117 Renal Transplant Complications
Key Points• Renal transplantation is highly successful. With appropriate immunosuppressive therapy, the rate of acute rejection during the first posttransplant year is less than 25%; 1-year survival rates approach 100%.
• Surgical complications that may be seen in the emergency department include hematoma formation, ureteral anastomotic leak, and ureteral obstruction. Computed tomography is the diagnostic imaging modality of choice for these surgical emergencies.
• Surgical infections that are common in the first posttransplant month include pneumonia, line sepsis, and wound infection. Opportunistic infections reach their peak incidence during the remainder of the first posttransplant year. After the first year, community-acquired infections predominate.
• Renal transplant patients have a high risk for atherosclerotic disease. Cardiovascular conditions account for 30% to 50% of deaths during the first posttransplant year.
• Fluoroquinolones and macrolides may increase levels of cyclosporine and tacrolimus; these antibiotic classes should not be used as first-line agents for the treatment of patients with posttransplant pneumonia.
• Fever and tenderness over the graft site may indicate acute rejection.
• Transplant recipients treated with corticosteroid therapy have functional adrenal insufficiency and require pulse doses of corticosteroids when they encounter physiologic stress.
Epidemiology
The kidney is the most commonly transplanted solid organ. According to the U.S. Organ Procurement and Transplantation Network, more than 298,260 kidney transplants have been performed to date.1 It is important that providers have a general understanding of the expected surgical and medical complications commonly observed in posttransplant patients.
Developments in Renal TransplantationS
Specific disease entities that causing chronic kidney disease are outlined in Box 117.1. Diabetic nephropathy is the most common single disease process leading to renal transplantation.1
Most renal grafts now function for longer than 10 years. The 1-year survival rate of renal transplant recipients is 95% to 98%. Renal transplants are more effective than hemodialysis at prolonging the life of patients with chronic kidney disease.2
Immunosuppression is initiated after transplantation and is divided into two phases: induction and maintenance.3 Agents such as tacrolimus and monoclonal and polyclonal antibodies are often included in the induction and maintenance phases of treatment (Box 117.2). With the use of immunosuppressive medications, the 1-year incidence of acute rejection is 15% to 25%.
Complications
Surgical Complications
Graft function may be delayed in up to 30% of cadaveric transplants, probably as a result of prolonged cold ischemia of the kidney during the period between harvesting and transplantation.4 Delayed graft function is a rare complication with living donor transplants. Patients may require continued dialysis until adequate posttransplant function is demonstrated.
Acute thrombosis of the arterial or venous anastomoses is usually seen within the first posttransplant week.3,4 Treatment is surgical exploration in an attempt to salvage the donor kidney.
Hematomas may develop around the transplanted kidney. Hematoma formation may be an early postoperative complication or rarely may result from acute rejection with spontaneous rupture of the kidney.4 Acute hematomas are surgical emergencies.
Medical Complications
Fever
Management of fever in posttransplant patients should be approached similar to that of fever in other immunocompromised patients.5 Because of suppressed immunologic and inflammatory responses, posttransplant patients may not exhibit the common findings of acute infection. Fever may or may not be associated with clinically significant infection.
