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.
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