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.     

Urological complications after renal transplantation

Urological complications occurred in 17.5% of the 80 patients who had received renal transplantations in our clinic between March, 1975 and May, 1984. Urinary fistulas occurred in 3 patients, urolithiasis occurred in 6 patients, ureteral stenosis occurred in 1 patient and urinary tract bleeding occurred in 4 patients. Graft loss was observed in 1 patient, but there were no patients whose death was directly attributable to urological complications. Urological complications can be avoided by careful procedures in donor nephrectomy and urinary tract reconstruction.     

Urological complications after living-donor renal transplantation

OBJECTIVE: To determine the incidence and management of urological complications after 1200 consecutive live-donor renal transplantations, all of which were carried out in one centre; the possible risk factors and the effect on patient and graft survival were also assessed. PATIENTS AND METHODS: Data were retrieved from an electronic database; the incidence of urological complications was determined, and correlated with relevant risk factors by univariate and multivariate analysis. The effect on patient and graft survival was assessed using Kaplan-Meier statistics. RESULTS: There were 100 complications in 96 patients (8%); urinary leaks occurred in 37, ureteric strictures in 23 and lymphoceles causing ureteric obstruction in 17. Percutaneous needle biopsy was complicated by haematuria and clot anuria in six patients. Late complications included 11 cases of stones, four of bladder malignancy and two of haemorrhagic cystitis. There was evidence that the age of the recipients (< 10 years), method of establishing urinary continuity (uretero-ureteric anastomosis) and a high dose of steroids had an independent positive effect on the incidence of urological complications. However, their development did not influence graft or patient survival. CONCLUSION: When there is meticulous attention to the technical details, renal transplantation should incur few urological complications. Early intervention with percutaneous drainage reduces morbidity and the likelihood loss of graft function. Proper and prompt management should not affect the graft and/or the patient's survival.     

Analysis of vascular complications after renal transplantation

Purpose

Despite medical and surgical advances, vascular complications remain common after renal transplant, occurring among 3%-15% of patients. These complications may compromise graft function. This study sought to evaluate the frequency and management of vascular complications after renal transplant.

Materials and Methods

We retrospectively analyzed the 1843 transplantations performed at 2 centers by our team since November 1975. The 1349 male and 494 female patients had an overall mean age of 31.5 ± 11.2 years; (range, 3-66). Grafts were obtained from a living-related donor in 1406 (76.29%) or a deceased donor in the remaining 437 (23.71%). The mean donor age was 40.7 ± 13.7 years (range, 2-76). Of 1843 transplants, multiple vascular anastomoses were performed in 155 cases (8.4%), including 130 involving renal arteries and 25 renal veins.

Results

Forty-seven vascular complications (2.55%) were observed in 43 procedures (2.33%), most frequently renal artery stenosis (n = 14). It was followed by allograft renal artery kinking (n = 7), renal vein kinking (n = 7), renal artery thrombosis (n = 5), renal vein laceration (n = 4), renal artery laceration (n = 3), renal vein thrombosis (n = 2), renal artery disruption (n = 2), renal and iliac vein obstructions owing to pressure from a lymphocele (n = 1), renal artery and vein obstruction owing to pressure from a hematoma (n = 1), or an arteriovenous fistula after percutaneous graft biopsy (n = 1). Fifteen of these 47 complications were treated by interventional radiologic procedures.

Conclusion

The vascular complication rates in our patients were somewhat lower than those reported in the literature. A thorough understanding of how complications impair allograft function and survival is essential for adequate treatment. Interventional radiology is invaluable in the postoperative management of transplant-related complications.     

Alimentary tract complications after renal transplantation.

