Can a patient with Antiphospholipid Antibody (APLA) syndrome who is brain dead from an intracranial thrombotic event be considered for kidney donation if they have normal kidney function and urinary output?

Kidney Donation from Brain Dead Patients with Antiphospholipid Antibody Syndrome

Patients with Antiphospholipid Antibody Syndrome (APLAS) who are brain dead from an intracranial thrombotic event can be considered for kidney donation if kidney function and urinary output are normal, but recipients should receive anticoagulation therapy to prevent graft thrombosis. 1

Understanding APLAS in Potential Kidney Donors

• Antiphospholipid antibodies (aPLA) are associated with venous and arterial thrombosis, thrombocytopenia, adverse pregnancy outcomes, and neurologic abnormalities 1
• APLAS can cause kidney damage through renal artery thrombosis, renal vein thrombosis, or injury to kidney microvasculature (APS nephropathy) 1
• The presence of antiphospholipid antibodies has been linked to early graft failure and graft thrombosis in transplant recipients 1

Risk Assessment for Kidney Transplantation

• Approximately 28-29% of renal transplant candidates have antiphospholipid antibodies, with clinical APLAS syndrome present in a subset of these patients 1
• Studies have shown that patients with APLAS who underwent transplantation without anticoagulation had high rates of graft thrombosis 1
• Brain death itself induces inflammatory activity in kidneys, which can affect graft function regardless of underlying conditions 2, 3

Donor Evaluation Protocol

• Normal kidney function and urinary output are essential prerequisites for considering donation 1
• Thorough evaluation of kidney function should be performed to ensure organ viability 1
• Visual inspection of kidneys during procurement is the final step in determining donor suitability 1

Recipient Management Considerations

• Recipients of kidneys from donors with APLAS should receive anticoagulation therapy to prevent graft thrombosis 1
• In one study, all seven patients with APLAS who underwent transplantation without anticoagulation had graft thrombosis, while grafts survived in three of four patients with APLAS who received anticoagulation 1
• Long-term anticoagulation with warfarin is recommended for recipients of kidneys from donors with APS nephropathy 1
• Direct oral anticoagulants are not recommended as they were inferior to warfarin in preventing thromboembolic events in this setting 1

Additional Management Strategies

• Immunosuppression protocols may need adjustment when using kidneys from donors with APLAS 4
• Low-dose rabbit anti-thymocyte globulin (r-ATG) as induction agent may provide better graft survival than basiliximab in recipients receiving kidneys with potential inflammatory conditions 4
• Meticulous attention to electrolyte levels, acid-base balance, and oxygenation is critical during donor management 5

Potential Complications and Monitoring

• Recipients should be monitored for signs of thrombosis, which is the primary concern when transplanting kidneys from donors with APLAS 1, 6
• Delayed graft function may occur more frequently, but with proper management, long-term outcomes can be favorable 7, 4
• Careful monitoring of anticoagulation therapy is essential to prevent both thrombotic and bleeding complications 1

Conclusion

While APLAS in a brain-dead donor presents additional risks, these can be mitigated with proper recipient selection, anticoagulation therapy, and close monitoring. The critical shortage of donor organs makes consideration of such donors important, especially when kidney function and urinary output are normal.