Urologic complications in 718 renal transplant patients

Urologic complications occurred in 13.2% of the 718 patients who received renal transplants performed during a 26-year period at the Peter Bent Brigham Hospital. The complication rate remained constant over the quarter century period, whereas the rate of death caused by complications decreased significantly during the last decade. This was due, in part, to recent use of ultrasound techniques permitting earlier recognition of complications. The majority of urologic complications occurred during the first month after transplantation. Contributing factors included technical problems, ischemia, and perhaps allograft rejection. No correlation could be found between degree of HLA match or mismatch and likelihood of complication. Internal indwelling stents offered substantial advantages over nephrostomy tubes for temporary urinary diversion. The most serious complications encountered were calyceal-cutaneous fistulas associated with donor kidneys with multiple renal arteries. "Bench" operation has proved to be a major technical advance in the prevention of these fistulas.     

Infectious complications in renal transplant recipients

Infectious complications present major challenges to physicians caring for renal transplant recipients. The high rate of infection reflects the net state of immunosuppression associated with end-stage renal disease, transplantation, donor and environmental exposure. An understanding of the factors that affect the patients' overall state of immunosuppression is essential to prevent and treat infectious complications, which may lead to significant morbidity, graft dysfunction, or mortality. Familiarity with the various pathogens, clinical presentation, diagnostic options, treatment, and prophylaxis is important to care for renal transplant patients. The authors present their approach, based on review of current literature, to these issues.     

Infectious complications in renal transplant recipients

Post-kidney transplant infection is the most common life-threatening complication of long-term immunosuppressive therapy. Optimal immunosuppression, in which a balance is maintained between prevention of rejection and avoidance of infection, is the most challenging aspect of posttransplantation care. The study of infectious complications in immunologically compromised recipients is changing rapidly, particularly in the fields of prophylactic and preemptive strategies, molecular diagnostic methods, and antimicrobial agents. In addition, emerging pathogens such as BK polyomavirus and West Nile flavivirus infections and the introduction of newer immunosuppressive agents that constantly change the risk profiles for opportunistic infections has added layers of complexity to this burgeoning field. Although remarkable progress has been made in these disciplines, comprehensive understanding of the clinical manifestations of infections remains limited, and the standardization of prophylaxis, diagnosis, and treatment of most infections is yet inadequately defined. The long-term goal for optimal care of transplant recipients, with respect to infection, is the prevention and/or early recognition and treatment of infections while avoiding drug-related toxicities.     

Infectious complications in renal transplant recipients

Renal transplantation has become a well-established therapeutic option for end-stage renal disease, but infectious diseases remain a significant cause of morbidity and mortality. Although a wide variety of pathogens may cause infection, viral ones must be regarded as the single most important class of infections. Progress has been made both in the prevention and the early recognition treatment of infections that are closely linked to rejection. Immunosuppressive therapy is central to the pathogenesis of both. Because of the particular characteristics of transplant recipients, it is desirable to establish a close collaboration between nephrologists, surgeons, and infectious disease specialists for the management of these patients. In this article, we describe the different kinds of infectious disease that may affect patients with kidney transplant and the fundamental principles of clinical management, particularly our experience in Polyoma virus (BK) infection.     

Gastrointestinal complications in renal transplant recipients

Gastrointestinal complications are frequent in renal transplant recipients and can include oral lesions, esophagitis, peptic ulcer, diarrhea, colon disorders and malignancy. Oral lesions may be caused by drugs such as cyclosporine and sirolimus, by virus or fungal infections. Leukoplakia may develop in patients with Epstein-Barr virus (EBV) infection. The commonest esophageal disorder is represented by fungal esophagitis usually caused by candida. A number of patients may suffer from nausea, vomiting and gastric discomfort. These disorders are more frequent in patients treated with mycophenolate mofetil (MMF). Peptic ulcer is more rare than in the past. Patients with a history of peptic ulcer are particularly prone to this complication. Other gastroduodenal disorders are caused by cytomegalovirus (CMV) and herpes simplex infection. Diarrhea is a frequent disorder which may be caused by pathogen microorganisms or by immunosuppressive agents. The differential diagnosis may be difficult. Colon disorders mainly consist of hemorrhage, usually sustained by CMV infection, or perforation which may be caused by diverticulitis or intestinal ischemia. Colon cancer, anal carcinoma, and EBV-associated lymphoproliferative disorders are particularly frequent in transplant recipients. A particular gastric lymphoma called mucosa-associated lymphoid tissue (MALT) lymphoma may develop in renal transplant patients. It usually responds to the eradication of Helicobacter pylori.     

