Infective complications in renal allograft recipients: epidemiology and outcome

INTRODUCTION: Successful renal transplantation strictly depends on good control of rejection and better prevention and treatment of infections, which remain serious threats. METHODS: This retrospective, observational study of 245 renal allograft recipients who underwent transplantation between January 2002 and December 2005 included a 21+/-10 months follow-up. RESULTS: A total of 110 (44.9%) patients developed an infective process during the posttransplantation period, namely, 232 infective processes. Eighty patients developed at least 1 episode of urinary tract infection (UTI) 11 patients (4%) had a wound infection, and 30 patients (12%) had pneumonia. We diagnosed 35 cases of bacteremia (35%), whereas cytomegalovirus (CMV) infection was demonstrated in 40 patients (16%). CONCLUSIONS: Immunosuppressive therapy, necessary to avoid acute and chronic rejection, exposes patients to a higher rate of infectious complications. The immunosuppressive protocols led to a relatively low incidence of infectious complications, mainly of little clinical significance. The highest incidence was evident by the sixth month after transplantation, when the immunosuppressive regimen exercised its most depressive effects on patient immune systems.     

Pseudolymphoma in renal allograft recipients.

Five renal transplant recipients exhibited giant systemic lymphadenopathy shortly after transplantation. Biopsy specimens did not show Hodgkin's lymphoma. Immunosuppression was continued in all patients. In contrast to the rapidly fatal course of malignant lymphoma in transplant recipients, adenopathy in these five patients has uniformly resolved. Patients have been observed for 6 to 15 months with no evidence of residual disease. Interval biopsy specimens are not malignant. Each patient received antithymocyte globulin from a single lot for 10 to 21 days after transplantation. During administration, T cell lymphocytes were suppressed to 5% of control values. When lymphadenopathy occurred, T cell values rebounded to 371% of control values. Toxoplasmosis titers as well as viral cultures of lymph node biopsy specimens were negative. These data indicate a benign course of this histologically malignant disease and suggest a lymphoblastic rebound phenomenon to antithymocyte globulin.     

Late complications after total hip replacement in renal allograft recipients

Summary Seventy nine hips in 53 recipients of renal allografts were treated by cemented total hip replacement for avascular necrosis of the femoral head between 1972 and 1992. Eight hips in 6 patients required revision for aseptic loosening after a mean of 11.2 years. Three replacements in 3 patients became infected with salmonella enteritidis after a mean of 6.2 years. One was revised, one had a disarticulation of the hip, and the third was treated with long term antibiotics. Survivorship analysis for total hip replacement and the renal allografts showed a hip reoperation rate of 9.9% at 10 years and 54.6% at 15 years with mortality rates of 32.2% and 42.2% respectively. Thus patients surviving 15 years are at a higher risk of failure of the prostheses than of dying.

---

Résumé Cinquante six transplantés rénaux (TR) ont été traités par arthroplastie totale de hanche (ATH) pour nécrose aseptique de la tête fémorale (NA), de 1972 à 1992 (recul moyen 6.9 ans). Huit hanches (10.1%) chez 6 patients (11.3%) ont dû être réopérées pour descellement aseptique après un délai moyen de 11.2 ans. Trois patients ont présenté une arthrite septique à Salmonella enteritidis, 6.2 ans en moyenne après l'intervention. Un des trois patients a été traité par révision de l'arthroplastie, le deuxième par une dèsarticulation de hanche en raison d'un risque vital et le troisième par antibiothérapie. Deux fois sur les trois, l'examen bactériologique des urines a révélé la présence de salmonelles. L'analyse des courbes de survie en cas d'ATH et de TR montre un risque de réintervention sur la hanche de 9.9% à dix ans et de 54.6% à quinze ans et un risque de mortalité de 32.2% à dix ans et de 42.2% à quinze ans. Donc les patients qui survivent quinze ans ont plus de risque de voir leur prothèse se desceller que de mourir. L'espérance de vie pour TR n'ayant cessé d'augmenter grâce à l'amélioration des traitements immuno-suppresseurs, les prothèses non-cimentées peuvent représenter une alternative intéressante pour ces jeunes patients, même s'ils souffrent d'une ostéopathie rénale et d'une ostéoporose par corticothérapie.

     

Ureteric obstruction in renal allograft recipients.

In 50 consecutive renal allograft recipients, operated upon between September 1975 and March 1977, we have encountered 10 cases of ureteric obstruction. The patients fell into two groups: those with ureteric obstruction of early onset due to intraluminal blood clot, oedema of the distal end of the ureter, ureteric tip necrosis or extrinsic compression by the spermatic cord, and those with obstruction of late onset due to ureteric fibrosis. Two cases of ureteric obstruction due to oedema and 1 due to intraluminal blood clot resolved spontaneously. Transurethral ureteric meatotomy, a recommended procedure for the relief of ureteric obstruction in suitable cases, was successful in 1 of our patients. The remaining 6 patients required open surgical procedures for relief of obstruction. In no instance did ureteric obstruction result in death or graft failure.     

HBs antigenemia in renal allograft recipients.

Serial HBs Ag determinations were performed on 98 renal allograft recipients with functioning grafts for 6 to 108 months, 85 of whom were followed from the initiation of dialysis. Twenty-six (27%) recipients had HBs antigenemia following transplantation. Thirteen (50%) of the 26 recipients were HBs Ag positive during the period of dialysis and 13 developed HBs antigenemia 1 to 44 months following transplantation. Seventeen (65%) of the 26 HBs Ag positive patients had hepatic dysfunction which was detected by biochemical surveillance and not associated with clinical symptomatology. There was no evidence of progressive hepatic insufficiency. HBs Ag persisted in 24 (92%) recipients for 6 to 49 months. Clearing of antigenemia occurred in only two patients, both of whom ultimately rejected their grafts. The presence of HBs Ag had no adverse effect on graft function. Temporary reduction in azathioprine dosage with hepatic dysfunction was not associated with rejection episodes. The major hazard posed by the HBs Ag positive recipient is the potential reservoir for spread to the general population because of the persistence of antigenemia.     

Reticuloendothelial function in human renal allograft recipients.

The phagocytic and metabolic functions of the reticuloendothelial system (RES) were determined, by measuring the plasma clearance rate of 125I-labelled microaggregated human serum albumin and the increase in plasma metabolites of this test substance, in patients with chronic renal failure and in renal transplant recipients at different times after transplantation. All transplant recipients received triple immunosuppressive therapy consisting of azathioprine, corticosteroids, and antilymphocyte globulin. The intravascular clearance of microaggregated albumin was significantly depressed in patients when tested at 1 to 12 days (P less than 0.001), 1 to 4 months (P less than 0.02), and 6 to 9 months (P less than 0.001) after transplantation compared to pretransplantation. The 1- to 3-year transplant survivors had a normal RES phagocytosis. Furthermore, the metabolic RES function in all groups of transplant recipients except the group of patients tested at 1 to 4 months after transplantation was significantly impaired compared to pretransplantation. Administration of antilymphocyte globulin and extremely high daily doses of steroids were probably responsible for the significant depression in the RES functions recorded immediately post-transplantation. The further development of the phagocytic ability of the RES was shown to be correlated to the cumulative dose of steroids given over the last 12 months. The azathioprine regime seemed to have no influence on the RES functions.