SUCCESSFUL KIDNEY TRANSPLANT FROM A METHANOL-INTOXICATED DONOR: A CASE REPORT

In Peru, the waiting list to receive a deceased donor kidney allograft is one of the longest in the world and in South America, with approximately 721 people until April 2022. To breaches this shortfall, the possibility of including donors intoxicated with methanol, which represent 1% of the total organ donors worldwide, has been considered.

Methanol is osmotically active and is distributed to all body systems and organs causing elevated anion gap metabolic acidosis. The most representative clinical manifestations are cerebral and visual. Symptoms may take up to 72 hours to appear after ingestion and may be further delayed if ethanol has also been ingested. Blood levels of methanol do not reflect brain concentrations, which can be several times higher than serum levels, so a negative methanol level does not necessarily rule out the diagnosis.

Up to October 13, 2022, during the epidemiological alert number 21-2022, 117 cases were reported in 9 hospitals in Lima and Callao. Seventy-nine percent were confirmed by clinical diagnosis and 21% by laboratory. Clinical or laboratory criteria were required for a confirmed case. In September 2022, the first cases of methanol intoxication were reported in hospitals in the Callao region. A total of 47 cases, including 25 deaths, were reported on November 7, 2022.

The use of organs for transplantation obtained from this type of donor has been little reported in the literature. The largest reported study to date was conducted in Spain, involving 29 kidneys, where the immediate postoperative period was favorable, ruling out the transmission of methanol to the recipients, and long-term survival of both the graft and the recipient was optimal.

There are doubts whether it would be successful to perform a donation in the context of intoxication because the donor's organs could contain the product that could also cause intoxication in the recipients. Furthermore, the possibility of significant tissue damage caused by the toxic agent could affect graft function.

The objective of this report is to demonstrate the experience of kidney transplantation from a methanol intoxicated donor, which could expand the opportunity for increased donation. The present case had clinical confirmation, history of alcohol consumption, structural brain injury and elevated anion gap metabolic acidosis. Although there was no confirmation of methanol at serum level, it is considered a confirmed case according to our epidemiological directive. The evolution of the recipient and the graft was favorable.

clinical case study

A 33-year-old male donor, blood group and factor O Rh +, with a history of psoriasis, overweight and alcohol consumption for 13 years, admitted to the emergency room for nausea, dizziness and decreased visual acuity. According to an interview with family members, he had consumed alcoholic beverages the previous day, we did not perform a methanol blood test, the diagnosis of methanol intoxication was clinical, as described below.

Blood gases showed severe metabolic acidosis with elevated anion gap associated with acute kidney injury (AKI) and poor respiratory pattern requiring mechanical ventilation and the use of vasopressors: noradrenaline and vasopressin. 2 hemodialysis sessions were performed and the acid-base alteration described above persisted (Table 1). Brain tomography showed subarachnoid and intraparenchymal hemorrhage, in addition to cerebral edema (Figure 1). Neurology and intensive medicine corroborate absence of truncal reflexes, with apnea test, atropine test and oculovestibular reflex contributing to brain death. Thus, organ donation procurement was activated, and the family accepts the donation.

A zero renal biopsy was made and the left kidney that was transplanted to our patient had 25 glomeruli, with a total score of 2 points of Ramuzzi scale, 1 for tubular atrophy and 1 for vascular sclerosis.

A deceased donor kidney transplant was carried out on September 3rd, 2022, to a 45-year-old female patient with CKD G5 on dialysis since 2017, peritoneal dialysis modality and uncertain etiology, received immunosuppression: methylprednisolone, antithymocyte globulin, tacrolimus, and mycophenolate sodium.  Cold ischemia time of 19 hours. In the immediate postoperative period, there was no consciousness disorders, visual alterations, or elevated gap metabolic acidosis. On postoperative day 2 she presented signs of pulmonary congestion, oliguria and nitrogen retention, so a hemodialysis session was scheduled. Then, she presented favorable evolution, adequate urinary flow, creatinine of 3.52 at discharge, and one month after surgery creatinine of 0.97. She had an episode of urinary tract infection by E. coli BLEE which resolved with antibiotic therapy. One year later, she preserves renal function, with no other complications at the moment. (Table 2).

Kidneys from donors intoxicated by methanol along with other substances are usually disregarded due to the risk of transmitting the toxic substance to the recipient or transplanting an organ with irreversible injury. Due to the existing evidence, it can be concluded that renal transplantation with methanol intoxicated donors is feasible and advisable. Graft and recipient survival of organs from donors dying from methanol does not differ in the short and long term from transplants performed with organs from donors dying from other causes, as can be evidenced in the case reported by us. Evaluation of the renal graft for transplantation should follow the general principles that are commonly applied.