Prevention of ischemic injury in renal transplantation

Abstract

Case presentation The prospective donor was a 17-year-old white female who had sustained a severe head injury in a motor vehicle accident. By the time she was brought to the Emergency Room, she had evidence of cerebral edema and increased intracerebral pressure; she was given intravenous dexamethasone, 10 mg, and mannitol, 100 ml of a 25% solution. Intravenous naloxone, 2 mg, was given empirically but had no effect on her neurologic condition. Surgical exploration of her wounds required the use of pancuronium, fentanyl, and thiamylal as anesthetic agents. In addition, she was given 100 mg of phenytoin intramuscularly to prevent seizures; 1 g of cefazolin intravenously as infection prophylaxis; and 300 mg of cimetidine intravenously to prevent gastric ulcers. Neurologic examination following her recovery from anesthesia could not demonstrate a response to painful external stimuli; corneal, vestibulocular, and gag reflexes were absent; the pupils were fixed; and neither motor nor cranial nerve responses could be elicited. Electroencephalography revealed no electrocerebral activity. An apnea test disclosed no spontaneous muscular movement or respiration despite a rise in the PaCO2 to 60mm Hg. At the conclusion of the test, ventricular tachycardia was successfully treated with 100 mg of lidocaine intravenously. Over a 4-hour period, the patient's urine flow averaged 512 mI/hr and she received an average of 410 mI/hr of 0.9% sodium chloride solution intravenously. At that time, the blood pressure was 106/62 mm Hg; pulse, 104 beats/mm; and temperature, 370 C. Laboratory data were: serum sodium, 155 mEq/liter; potassium, 3.4 mEq/liter; chloride, 124 mEq/liter; bicarbonate, 19 mEq/liter; and glucose, 720 mg/dl. The BUN was 13 mg/cl! and the serum creatinine 1.2 mg/dl. The hematocrit was 35.7%; white blood cell count, 27,100 mm3; and platelets, 272,000 mm3. Urinalysis showed a specific gravity of 1.010, a pH of 5.0, and 2+