…surprise at recovery

No Malignancy known in the donor

a) Stop recovery due to suspected malignancyb) Small renal cell cancer possible, standard risk donor, no need to worryc) Discard kidney for pathological examination, inform other teamsd) Perform R0 resection, sent to pathology, inform teams, use kidney if ok

…surprise at recovery

No Malignancy known in the donor

In any suspect lesion malignancy must be ruled out (histology), inform every team !R0 resection of renal mass < 1.0 cm (kidney may be used if no renal cell cancer is confirmed ) !Remove always fat tissue around kidney without capsule lesion and damage to no touch area !

-> infarct, not older than 24 hours. Kidney was transplanted & all other organs too.

a) Cardiac reason for brain death -> all other organs may be used

b) Recreational drug abuse caused complication -> organs may be used

c) Unclear situation, stop recovery

24 yr., female, brain death after cardiac arrest

head ache, psychosis since 2 weeks after oral drug abuse (recreational drugs), trip to India 3 months ago, treated for psychosis ….brain death (cardiac resuscitation, severe brain edema, EF 20%)

24 yr., female, brain death after cardiac arrest

• ECD, coordinator insisted on autopsy ~ 4 weeks: brain-stem encephalitis possible, no myocarditis ~ 6 weeks: neurological alteration in two recipients ~ 2nd look donor brain -> -> RT-PCR: Rabies

third source information: “a dog scratched her…”

Try to obtain information as much as possibel !!! donor brain IF-Antibody recipient brain IF-Antibody

head ache, psychosis since 2 weeks after oral drug abuse (recreational drugs), trip to India 3 months ago, treated for psychosis ….brain death (cardiac resuscitation, severe brain edema, EF 20%)

Remember: any uncertain encephalitis is a contraindication until you know the pathogen !

8 months, boy, head injury, brain death

Donor:• head trauma, neurosurgery,

10 transfusions (72-48 hrs. ago), brain death, consent…Leucos., CRP, platelets

Mother:• pregnancy in Africa

Father: • suspected drug abuse, Africa

Questions

a) Sepsis -> stop

b) Risk of untreatable tropical infections -> stop

c) Problems should be further investigated

d) Standard risk donor, no problem

Donor:• head trauma, neurosurgery,

10 transfusions (72-48 hrs. ago), brain death, consent…Leucos., CRP, platelets

Mother:• pregnancy in Africa

Father: • suspected drug abuse, Africa

Solution

Mother: 1st-7th mo. of pregnancy in South Africa anti-HIV neg, anti-HCV neg, HBsAg neg, anti-HBc neg sanitary living conditions, no animal contacts

Father: alcohol problem, therefore divorced

8 months, boy, head injury, brain death

Donor:• head trauma, neurosurgery,

10 transfusions (72-48 hrs. ago), brain death, consent…Leucos., CRP, platelets

Mother:• pregnancy in South Africa (1st-7th

month), Virology o.k.

Father: • Alc., South-Africa (well urbanized)

Which organs (80cm, 11kg) ?

a) Heart, liver, kidney

b) Heart, lung, liver, kidney

c) Heart, lung, liver, intestine, kidney

d) Heart, lung, liver, intestine, pancreas, kidney

8 months, boy, head injury, brain death

Donor:• head trauma, neurosurgery,

10 transfusions (72-48 hrs. ago), brain death, consent…Leucos., CRP, platelets

Mother:• pregnancy in South Africa (1st-7th

month), Virology o.k.

Father: • Alc., South-Africa (well urbanized)

Which organs (80cm, 11kg)?

a) Heart, liver, kidney, small bowel+colon transplanted

b) Lung, pancreas: no centre accepted

c) Consider multivisceral-package for small childs

8 months, boy, head injury, brain death

• absolute Arrhythmia, norepinehrine, anuria, haemoflitration (4 days)

• Diabetes Typ II, COPD (paCO2>60mmHg), hypertension, smoker, coronary artery disease, , 90 kg, 170cm,

• Lab: Bili 0,8, ASAT 428, ALAT 188, y-GT 140, Quick 60, Crea 3,3

• ultrasound abdomen: Liver steatotic, arteriosclerosis

67 yr., 4 days ago cardiac resuscitation (45 min)

Questions:

a) Brain death impossible to certify (paCO2> 60 mmHg = no apnoe test = DCD)

b) No organ suitable for donation -> tissue only donor

c) Liver and kidney: intra-operative assessment -> then further decisions

• absolute Arrhythmia, norepinehrine, anuria, haemoflitration (4 days)

