EXPANSION OF THE DONOR KIDNEY POOL: EXPERIENCE WITH ACUTE TUBULAR NECROSIS WITH MYOGLOBIN CASTS AND IRON OVERLOADED DONOR KIDNEYS

 

Billie Fyfe, Bethany Carlisle, Michael Heifets and Mysore S. Anil Kumar

 

Department of Pathology, Department of Medicine and Department of Surgery, Division of Transplantation

Drexel University College ofMedicine, Philadelphia, PA

 

Background: Increasing allograft need has lead to histologic evaluation of marginal donor organs, occasionally revealing findings of unknown impact on graft outcome. Therefore, we report the clinical and pathologic outcome following transplantation of an iron-overloaded renal allograft and three allografts with myoglobinuric acute renal failure (ARF).

 

Design: Donor renal biopsy and follow-up protocol renal biopsy data, recipient and donor clinical information were reviewed. Quantitative iron studies were performed in the iron overloaded kidney. Immunohistochemical stains for myoglobin were performed in the myoglobinuric ARF kidneys.

 

Results: Iron overload: A 73 year-old diabetic, hypertensive woman received a kidney from a 63 year-old man with a mechanical heart valve and an embolic stroke. Other centers rejected the paired organ. Donor organ biopsy was performed at implantation. Severe tubular epithelial iron overload was diagnosed histologically and quantitated at 3985 ug/g dry weight.

Glomerulosclerosis was 10%, fibrosis and arterial sclerosis were grade I and tubular changes were grade 0 (Banff '97). A 2- month biopsy for clinical rejection revealed Banff '97 type IA rejection, qualitatively decreased iron, and fibrosis, vascular and tubular grades equal to donor biopsy. One-year protocol biopsy revealed qualitatively decreased iron, no rejection, and fibrosis, vascular and tubular grades equal to the donor biopsy. Tissue was insufficient for iron quantification. One year post-transplant serum creatinine level is 2.0mg/dl.

Myoglobinuric ARF: Three kidneys from two cadaveric donors who had acute renal failure at the time of donation were evaluated by donor renal biopsy. All three donor kidney biopsies revealed acute tubular necrosis with myoglobin casts, confirmed by immunohistochemical evaluation. Donor disease was related to narcotic overdose in one donor and trauma in the second donor. Recipients were a 56-year-old woman, a 54-year-old man, a 45-year-old man. All patients experienced delayed graft function. Biopsies were performed at 7-10 days post-transplant for delayed graft function. All early biopsies demonstrated acute tubular necrosis with myoglobin casts. At one month biopsy myoglobin casts are gone in two patients and rare in one patient. One patient had borderline changes in both biopsies and all three patients demonstrated tubular epithelial cyclosporine toxicity. Serum creatinine levels at three months (2 patients) are 1.3 mg/dl, 2.2 mg/dl and at two months (1 patient) are 2.2 mg/dl.

 

Conclusion: Utilization of suboptimal donor kidneys including iron overload and myoglobinuric ARF may be clinically feasible. Pathologic evaluation of suboptimal donor kidneys is mandatory.  Kidneys with myoglobinuric ATN appear predisposed to cyclosporine toxicity.

 

 

 

 

EXPANSION OF THE DONOR KIDNEY POOL: EXPERIENCE WITH ACUTE TUBULAR NECROSIS WITH MYOGLOBIN CASTS AND IRON OVERLOADED DONOR KIDNEYS

 

Billie Fyfe, Bethany Carlisle, Michael Heifets and Mysore S. Anil Kumar

 

Department of Pathology, Department of Medicine and Department of Surgery, Division of Transplantation

Drexel University College ofMedicine, Philadelphia, PA

 

CORRESPONDING AUTHOR:

 

Billie Fyfe, MD

Department of Pathology

Hahnemann University Hospital

245 North 15th Street

Philadelphia, PA  19102-1192

 

Ph: 215-762-1456

Email: Billie.Fyfe@Drexel.edu

FAX: 215-246-5918