A computer analysis of post renal transplantation gastrointestinal problems was performed to identify important associated clinical factors. Thirty-seven per cent of all transplant recipients developed one or more significant problems. Hemorrhage, nondiverticular intestinal perforation, and esophagitis occurred most frequently in hospitalized patients. Pancreatitis, diverticulitis, and gastroduodenal perforation occurred characteristically in long-term survivors with well functioning allografts. Eleven of 32 HLA identical recipients treated with maintenance corticosteroids during stable kidney function developed gastrointestinal disease while only one of 13 HLA identical recipients not given maintenance steroids developed a problem, which strongly suggests a causal role for steroids in the development of late complications. The association of preexisting peptic ulcer and diverticular disease with hemorrhage and perforation supports previous recommendations that documented peptic ulcer disease or diverticulitis should be corrected surgically prior to transplantation.     

Pulmonary complications in renal recipients after transplantation

Background

Renal transplantation is the most common type of solid organ transplantation. Recipients are susceptible to a variety of pulmonary complications, in particular during intense immunosuppression therapy.

Objective

To evaluate pulmonary complications during the first year after renal transplantation.

Materials and Methods

Medical records were reviewed retrospectively for all patients who underwent renal transplantation between 2007 and 2010. Data pertinent to pulmonary complications were obtained including patient demographics, findings at chest radiography and pulmonary function testing, concentrations of C-reactive protein and albumin, and white blood cell count.

Results

The study included 136 patients (71.3% men), with mean (SD) age of 36.3 (12.2) years. The most frequently prescribed immunosuppression therapy included prednisolone plus cyclosporine, tacrolimus, or rapamycin. Fifteen patients developed complications during the first year after surgery including respiratory infections in 12 (80%), namely, bacterial pneumonia in 10 (66.6%), and tuberculosis (caused by Mycobacterium tuberculosis) in 2 (33.3%). Pneumonia developed within the first 5 months after transplantation in 6 patients, and tuberculosis after the third month. Microbiologic agents were detected in 3 of the 6 patients (20%), and empyema, postoperative atelectasis, and pulmonary embolism, respectively, in the other 3 patients. No association was observed between complications and baseline pulmonary function test results. C-reactive protein concentration was significantly increased in patients with pulmonary complications. No invasive procedures were performed to diagnose complications, all of which resolved with appropriate treatment.

Conclusion

Pulmonary infections are a primary complication in renal transplant recipients, and are observed most frequently in the first 6 months after surgery. Immunosuppression therapy is the most likely cause of these complications, and rigorous monitoring of drug concentrations is essential. An invasive diagnostic approach may not always be necessary to determine the early specific therapy.     

Surgical treatment of urologic complications after renal transplantation

AIM: The incidence of urologic complications after renal transplantation has been reported to be between 2.5% and 27%. The aim of this study was to evaluate urologic complications of and their surgical treatment in our series of renal transplantations. MATERIALS AND METHODS: We retrospectively evaluated urologic complications among 395 renal transplant recipients in our institute. RESULTS: The urologic complications were ureteral leakage (n = 8), stricture of ureteral anastomosis (n = 3), hydronephrosis secondary to stone (n = 2) and bladder outlet obstruction (n = 2), recurrent urinary infection because of vesicoureteral reflux to native kidney (n = 2), renal tumor in native kidney (n = 1), hydroceles (n = 3), technical complications (n = 2), and clot retention (n = 1). CONCLUSION: Major urologic complications following renal transplantation are ureteral leakage and stricture resulting from disrupture of the distal ureteral blood supply during the donor operation. Extravesical ureteroneocystostomy over a JJ stent seems feasible to minimize urologic complication. Early diagnosis and endourologic techniques are the mainstays of treatment.     

Cardiovascular complications after renal transplantation and their prevention

By the time of renal transplantation, end-stage renal disease patients have a huge burden of cardiovascular disease (CVD) and are heavily saturated with atherosclerotic risk factors. Worsening of preexisting risk factors or new CVD risk factors may develop in the posttransplant period consequent in part to the diabetogenic and atherogenic potential of immunosuppressive drugs. The annual risk of a fatal or non-fatal CVD event of 3.5 to 5% in kidney transplant recipients is 50-fold higher than the general population. Renal allograft dysfunction, proteinuria, anemia, moderate hyperhomocysteinemia and elevated serum C-reactive protein concentrations, each dependently confer greater risk of CVD morbidity and mortality in the posttransplant period. Long-term care of renal transplant recipients should programmatically incorporate the recommendations of the National Kidney Foundation Working Groups and European Best Practice Guidelines Expert Group on Renal Transplantations into the management of hypertension, dyslipidemia, smoking, and posttransplant diabetes mellitus. Timely utilization of coronary revascularization procedures should be undertaken as these treatments are equally effective in the kidney transplant population.     

