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Methanol-intoxicated donors: an acceptable source of organs
CADAVERIC DONORS Heart Beating
EXTENDED CRITERIA
Methanol-Intoxicated Donors: An Acceptable Source of Organs W.G. Polak, P. Chudoba, D. Patrzalek, and P. Szyber
T
HE CURRENT ORGAN shortage results in extension of the classical criteria for donor acceptance. Now even fatally intoxicated patients may be recognized under some circumstances as organ donors for transplantation.1,2 Methanol ingestion is an uncommon form of poisoning that can cause severe metabolic disorders leading to blindness, neurologic dysfunction, and brain death.3 There is limited experience with organ donation in methanol-intoxicated donors, but the results are encouraging.4,5 In this report we describe a case of successful organ donation from methanol-poisoned donor. CASE REPORT The donor was a 24-year-old previously healthy man who was admitted to the ICU in his local hospital in a deep coma. His blood pressure was 100/80, pulse of 80, and temperature of 37.0°C. Toxicological examinations showed a methanol level of 33 mg/100 mL and laboratory examinations revealed severe metabolic acidosis with pH of 6.65 and BE of ⫺34.8. To exclude intracranial bleeding a CT scan was performed, which showed only massive cerebral edema. Serum creatinine was 2.24 mg/dL on admission and increased to 3.3 mg/dL after 2 days; liver enzymes were elevated (ASAT 22 U/L, ALAT 166 U/L) and prothrombin time was prolonged to 25.2 seconds. The patient was treated with intravenous ethanol and underwent hemodialysis, but his neurological status did not improve. After 5 days in the ICU, when methanol was not detectable in his blood, the diagnosis of brain death was established. The possibility of organ donation was discussed with his family. Despite the elevated serum creatinine, kidney procurement was believed to be acceptable. Heart, liver, and pancreas were not accepted for transplantation. During the procurement two
kidneys, heart valves for the graft bank, and an aortobifemoral graft were procured. The biopsy of the harvested kidneys revealed normal histology and the biopsy of the nonprocured liver demonstrated chronic hepatitis. Both kidneys were transplanted. The recipient of the left kidney was a 57-year-old female treated by hemodialysis for 2 years due to chronic glomerulonephritis. The cold ischemia time was 13 hour. Urine production started immediately after transplantation; the patient did not required hemodialysis. Serum creatinine at 1 week was 1.1 mg/dL and after 6 months 1.0 mg/dL. The patient received triple immunoupression with cyclosporine, azathioprine, and prednisone. The recipient of the right kidney was a 43-year-old male who had received chronic dialysis for 2 years due to chronic glomerulonephritis. The cold ischemia time was 30 hours. He displayed immediate kidney function after transplantation and did not required hemodialysis. The patient received the same immunosuppression as the recipient of the left kidney. The serum creatinine after 1 week was 1.0 mg/dL and after 6 months 1.3 mg/dL.
DISCUSSION
Severe methanol poisoning usually leads to metabolic acidosis, which may result in cerebral edema and brain death.3 In such a case, if the function of other organs is normal or having recovered, organ donation can be proposed. Of From the Department of Vascular, General and Transplantation Surgery, Medical University in Wroclaw, Wroclaw, Poland. Address reprint requests to Dr Wojciech G. Polak, Division of Hepatobiliary Surgery and Liver Transplantation, University Hospital Groningen, Hanzaplein 1, 9713 GZ Groningen, The Netherlands.
© 2002 by Elsevier Science Inc. 360 Park Avenue South, New York, NY 10010-1710
0041-1345/02/$–see front matter PII S0041-1345(02)03428-0
Transplantation Proceedings, 34, 2569 –2570 (2002)
2569
2570
POLAK, CHUDOBA, PATRZALEK ET AL
Table 1. Experiences With Organ Procurement and Transplantation From Methanol-Poisoned Donors in the Medical Literature
Lungs
Pancreas
Kidney
Liver
Heart
Lungs
Pancreas
Kidney
Liver
Heart
Lungs
Pancreas
8 7 5 2 3
Heart
Caballero et al7 Hantson et al6 Chari et al8 Friedlaender et al5 Bentley et al9
Number of Donors
Good late outcome
Liver
References
Immediate function
Kidney
Number of grafts
11 13 9 4 —
3 3 4 — —
2 1 2 — 3
— 1 2 — —
— — 1 — —
8 13 9 1 —
3 3 4 — —
2 1 1 — 3
— 1 ? — —
— — 1 — —
10 5 8 4 —
3 2 3 — —
1 1 1 — 3
— 1 ? — —
— — 1 — —
course the poisoned patient might be considered for organ donation only after the drug or toxin has been eliminated and no longer contributes to clinical state. The first report describing organ donation from methanol-intoxicated donors came from Belgium, where Hantson et al demonstrated excellent results of kidney transplantation from donor who died of methanol poisoning.4 Table 1 summarizes the data published in the literature on organ procurement from methanol-intoxicated donors until the present observation. All authors agree that methanol is not directly toxic to the kidney, liver, lungs, and pancreas; if their function is normal, these organs should be considered for transplantation. We suggest that elevation of the serum creatinine and hemodialysis should not represent contraindications