infusions were not enough for dystonia management, and he needed the addition of a neuromuscular blocking infusion. He finally responded to these interventions, and the CK normalized after a month. He required a month of mechanical ventilation and two and a half months of hospitalization and extensive rehabilitation. We were able to avert renal replacement therapy despite pulmonary edema and an estimated glomerular filtration rate nadir of 21 mL/min/1.73 m2 based on the bedside Schwartz formula. He made a complete recovery and was discharged home. His growth and development were satisfactory for two years after that event. His extensive diagnostic workup was negative. Unfortunately, he died from septic and cardiogenic shock with mild rhabdomyolysis two years later. Prompt recognition, early institution of appropriate therapies, identification of underlying disease, and triggering events are pivotal in rhabdomyolysis management. Evidence-based guidelines are needed in this context.

Donor rhabdomyolysis, acute kidney injury and kidney transplant outcomes

BACKGROUND

Donor rhabdomyolysis may constrain kidney utilization due to anticipated unfavorable graft outcomes-especially in combination with acute kidney injury (AKI). There is a paucity of empiric data to inform organ acceptance decision-making.

METHODS

A single-center retrospective cohort study of adult transplant recipients of deceased-donor kidneys with reported donor creatine phosphokinase (CPK) levels was conducted between 2014 and 2020. Recipients of CPK ≥ 1000 U/L kidneys were propensity matched to CPK < 1000 recipients according to outcome-predictive baseline covariates, except AKI.

RESULTS

A total of 254 kidney transplants were propensity matched into CPK ≥ 1000 (n = 90) vs CPK<1000 (n = 90) groups. Transplant outcomes with high versus low CPK kidneys were similar in terms of delayed graft function (p = 0.64), 1-year estimated glomerular filtration rate <25^th percentile (p = 0.69) and mean (p = 0.58), and time to all-cause graft failure (p = 0.58). There was no interaction between AKI and high CPK for these outcomes. Extreme CPK thresholds as high as >8672 U/L were not associated with overall graft survival in the unmatched sample (p = 0.81).

CONCLUSIONS

In a single center study, donor rhabdomyolysis was not associated with short-term kidney transplant graft outcomes, nor was there an additive effect of AKI. However, studies with greater CPK and AKI severity and longer follow-up are warranted. This article is protected by copyright. All rights reserved.

Short- and Long-term Outcomes of Kidney Transplants From Very Small (≤15 kg) Pediatric Donors With Acute Kidney Injury

BACKGROUND

Kidneys from small deceased pediatric donors with acute kidney injury (AKI) are commonly discarded owing to transplant centers' concerns regarding potentially inferior short- and long-term posttransplant outcomes.

METHODS

We retrospectively analyzed our center's en bloc kidney transplants performed from November 2007 to January 2015 from donors ≤15 kg into adult recipients (≥18 y). We pair-matched grafts from 27 consecutive donors with AKI versus 27 without AKI for donor weight, donation after circulatory death status, and preservation time.

RESULTS

For AKI versus non-AKI donors, median weight was 7.5 versus 7.1 kg; terminal creatinine was 1.7 (range, 1.1-3.3) versus 0.3 mg/dL (0.1-0.9). Early graft loss rate from thrombosis or primary nonfunction was 11% for both groups. Delayed graft function rate was higher for AKI (52%) versus non-AKI (15%) grafts (P = 0.004). Median estimated glomerular filtration rate was lower for AKI recipients only at 1 and 3 months (P < 0.03). Graft survival (death-censored) at 8 years was 78% for AKI versus 77% for non-AKI grafts. Late proteinuria rates for AKI versus non-AKI recipients with >4 years follow-up were not significantly different.

CONCLUSIONS

Small pediatric donor AKI impacted early posttransplant kidney graft function, but did not increase risk for early graft loss and decreased long-term function. The presently high nonutilization rates for en bloc kidney grafts from very small pediatric donors with AKI appear therefore unjustified. Based on the outcomes of the present study, we infer that the reluctance to transplant single kidneys from larger pediatric donors with AKI lacks a rational basis as well. Our findings warrant further prospective study and confirmation in larger study cohorts.