standard measures were used to treat hy- potension, acidosis, and hyperkalemia. Active cooling was performed. The pa- tient stabilized and was transferred to the intensive care unit where dantrolene (2.5 mg/kg every 6 hours) was continued for 24 hours. The patient remained in hospital for 6 days, during which she developed a wound infection, Clostridium difficile di- arrhea, and deep vein thrombosis, all of which responded to appropriate ther- apy. The patient has subsequently been well for 1 year. Application of an MH clinical grading scale to this scenario results in a score of 63, classifying the clinical epi- sode as almost certain MH (1). Genetic testing identified a novel mutation in a skeletal muscle L-type calcium chan- nel, other mutations of which are associated with MH (2). The patient declined open muscle biopsy for defin- itive diagnosis using the caffeine halo- thane contracture test. This case emphasizes the vari- able presentation of MH. Although the syndrome classically manifests soon after first exposure to a triggering agent, departures from this pattern can occur (3, 4). This patient had pre- sumably been exposed to volatile anes- thetic agents without complications previously, and the manifestations of MH in this case became apparent 2 hours after exposure to sevoflurane. This case also serves to reinforce a number of important considerations for living donor programs. Despite best ef- forts to minimize donor complications, it is inevitable that unpredictable and unpreventable life-threatening scenar- ios will occur, including MH, anaphy- laxis, or acute respiratory distress syndrome. Although the risks of these extremely rare adverse events occurring in ill patients undergoing needed sur- gery are heavily outweighed by the ben- efits of a proposed intervention, such an argument is not relevant in the case of living donors. We place great emphasis on fully apprising potential donors about all potential risks involved in do- nation. In light of cases such as this one, we believe that the informed consent process should include a discussion of potentially catastrophic events however rare they may be. The successful salvage of this patient reflects the importance of prompt recog- nition and treatment of MH by a multidis- ciplinary team once the syndrome was suspected. Despite resolution of the acute crisis, a number of secondary complica- tions followed, illustrating the aphorism that “complications beget complications.” For otherwise healthy living donors, in whom the desired outcome is full and nor- mal resumption of preoperative activities, the morbidity associated with numerous minor complications may equal that of an isolated major complication. Although prevention of complica- tions is an important component of patient safety, the ability to “rescue” pa- tients from adverse events is a significant predictor of patient outcomes (5). In re- porting the first case of MH developing in a living organ donor, this case highlights the need for transplant programs offering surgery to living donors to actively main- tain the resources and expertise necessary to recognize and respond to both com- mon and unusual complications, such that the chance of donor survival is maxi- mized should adverse events occur. Anand Ghanekar 1 Robert M. Richardson 2 W. Scott Beattie 3 1 Department of Surgery Toronto General Hospital University Health Network Toronto, ON, Canada 2 Department of Medicine Toronto General Hospital University Health Network Toronto, ON, Canada 3 Department of Anesthesia Toronto General Hospital University Health Network Toronto, ON, Canada Address correspondence to: Anand Ghanekar, M.D., Ph.D., Toronto General Hospital, CSB 11C-1227, University Health Network, 585 University Ave- nue, Toronto, ON, Canada M5G 2N2. E-mail: anand.ghanekar@uhn.on.ca All authors contributed to the care of the patient described in this report. A.G. prepared the manuscript, and R.M.R. and W.S.B. edited the manuscript. Received 6 August 2010. Accepted 19 August 2010. Copyright © 2010 by Lippincott Williams & Wilkins ISSN 0041-1337/10/9010-1135 DOI: 10.1097/TP.0b013e3181f8692f REFERENCES 1. Larach MG, Localio AR, Allen GC, et al. A clin- ical grading scale to predict malignant hyperther- mia susceptibility. Anesthesiology 1994; 80: 771. 2. Toppin PJ, Chandy TT, Ghanekar A, et al. A report of fulminant malignant hyperthermia in a patient with a novel mutation of the CACNA1S gene. Can J Anaesth 2010; 57: 689. 3. Hopkins PM. Malignant hyperthermia: Ad- vances in clinical management and diagno- sis. Br J Anaesth 2000; 85: 118. 4. Larach MG, Gronert GA, Allen GC, et al. Clin- ical presentation, treatment, and complica- tions of malignant hyperthermia in North America from 1987 to 2006. Anesth Analg 2010; 110: 498. 5. Ghaferi AA, Birkmeyer JD, Dimick JB. Com- plications, failure to rescue, and mortality with major inpatient surgery in medicare pa- tients. Ann Surg 2009; 250: 1029. Energy Expenditure During a Day of Sport Competitions in Kidney Transplant Recipients Kidney transplant recipients show a reduction in maximal exercise capacity and cardiorespiratory fitness that may be counteracted by physical and sport- ing activities (1). However, not all pa- tients increase their physical activity after transplant, and kidney transplant recipients show a continuum of differ- ent attitudes: on one hand, patients may stay inactive because of fears of injuring the transplant graft or simple lack of motivation, whereas other patients may restart (or begin) strenuous sporting ac- tivities. This spectrum of attitudes may be influenced by a lack of counseling from transplant professionals and com- munity nephrologists about the benefits of exercise or by those providers who may themselves fear the risk of cardiac complications from exercise (2). The overall population of kidney transplant recipients is heterogeneous, suggesting that tailored exercises regi- mens are needed to ensure patient safety (2), but to make effective exercise train- ing recommendations without being overly cautious, it is helpful to know the upper limits of human performance also in kidney transplant recipients. Since the foundation of the Trans- plant Games in 1978 (3), participation in competitions for transplant recipients at international, national, and local levels 1136 | www.transplantjournal.com Transplantation • Volume 90, Number 10, November 27, 2010