for kidney donation in such donors. In doubtful cases graft biopsy should be done before transplantation, as described by Friedlaender et al.5 Previous reports noted successful liver transplantation in 10 cases, but in our opinion liver procurement should be carefully discussed, because most of the incidentally poisoned donors have a history of chronic alcohol abuse. In our case a biopsy of the nonprocured liver showed chronic hepatitis.6 – 8 Although it is believed that methanol poisoning is a contraindication for cardiac transplantation, because of the risk of poor graft function as a result of methanol cardiotoxicity, recent observations demonstrate excellent long-term function and results of heart transplantation.9 There is only one report describing kidney-pancreas transplantation from a methanol-intoxicated donor. The authors suggest that this intoxication should not preclude successful pancreas transplantation.8 In case of lung procurement from methanol-intoxicated donors two
reports demonstrated good outcomes of double lung transplantation, but as for the pancreas, experiences are still limited.8,10 CONCLUSIONS
In our opinion methanol intoxication should not be contraindication for multiorgan procurement. The outcome of transplanted kidneys from donors who died of acute methanol intoxication is excellent. Moreover, as other centers demonstrated, after evaluation, such organs as liver, pancreas, heart, and lung can also be procured from methanolintoxicated donors, because the function of these grafts is acceptable. REFERENCES 1. Leikin JB, Heyn-Lamb R, Aks S, et al: AM J Emerg Med 12:151, 1994 2. Barkoukis TJ, Sarbak CA, Lewis D, et al: Transplantation 55:1434, 1993 3. Kruse JA: Intensive Care Med 18:391, 1992 4. Hantson P, Vekemans MC, Squifflet JP, et al: Transpl Int 8:185, 1995 5. Freidlaender MM, Rosenmann E, Rubinger D, et al: Transplantation 61:1549, 1996 6. Hantson P, Vanormelingen P, Lecomte C, et al: Transplant Proc 32:491, 2000 7. Caballero F, Cabrer C, Gonzalez-Segura C, et al: Transplant Proc 31:2591, 1999 8. Chari RS, Hemming AW, Cattral M: Transplantation 66:674, 1998 9. Bentley MJ, Mullen JC, Lopushinky SR, et al: Ann Thorac Surg 71:1194, 2001 10. Evrard P, Hantson P, Ferrant E, et al: Chest 115:1458, 1999
EXTENDED CRITERIA
Methanol-Intoxicated Donors: An Acceptable Source of Organs W.G. Polak, P. Chudoba, D. Patrzalek, and P. Szyber
T
HE CURRENT ORGAN shortage results in extension of the classical criteria for donor acceptance. Now even fatally intoxicated patients may be recognized under some circumstances as organ donors for transplantation.1,2 Methanol ingestion is an uncommon form of poisoning that can cause severe metabolic disorders leading to blindness, neurologic dysfunction, and brain death.3 There is limited experience with organ donation in methanol-intoxicated donors, but the results are encouraging.4,5 In this report we describe a case of successful organ donation from methanol-poisoned donor. CASE REPORT The donor was a 24-year-old previously healthy man who was admitted to the ICU in his local hospital in a deep coma. His blood pressure was 100/80, pulse of 80, and temperature of 37.0°C. Toxicological examinations showed a methanol level of 33 mg/100 mL and laboratory examinations revealed severe metabolic acidosis with pH of 6.65 and BE of ⫺34.8. To exclude intracranial bleeding a CT scan was performed, which showed only massive cerebral edema. Serum creatinine was 2.24 mg/dL on admission and increased to 3.3 mg/dL after 2 days; liver enzymes were elevated (ASAT 22 U/L, ALAT 166 U/L) and prothrombin time was prolonged to 25.2 seconds. The patient was treated with intravenous ethanol and underwent hemodialysis, but his neurological status did not improve. After 5 days in the ICU, when methanol was not detectable in his blood, the diagnosis of brain death was established. The possibility of organ donation was discussed with his family. Despite the elevated serum creatinine, kidney procurement was believed to be acceptable. Heart, liver, and pancreas were not accepted for transplantation. During the procurement two
kidneys, heart valves for the graft bank, and an aortobifemoral graft were procured. The biopsy of the harvested kidneys revealed normal histology and the biopsy of the nonprocured liver demonstrated chronic hepatitis. Both kidneys were transplanted. The recipient of the left kidney was a 57-year-old female treated by hemodialysis for 2 years due to chronic glomerulonephritis. The cold ischemia time was 13 hour. Urine production started immediately after transplantation; the patient did not required hemodialysis. Serum creatinine at 1 week was 1.1 mg/dL and after 6 months 1.0 mg/dL. The patient received triple immunoupression with cyclosporine, azathioprine, and prednisone. The recipient of the right kidney was a 43-year-old male who had received chronic dialysis for 2 years due to chronic glomerulonephritis. The cold ischemia time was 30 hours. He displayed immediate kidney function after transplantation and did not required hemodialysis. The patient received the same immunosuppression as the recipient of the left kidney. The serum creatinine after 1 week was 1.0 mg/dL and after 6 months 1.3 mg/dL.
