Renal Transplantation

Graft Dysfunction

Causes of early renal allograft dysfunction include rejection, vascular complications such as renal arterial or venous thrombosis, urinary tract obstruction, urine leak secondary to ureteral necrosis/anastomotic disruption, and acute tubular necrosis (Table 17.2). The spectrum of graft dysfunction may range from frank anuria (< 50cc of urine/day) to oliguria (< 500cc/day), to moderate dysfunction manifested through sluggish fall in serum creatinine. It is essential to make the correct diagnosis of in cases of posttransplant graft dysfunction, since the management of each complication is very different. Vascular complications such as

Table 17.1. Early complications of organ transplantation (adapted from references)

Transplant Surgical/Mechanical

Medical

Renal Lymphocele

Urine leak Renal artery stenosis Vascular thrombosis Bleeding Drug toxicity Infection Recurrent disease Liver Hepatic artery/portal vein thrombosis

Biliary obstruction/leak Vena cava obstruction Liver infarction Bleeding

Pancreas Vascular thrombosis

Bleeding (GI vs. bladder) Pancreatic leak Peripancreatic abscess Heart Primary nonfunction

Arrhythmias Poor function Bleeding Infection Hypotension

Pulmonary artery hypertension Lung Pulmonary venous obstruction

Dehiscence of airway anastomosis

Bronchomalacia

Phrenic nerve injury

Bleeding

Pleural effusion

Acute rejection Ureteral obstruction Delayed graft function/ATN CsA/FK506 nephrotoxicity Prerenal/hypovolemia

Acute rejection Preservation injury Recurrent disease Infection (cholangitis) Drug toxicity Rejection Pancreatitis Infection

Bleeding (GI vs. bladder)

Rejection

Infection

Poor function

Reperfusion injury Acute rejection Infection

Pulmonary embolism renal arterial or venous thrombosis require immediate surgical intervention. Hyperacute rejection of an allograft is a very rare event that invariably leads to loss of the organ immediately posttransplant; confirmation of blood group compatibility and proper crossmatching should be performed if suspected. Acute rejection can occur in the first week after transplant and should always be considered in the evaluation of early graft dysfunction; allograft biopsy is an important diagnostic tool that should be used if the diagnosis is unclear. The reader is referred to Chapters 2 and 6 for management of allograft rejection.

Urinary tract obstruction leading to oliguria or anuria in the immediate posttransplant period is commonly caused by clot obstruction of the bladder catheter. Catheter irrigation and/or replacement should be performed to ensure patency. Obstruction may also be caused through external compression by a lymphocele or by development of a stricture at the ureteroneocystostomy. Lymphoceles represent fluid collections which form as a consequence of the retroperitoneal vascular dissection performed during the transplant procedure.

Table 17.2. Differential diagnosis of acute renal allograft dysfunction in the immediate posttransplant period
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