Ureteroscopic management of urological complications after renal transplantation

OBJECTIVE: To determine the feasibility, safety and efficacy of diagnostic and therapeutic ureteroscopy in renal allograft ureters. MATERIAL AND METHODS: We reviewed 1560 consecutive renal allografts performed between June 1989 and February 2002. A total of 28 patients (1.8%) had indications for an endoscopic procedure on the allograft ureter, as follows: obstructive ureteral calculi with a history of failed extracorporeal shock-wave lithotripsy, n=6; suspected ureteral stricture, n=3; upwardly migrated ureteral stents, n=9; and ureteral stricture at the ureteroneocystostomy site, n=10. Ureters were anastomosed to the bladder using the Leadbetter-Politano and Lich-Gregoire methods in six and 22 cases, respectively. Ureteroscopies were performed with a semi-rigid 9.8 F Wolf ureteroscope. RESULTS: Identification of the ureteral orifice and insertion of a guide-wire into it was successful in 19 cases (68%). If we exclude the 10 patients with ureteral stricture, ureteroscopy was successful in 13/18 cases (72%). Four ureteral calculi (67%) were removed with the ureteroscope. Seven out of nine migrated stents (78%) were retrieved. Four patients with ureteral stricture at the ureteroneocystostomy site (40%) underwent successful ureteral dilatation and double-J ureteral catheters were also inserted. Diagnostic ureteroscopy was successful in all cases. Two complications (one urinary leakage and one symptomatic urinary tract infection) occurred and were managed conservatively. CONCLUSIONS: Ureteral endoscopy is a safe and effective method for the management of urological complications after renal transplantation. This procedure can be considered the first choice, in preference to percutaneous and antegrade modalities.     

Low incidence of urologic complications after renal transplantation

The incidence of urologic complications after renal transplantation has been reported to range from less than 1 to 10 percent. They are still a significant source of morbidity and mortality. We report on 111 kidney transplants performed at the San Juan Veterans Administration Hospital in 85 of whom urinary continuity was restored with a Politano-Lead-better ureteroneocystostomy, 23 with the Lich-Grégoir operation, and 3 with extravesical urinary, diversions. Important factors included meticulous attention to details during ureter manipulation, the use of prophylactic antibiotics, unabsorbable sutures in the closure of the muscular part of the bladder wall and infrequent use of drains. This resulted in a low rate of complications which included early ureteral obstruction (3.6 percent), late ureteral obstruction (1.8 percent), lithiasis (1.8 percent), urinary extravasation (0.9 percent), and ureteropelvic necrosis. No kidneys or patients were lost to technical complications, and no deep wound infections were observed. Our experience demonstrates the beneficial effects of a low complication rate on patient and graft loss.     

Urological complications after simultaneous renal and pancreatic transplantation.

OBJECTIVE: To report the urological complications after simultaneous renal and pancreatic transplantation. DESIGN: Retrospective study. SETTING: Teaching hospital, Italy. SUBJECTS: 143 consecutive patients having simultaneous renal and pancreatic transplantation by one of three techniques. 33 segmental pancreas with duct occlusion, 77 whole pancreas with bladder diversion, and 33 enteric diversion with systemic (n = 26) or portal venous drainage (n = 7). Urological complications were related to the pancreatic transplant, to the renal transplant, or unrelated to the transplant. MAIN OUTCOME MEASURES: Morbidity. RESULTS: After occlusion of the duct and enteric diversion, there were no urological complications related to the pancreatic transplant. On the other hand, among the 77 patients with pancreatic drainage into the bladder, urological complications were common (56/77; 73%). Complications related to the renal transplant were recorded in 6/33 (18%), 26/77 (34%) and 12/33 (36%), respectively. Complications unrelated to the transplant occurred in 6/77 patients (8%) in the bladder drainage group. Five patients after bladder drainage required cystoenteric conversion. CONCLUSIONS: Enteric diversion is a safe alternative to bladder diversion and results in significantly fewer urological complications.     

