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Kidney transplantation is a complex surgical procedure which involves dissection, anastomosis of major abdominal vessels, organ storage and reperfusion. In patients of CKD 5 on hemodialysis, the post transplant risk of hemorrhage is not uncommon. However, massive blood transfusion leading to transfusion related acute lung injury (TRALI) is a dreaded complication with high mortality and morbidity.
A case of 24 years female of CKD 5 on maintenance hemodialysis underwent deceased donor kidney transplantation on an emergency basis to minimize the ischemia time and the pre operative coagulation profile was normal. Post surgery, the drain output started to increase and patient developed hypotension, tachycardia and acidosis on ABG. Immediately blood transfusion started and patient was shifted to operation theatre for re-exploration. Patient was on standard immunosuppression protocol consisting of tacrolimus, mycophenolate, steroid and induction agent was r-ATG. There was no reduction in the urine output and biochemical parameters were within normal limit. As per the need of the hour, 10 units of Packed RBC and 25 units of FFP were transfused over 24 hours and subsequently patient developed worsening thrombocytopenia for which 2 units of SDP and 26 units of RDPs were transfused.
Within 6 hours of massive transfusion patient had severe respiratory distress in the form of cyanosis, SpO2 reduced to 82% and was put on mechanical ventilation. Chest X ray revealed bilateral pulmonary infiltrates. After 3 days of mechanical ventilation patient was weaned off and kept on oxygen therapy. X ray chest gradually became normal and patient improved clinically. Transfusion associated circulatory overload (TACO) was ruled out with bedside ultrasonography of chest and IVC compressibility along with CVP monitoring.
This was a unique experience in the field of kidney transplantation. Early diagnosis and timely intervention saved the life of the patient and minimized the morbidity.