Neurologic complications in adult living donor liver transplant recipients

BACKGROUND: Neurologic complications (NC) after liver transplantation are not uncommon, with serious complications such as central pontine myelinolysis (CPM), often causing disability. OBJECTIVE: We investigated the incidence and features of NC following liver transplantation in adult recipients. PATIENTS AND METHODS: We retrospectively reviewed the medical records of 319 adult patients who underwent liver transplantation between January 2004 and May 2005 at the Asan Medical Center. RESULTS: Neurologic complications developed in 49 of 319 patients (15.4%). Although most of these complications were minor, including tremor and foot drop, three patients developed CPM, and one each developed posterior leukoencephalopathy, cerebral hemorrhage, and cerebral infarction. One-yr survival rates were 95.9% in patients without NC and 83.7% in patients with NC (p = 0.004). Hospital stay was prolonged in patients with NC. Graft-to-recipient body weight ratio (GRWR) did not affect occurrence of NC. CONCLUSIONS: Neurologic complications were not uncommon in liver transplant recipients. These complications contributed to prolongation of hospital stay, increased in-hospital mortality, and decreased graft and patient survival. Every effort should be made to prevent NC, as well as to detect and treat them as soon as possible.     

Urologic complications in adult kidney recipients

In this article, the authors study the complications following all the kidney transplantations performed in their hospital between 1969 and 1980. During this period, 580 patients underwent 637 transplantations, including 120 (19%) with urological complications: urinary fistulae (49%), stenoses (28%), vesicorenal refluxes (13%), and calculi (10%). The postoperative mortality rate was 2.7%. Some patients presented with two or more complications. The circumstances of the discovery of the sequelae and the treatment prescribed are described in each case and a comparative study is made with other transplantation centers.     

Parvovirus-B19-associated complications in renal transplant recipients

Parvovirus B19 is a common human pathogen, causing erythema infectiosum in children, hydrops fetalis in pregnant women, and transient aplastic crisis in patients with chronic hemolytic anemia. Immunosuppressed patients can fail to mount an effective immune response to B19, resulting in prolonged or persistent viremia. Renal transplant recipients can develop symptomatic B19 infections as a result of primary infection acquired via the usual respiratory route or via the transplanted organ, or because of reactivation of latent or persistent viral infection. The most common manifestations of B19 infection in immunosuppressed patients are pure red cell aplasia and other cytopenias. Thus, this diagnosis should be considered in transplant recipients with unexplained anemia and reticulocytopenia or pancytopenia. Collapsing glomerulopathy and thrombotic microangiopathy have been reported in association with B19 infection in renal transplant recipients, but a causal relationship has not been definitively established. Prompt diagnosis of B19 infection in the renal transplant recipient requires a high index of suspicion and careful selection of diagnostic tests, which include serologies and polymerase chain reaction. Most patients benefit from intravenous immunoglobulin therapy and/or alteration or reduction of immunosuppressive therapy. Conservative therapy might be sufficient in some cases.     

Gastrointestinal complications in renal transplant recipients: MITOS study

INTRODUCTION AND METHODS: An epidemiologic multicenter study was performed to evaluate the prevalence and management of gastrointestinal (GI) complications in solid organ transplant patients. A total of 1788 recipients were included, 1132 of which corresponded to renal transplanted patients. RESULTS: The mean age for the renal transplanted patients was 52 +/- 13.2 years. The mean time from the transplantation was 5.4 +/- 5.4 years. 17.7% showed some pretransplant GI disease, while 53% presented this type of complication in the posttransplant period. Diarrhea was the most prevalent GI complication (51.5%) and digestive perforation was the GI disorder that affected the patients daily living the most. From the patients with GI complications, 71% received pharmacological treatment, using gastric protectors in 91.3% of the cases. Regarding immunosuppressive drugs, in 30.9% of the cases the dose of the drug was reduced, in 9.3% discontinued temporarily and in 7.5% discontinued permanently. These changes mainly affected the MMF (89%, 83% and 74% for dose change, temporary and permanent discontinuation, respectively). CONCLUSIONS: The prevalence of GI complications in renal transplant exceeded 50%, and affected patients' daily living. The management of these complications was based on treatment with gastric protectors, dose reduction and/or partial or definitive MMF discontinuation.     

Biliary complications in 96 consecutive right lobe living donor transplant recipients

BACKGROUND: Biliary reconstruction represents one of the most challenging parts of right lobe (RL) living donor liver transplantations (LDLTs). Different causes, surgical techniques, and treatments have been suggested but are incompletely defined. METHODS: Between June 1999 and January 2002, 96 RL LDLTs were performed in our center. We reviewed the incidence of biliary complications in all the recipients. RESULTS: Roux-en-Y reconstruction was performed in 53 cases (55.2%) and duct-to-duct was performed in 39 cases (40.6%). Both procedures were performed in 4 cases (4.2%). Multiple ducts (> or =2) were found in 58 grafts (60.4%). Thirty-nine recipients (40.6%) had 43 biliary complications: 21 had bile leaks, 22 had biliary strictures, and 4 had both complications. Patients with multiple ducts had a higher incidence of bile leaks than those patients with a single duct (P=0.049). No significant differences in complications were found between Roux-en-Y or duct-to-duct reconstructions. Freedom from biliary complications was 59% at 1 year and 55% at 2 years. The overall 1-year and 2-year survival rates for patients were 86% and 81%, respectively. The overall 1-year and 2-year survival rates for grafts were 80% and 77%, respectively. Occurrence of bile leaks affected patient and graft survival (76% and 65% 2-year patient and graft survival, respectively, vs. 89% and 85% for those without biliary leaks, P=0.07). CONCLUSIONS: Despite technical modifications and application of various surgical techniques, biliary complications remain frequent after RL LDLT. Patients with multiple biliary reconstructions had a higher incidence of bile leaks. Patients who developed leaks had lower patient and graft survival rates.     