New immunosuppressive therapies and surgical complications after renal transplantation

Background

To analyze the association between the principal immunosuppressive drugs (mycophenolate mofetil, calcineurin inhibitors and mammalian target of rapamycin [mTOR] inhibitors) used in the routine management of kidney transplant patients and the development of postoperative surgical complications.

Materials and Methods

We analyzed 415 kidney transplants, studying the influence of various immunosuppressive regimens on the main postoperative surgical complications.

Results

The mean follow-up for the entire group was 72.8 months (± 54.2 SD). Patients treated with myeophonolate mofetil (MMF) and cyclosporine (n = 121) experienced a higher frequency of wound eventration odds ratio [OR], 5.2; 95% confidence interval [CI], 1.2-23.5; P = .03) compared with azathioprine and cyclosporine (n = 71). Compared with transplant recipients treated with tacrolimus and MMF (n = 181), transplant recipients treated with cyclosporine and MMF (n = 121) had a significantly greater frequency of wound eventration (OR, 3.7; 95% CI, 1.5-9.5; P = .005), urologic (OR, 2; 95% CI; 1.02-3.9; P = .04), wound (OR; 2.2; 95% CI; 1.07-4.6; P = .03), late (OR, 1.7; 95% CI; 1.01-3.03; P = .04), and Clavien grade 3 surgical complications (OR; 1.9; 95% CI, 1.1-3.37; P = .01). Patients treated with mTOR inhibitors (n = 26) had higher rates of lymphocele (OR, 3.6; 95% CI, (1.1-11.4; P = .002) compared with those who received tacrolimus (n = 197).

Conclusions

New immunosuppressive drugs have improved short-term functional results; however, in some cases they seem to increase surgical complications rates.     

Study of factors that affect complications after renal transplantation

There are no multifactorial studies of complications after renal transplant in the Hispanic population. The objective of this study was to identify which factors are associated with the development of complications after renal transplantation. This retrospective study was performed on all patients transplanted in the Puerto Rico Transplant Program during 2002. Independent variables included preoperative albumin, white blood cell (WBC) count, hemoglobin, creatinine, weight, height, body mass index (BMI), type of dialysis, time on dialysis, and urine production after transplant. Dependent parameters included posttransplant diuresis, wound infection, wound dehiscence, lymphoceles, acute tubular necrosis, length of stay, postoperative weight, graft survival, and patient survival. Data were analyzed with parametric and nonparametric techniques using STAT 200 software. Sixty-four patients were included in the study: 37 male, 27 female. No significant differences in complication rate or length of stay were found with age, preoperative albumin, WBC count, hemoglobin, creatinine, weight, height, dialysis modality, and donor type. Significant factors included type of dialysis, time on dialysis, and BMI. Preoperative albumin if > 3 was not a prognostic indicator for the development of surgical complications following renal transplantation. Only preoperative weight, BMI, and dialysis duration were significant factors in the development of postoperative complications and prolonged hospital stay in this sample Hispanic transplant population. These data are important in formulating selection, education, and transplant management policy.     

Thromboembolic complications after renal transplantation: A retrospective analysis

In a retrospective study of 125 transplanted patients, 8.8% developed thromboembolism (diagnosed with objective methods) during the first year after transplantation. In one patient pulmonary embolism was the cause of death and in one it was contributory. The thromboembolism developed rather late after transplantation. The side of the transplant did not determine the site of the thrombosis. Juvenile diabetes mellitus was found to be a significant risk factor.