DISCUSSION
Severe methanol poisoning usually leads to metabolic acidosis, which may result in cerebral edema and brain death.3 In such a case, if the function of other organs is normal or having recovered, organ donation can be proposed. Of From the Department of Vascular, General and Transplantation Surgery, Medical University in Wroclaw, Wroclaw, Poland. Address reprint requests to Dr Wojciech G. Polak, Division of Hepatobiliary Surgery and Liver Transplantation, University Hospital Groningen, Hanzaplein 1, 9713 GZ Groningen, The Netherlands.
© 2002 by Elsevier Science Inc. 360 Park Avenue South, New York, NY 10010-1710
0041-1345/02/$–see front matter PII S0041-1345(02)03428-0
Transplantation Proceedings, 34, 2569 –2570 (2002)
2569
2570
POLAK, CHUDOBA, PATRZALEK ET AL
Table 1. Experiences With Organ Procurement and Transplantation From Methanol-Poisoned Donors in the Medical Literature
Lungs
Pancreas
Kidney
Liver
Heart
Lungs
Pancreas
Kidney
Liver
Heart
Lungs
Pancreas
8 7 5 2 3
Heart
Caballero et al7 Hantson et al6 Chari et al8 Friedlaender et al5 Bentley et al9
Number of Donors
Good late outcome
Liver
References
Immediate function
Kidney
Number of grafts
11 13 9 4 —
3 3 4 — —
2 1 2 — 3
— 1 2 — —
— — 1 — —
8 13 9 1 —
3 3 4 — —
2 1 1 — 3
— 1 ? — —
— — 1 — —
10 5 8 4 —
3 2 3 — —
1 1 1 — 3
— 1 ? — —
— — 1 — —
course the poisoned patient might be considered for organ donation only after the drug or toxin has been eliminated and no longer contributes to clinical state. The first report describing organ donation from methanol-intoxicated donors came from Belgium, where Hantson et al demonstrated excellent results of kidney transplantation from donor who died of methanol poisoning.4 Table 1 summarizes the data published in the literature on organ procurement from methanol-intoxicated donors until the present observation. All authors agree that methanol is not directly toxic to the kidney, liver, lungs, and pancreas; if their function is normal, these organs should be considered for transplantation. We suggest that elevation of the serum creatinine and hemodialysis should not represent contraindications for kidney donation in such donors. In doubtful cases graft biopsy should be done before transplantation, as described by Friedlaender et al.5 Previous reports noted successful liver transplantation in 10 cases, but in our opinion liver procurement should be carefully discussed, because most of the incidentally poisoned donors have a history of chronic alcohol abuse. In our case a biopsy of the nonprocured liver showed chronic hepatitis.6 – 8 Although it is believed that methanol poisoning is a contraindication for cardiac transplantation, because of the risk of poor graft function as a result of methanol cardiotoxicity, recent observations demonstrate excellent long-term function and results of heart transplantation.9 There is only one report describing kidney-pancreas transplantation from a methanol-intoxicated donor. The authors suggest that this intoxication should not preclude successful pancreas transplantation.8 In case of lung procurement from methanol-intoxicated donors two
reports demonstrated good outcomes of double lung transplantation, but as for the pancreas, experiences are still limited.8,10 CONCLUSIONS
In our opinion methanol intoxication should not be contraindication for multiorgan procurement. The outcome of transplanted kidneys from donors who died of acute methanol intoxication is excellent. Moreover, as other centers demonstrated, after evaluation, such organs as liver, pancreas, heart, and lung can also be procured from methanolintoxicated donors, because the function of these grafts is acceptable. REFERENCES 1. Leikin JB, Heyn-Lamb R, Aks S, et al: AM J Emerg Med 12:151, 1994 2. Barkoukis TJ, Sarbak CA, Lewis D, et al: Transplantation 55:1434, 1993 3. Kruse JA: Intensive Care Med 18:391, 1992 4. Hantson P, Vekemans MC, Squifflet JP, et al: Transpl Int 8:185, 1995 5. Freidlaender MM, Rosenmann E, Rubinger D, et al: Transplantation 61:1549, 1996 6. Hantson P, Vanormelingen P, Lecomte C, et al: Transplant Proc 32:491, 2000 7. Caballero F, Cabrer C, Gonzalez-Segura C, et al: Transplant Proc 31:2591, 1999 8. Chari RS, Hemming AW, Cattral M: Transplantation 66:674, 1998 9. Bentley MJ, Mullen JC, Lopushinky SR, et al: Ann Thorac Surg 71:1194, 2001 10. Evrard P, Hantson P, Ferrant E, et al: Chest 115:1458, 1999