Management of surgical gastrointestinal complications in renal transplant recipients.

Gastrointestinal (GI) complications developed in 19 (7.2%) of 265 patients after renal transplantation, and 3 (16%) patients died. Complications included colon perforations, colonic bleeding, small-bowel infarction, pancreatitis, subphrenic abscess, and upper GI tract bleeding. Ulcers located in the second portion of the duodenum developed in six patients; four of them required operation for massive hemorrhage, which occurred during or immediately after the administration of high-dose methylprednisolone for rejection. However, the association of methylprednisolone and colon perforation was not clear from this report. Early diagnosis and prompt operation for surgical-type GI complications in transplant recipients contribute to a low mortality.     

Urologic complications after renal transplantation

BACKGROUND: Renal transplantation is associated with several nonimmunological problems. Although urologic complications may be serious and carry a high risk of graft loss, they are amenable to successful treatment if diagnosed early and treated properly. Their incidence in the literature varies from 2.5% to 15%. OBJECTIVE: We sought to assess the incidence, pattern, management options, and outcomes of urologic complications in 560 consecutive renal transplantations performed at a single center between November 1993 and October 2004. PATIENTS AND METHODS: Twenty-one (16 male and 5 female) recipients developed posttransplantation urinary complications at 2 days to 76 months after renal transplantation. Their kidney grafts were obtained from 13 living and eight deceased donors. Complications included ureteric stricture in 11 and urine leak in 10 recipients. Ultrasonography and isotope renal scanning were the main diagnostic tools. Complications were treated either conservatively, by percutaneous dilatation and stenting, or by surgical reconstruction. RESULTS: The incidence of urologic complications following renal transplantation in the present series was 3.7%. All cases were successfully treated with no graft loss secondary to these complications. CONCLUSIONS: Posttransplantation urologic complications are associated with a good prognosis if diagnosed early and properly treated. Percutaneous transluminal dilatation of ureteric stenosis in renal transplant patients has good initial success, low morbidity, few recurrences, and long-term effectiveness.     

Urologic complications in renal transplantation.

The current overall reported incidence of major urologic complications following renal transplantation is 5 per cent. The presence of such a complication increases the likelihood of patient mortality by a factor of three. Standard utilization of postoperative radionuclide scanning is very useful in early diagnosis. Vesical fistulas generally result from improper bladder closure. The incidence of bladder complications increases with secondary and tertiary grafts. Ureteral complications result when the blood supply of the ureter is impaired. These include fistula formation, necrosis, and obstruction. Immediate surgical correction is indicated in almost all serious urologic complications following transplantation; otherwise there is marked increase in morbidity and mortality. Complications appearing early in the postoperative period carry a poor prognosis for both graft and recipient survival. The presence of urinary tract infection early in the postoperative period also correlates negatively with graft survival. The presence of multiple renal arteries in the donor has been associated with an increased rate of urologic complications. Ureteral fistulas can be avoided by meticulous dissection of the donor at the time or organ harvesting. Great care must be taken to preserve the arterial and venous blood supply to the ureter by avoiding any dissection into the renal hilum. Aberrant renal arteries must be preserved or repaired if damaged. Ureteroneocystostomy is the preferred method for re-establishing urinary tract continuity following transplantation. The immediate surgical correction of urologic complications is mandatory, and the techniques involved are highly specialized and must be individualized with each patient.     

The influence of donor age on renal function in transplant recipients

To the extent that age-related declines in kidney function are caused by intrarenal alterations, donor age should affect glomerular filtration rate (GFR) after renal transplantation. Although some investigations have suggested that transplantation of aging kidneys may cause an increased incidence of primary allograft failure, the effects of donor age on GFR are unknown. In the present study, 201 patients who had allografts that survived for at least 24 months were investigated. The age range of the donors was 7 to 61 years. Multivariate regression analysis demonstrated that both donor and recipient age had significant, independent effects on creatinine clearance at 1 year, and at last follow-up, 5.0 +/- 1.9 years (mean +/- SD) after transplantation. The effect of donor age on renal function could not be attributed to differences in the number of rejection episodes, the frequency or duration of posttransplant acute tubular necrosis, age of the recipient, or other factors. Donor age had no effect on allograft survival, and did not affect the rate of decline in creatinine clearance between 1 year and last follow-up. Thus, these results suggest that donor age is associated with intrarenal alterations that lead to reductions in renal function after transplantation, but donor age may not affect long-term prognosis or allograft survival in the late posttransplant period.