Liver Transplantation After Organ Donation Due to Hydrogen Sulfide Intoxication: Report of the First Case.

Abstract

The discrepancy of patients on the waiting list and the availability of organs suitable for transplantation continues to represent a relevant problem in transplantation medicine. Regarding liver transplantation, the increasing use of organs from donors with so-called extended criteria meanwhile has become daily practice in many countries.1 Consequently, every potential donor reported is carefully evaluated for suitability for organ donation. When a liver from a young brain-dead donor after hydrogen sulfide (H2S) intoxication was offered for a high-urgency listed patient, research of the literature did not provide any help for decision making in organ allocation. Herewith, we want to share our experience following the successful use of this donor liver for transplantation. A 60-y-old female patient with acute liver failure caused by an autoimmune hepatitis was transferred to our center and eventually listed for high-urgency liver transplantation following biopsy-proven diagnosis and rapid worsening of the clinical condition despite thorough intensive medical treatment (see Figure 1). Within 5 h after approval of high-urgency status, we were offered a liver from a 19-y-old female brain-dead donor following H2S intoxication in suicidal intent. Apart from depression, the donor was in excellent general condition before intoxication and had no other known illnesses. Despite recently promoted organ protective effects in experimental studies,2 inhalation of H2S in higher concentrations is highly toxic and eventually led to cardiac arrest in this patient.3 Following a short period of resuscitation, the donor was admitted to an intensive care unit and eventually diagnosed brain dead. Within 24 h, severe lung edema and subsequently respiratory failure developed as signs of multiorgan failure. Regarding the liver, apart from an initial peak of transaminases (peak AST and ALT levels of 357 and 438 U/L, respectively), the laboratory findings were all unremarkable. Because of the severe condition of our recipient with severe hepatic encephalopathy, we thus accepted the organ after intense interdisciplinary discussion despite the lack of any data on successful use of organs for transplant under these conditions. Upon arrival of the organ at our center, histological work-up of the liver by frozen section was performed despite excellent macroscopic appearance, which did not reveal any signs of acute liver injury or chronic alterations‚ such as steatosis or fibrosis (see Figure 2). Subsequent liver transplantation was completely uneventful. The patient’s clinical condition improved rapidly, with discharge at day 15 after transplantation (see Figure 1). During follow-up of 6 mo, no irregularities were observed, with excellent graft function and medical condition of the recipient at last visit. In conclusion, to our knowledge‚ this is the first report of a liver transplant from a brain-dead donor after hydrogen sulfide intoxication. Based on this single-case experience, potential donors after hydrogen sulfide intoxication should be carefully evaluated and considered for organ donation. Particularly evaluation of potential grafts applying normothermic machine perfusion might represent another valuable option in case of less urgent conditions of the recipients.4FIGURE 1.: Course of laboratory parameters (AST, ALT [both U/L], bilirubin [µmol/L], and INR) of the recipient before and after LTx, with time points of liver biopsy, PE and steroid therapy‚ and day of transplantation indicated by gray bars. ALT, alanine aminotransferase; AST, aspartate aminotransferase; INR, international normalized ratio; LTx, liver transplantation; PE, plasmapheresis.FIGURE 2.: Histopathology of liver wedge biopsy: hematoxylin and eosin staining shows no steatosis, fibrosis, or cirrhosis ([A] ×40 magnification and [B] ×100 magnification), and Elastica van Gieson staining highlights absence of fibrosis within the liver parenchyma ([C] ×40 magnification and [D] ×100 magnification).