• Diabetes Typ II, COPD (paCO2>60mmHg), hypertension, smoker, coronary artery disease, , 90 kg, 170cm,

• Lab: Bili 0,8, ASAT 428, ALAT 188, y-GT 140, Quick 60, Crea 3,3

• ultrasound abdomen: Liver steatotic, arteriosclerosis

• Wife: he carried a donor card • Brain death: cerebral circulatory arrest in all 4 vessels (TCD)

-> intraoperatively: Liver yes, Kidney no (severe Arteriosclerosis)- arteriosclerosis might be risk factor for biliary tree arteries- still: acute kidney injury is reversible

-> Liver recipient: 40 yr. (child B cirrhosis: HBV + HCC), functioning > 2 yr.

67 yr., 4 days ago cardiac resuscitation (45 min)

55 yr., male, head trauma

• Car-crash (side), multiple head fractures & traumatic SAH• Listed for liver transplantation (Hepatitis C, Child A cirrhosis)• anti-HAV-IgG + (IgM -), anti-HEV-IgG + (IgM -)• Hepatitis C genotype 4, non-responder to antiviral therapy

Phone call 21:30 – donor?:• proceed with request to donation and brain death determination?• neurosurgeon: stopped therapy for patient (no brainstem reflexes)!

Questions:a) Proceed with donation, Hepatitis C is no contraindication for donation

b) Proceed with donation, but only the few Hepatitis C-viraemic recipients are eligible as recipient

c) Stop, multiple Hepatitis infection are a contraindication.

d) Wait: Child A cirrhosis is not an indication for liver transplantation, information is missing

55 yr., male, head trauma

• Car-crash (side), multiple head fractures, traumatic SAH etc.• Listed for liver transplantation (Hepatitis C, Child A cirrhosis)• anti-HAV-IgG + (IgM -), anti-HEV-IgG + (IgM -)• Hepatitis C genotype 4, non-responder to antiviral therapy• heaptocellular carcinoma (HCC) segment 8, MRT-TACE scheduled,

chemoembolisation done, CT Abdomen and CT Thorax before LTX!!!!!!

At the phone 21:32 – donor?:• indication for liver transplantation is HCC

Questions:a) Proceed with donation, only Hepatitis C-viraemic and extended recipients are eligible.

b) HCC transmission risk limits use of organs to special cases (plus Hepatitis C problem)

c) Stop, HCC under therapy is a contra indication

d) If no metatases are detected in the Thorax-Abdomen CT you may consider EDC-donation

55 yr., male, head trauma

• Car-crash (side), multiple head fractures, traumatic SAH etc.• Listed for liver transplantation (Hepatitis C, Child A cirrhosis)• anti-HAV-IgG + (IgM -), anti-HEV-IgG + (IgM -)• Hepatitis C genotype 4, non-responder to antiviral therapy• heaptocellular carcinoma (HCC) segment 8, MRT-TACE,

chemoembolisation, CT Abdomen and CT Thorax before LTX!!!!!!

Decision: no donor• the current situation does not exclude metastases even after normal CT. • guidelines: current cancer-therapy = contra indication• LTX is done on the assumption that no metastases exist and therefore

immuno-suppression is of no harm (CT before LTX). Then theoretically organs should be free of tumor cells, but true evidence is lacking………

Bloodgroup control: helpful?

• ten months ago hip operation: 0 Dpos, two transfusion of 0 Dpos

• 0 cc??ee, Anti-D at control

Donor 75 yr., Intracranial beeding (phenprocumon, minor trauma)

Questions:

a) Impossible, something got mixed up !

b) Rhesus anti-D and bloodgroup determination trouble excludes donation !

c) Rhesus is not considered in transplantation -> unimportant !

d) Gene defect without harm to organs, but consider immunological pitfalls !

Bloodgroup control: helpful?

• ten months ago hip operation: 0 Dpos, two transfusion of 0 Dpos

• 0 cc??ee, Anti-D

- transfusions 0 ccddee

- pitfall in blood grouping

- check everything for correctness, bedside test helpful too

• RHD-gene Dpartial 0 cc Dpa ee (DHAR RH33)

- expressed on erythrocyte*

- counseling for offspring

Donor 75 yr., Intracranial beeding (phenprocumon, minor trauma)

*passenger lymphocyte -> haemolysis in recipient