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Resumen En un estudio retrospectivo de 125 pacientes con transplante renal se encontró que el 8.8% desarrolló tromboembolismo, diagnosticado por métodos objetivos, en el curso del primer año después del transplante. En un paciente la embolia pulmonar fue la causa de muerte y en uno fue causa contribuyente. El tromboembolismo apareció más bien tardíamente después del transplante; el período de riesgo de tromboembolismo es bastante prolongado, en comparaciôn con otros tipos de cirugía donde el riesgo es insignificante después del primer mes postoperatorio. El lado del transplante no fue factor determinante de la localización de la trombosis. La diabetes juvenil fue identificada como un factor significativo de riesgo.

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Résumé L'étude rétrospective de 125 transplantés rénaux a permis de constater que la fréquence de la thrombose veineuse s'élevait à 8,8% au cours de la première année suivant la transplantation. Chez un malade la mort fut la conséquence indiscutable d'une embolie, tandis qu'elle y contribua très probablement chez un autre opéré.La thrombose se développe généralement tard après la transplantation. Le côté de la transplantation ne détermine pas la localisation de la thrombose. Le diabète juvénile constitue un facteur de risque indiscutable.

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Supported by the Swedish Medical Research Council (project No. 00759).     

Obesity favors surgical and infectious complications after renal transplantation

The prevalence of obesity is increasing in the renal transplant population. There are controversial data with respect to posttransplant outcome. We performed a study comparing the incidence of surgical and infectious complications among 40 obese patients (body mass index [BMI] pretransplant > or =30 kg/m2) versus a matched nonobese control group (BMI <30 kg/m2) transplanted at our center between June 1989 and March 2001. RESULTS: There were no differences in patient demographic variables (mean age, gender, cause of renal failure, or percentage of diabetes or hepatitis C virus infection). Donor age, HLA mismatching, sensitization, cold ischemia time, and immunosuppressive regimen were similar in both groups. The mean pretransplant BMI in obese and nonobese patients was 34.1+/-4.0 versus 23.00+/-2.73 kg/m2 (P<.01). The obese group showed a higher incidence of delayed graft function (30% versus 5%, P<.05) and wound infections (12.5%) posttransplant with similar incidences of wound dehiscence, perigraft collections, and graft function at the end of follow up.     

Musculoskeletal complications after renal transplantation: pathogenesis and treatment.

Renal transplantation is associated with several abnormalities of function and structure of the musculoskeletal system. Some of these skeletal problems result from incomplete resolution of abnormalities of bone and mineral metabolism present at the time of transplantation. In this regard, persistent hyperparathyroidism, diabetes mellitus type 1, and accumulation of beta 2-microglobulin may lead to residual skeletal effects despite excellent function of the allograft. Persistent hyperparathyroidism may accelerate bone loss and increase the risk for osteonecrosis, as well as cause hypercalcemia and hypophosphatemia; some patients with severe hyperparathyroidism require parathyroid surgery. Osteonecrosis is the most debilitating skeletal complication after transplantation and frequently requires surgical therapy. Although osteomalacia associated with aluminum overload generally resolves after transplantation, bone complications due to dialysis amyloidosis and diabetes mellitus type 1 often fail to improve. Alternatively, skeletal abnormalities can be acquired after transplantation. Most of the new derangements of bone and mineral metabolism are due to the immunosuppressive medications. Toxic effects of glucocorticoids on bone contribute to the pathogenesis of osteonecrosis, increase the risk for fractures by decreasing cancellous bone mass and synthesis of bone matrix, and dampen the linear growth response in pediatric recipients. Whether cyclosporine independently causes appreciable toxic effects on bone metabolism is not yet clear, but use of this drug increases the prevalence of gout and dental problems. Osteonecrosis, osteopenia, and short stature remain important skeletal complications in recipients of renal allografts. Therapeutic efforts should be directed toward alleviating pretransplant bone disease and attenuating bone loss after transplantation.