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Early postoperative complications include the following:

  1. Delayed graft function (DGF): DGF is rare with living donor grafts, probably because of the short cold ischemia time (CIT is the time between perfusion of the graft with ice-cold preservative solution and reperfusion with blood in the recipient.
  2. For cadaver kidneys, CIT remains the best predictor of DGF).
  3. Vascular-related and ureter-related complications:
    1. Renal artery thrombosis occurs in about 1% of transplants.
      1. Nephrectomy is generally indicated.
    2. Arterial stenosis occurs in 2-10% of cases, and is associated with the abrupt onset of hypertension.
      1. It can be suspected on the basis of Doppler ultrasound; confirmation generally requires angiography. Management of arterial stenosis is angioplasty and stent-placement.
    3. Venous thrombosis occurs in 0.5%-4% of cases.
      1. Thrombosis of the main renal vein has in rare instances been successfully treated with thrombolytic agents, though nephrectomy is generally required.
  4. Ureteral obstruction is the most common urinary tract problem associated with transplantation.
    1. Early obstruction may result from distal obstruction, clot, edema, or technical problems associated with the ureteroneocystostomy.
    2. When Foley catheter placement and expectant management does not resolve the problem, surgical revision of the ureteroneocystostomy over a stent may be required.
    3. Late obstruction, when not caused by external compression (lymphocele, pregnancy, etc.), is most typically associated with fibrosis. Q
    4. Management is typically by radiologic or cystoscopic stent placement and stricture dilatation.
      1. Urine leak can be suspected when a patient with good or improving graft function develops a fluid leak from the wound or abdominal pain or perineal swelling.
      2. Nuclear renal scan is probably the most sensitive test for urine leak.
      3. Small bladder leaks can often be managed by bladder decompression with a foley catheter.
      4. Larger leaks typically require exploration and repair.
      5. Lymphocele Leakage from perivascular lymphatic vessels can lead to significant collections of lymph between the lower pole of the transplanted kidney and the bladder.
      6. Sclerotherapy with 10% povidone-iodine solution may be successful in small unloculated collections but has a high rate of recurrence.
      7. The current standard of care is internal drainage of the lymphocele into the abdominal cavity.
      8. This is increasingly being done laparoscopically. 
  5. Infections Allograft regection
    1. Hyper acute: An irreversible process that occurs immediately after renal revascularization and mediated by pre formed circulating antibodies.  
    2. Accelerated rejection: It is mediated by humoral and cellular components, occurs within days and weeks and usually does not respond to antirejection treatment. Q
    3. Acute rejection:
    4. In the first year following transplantation, acute rejection is observed in approximately 25% of patients.
    5. Rejection usually is asymptomatic, or associatd with fever, increased BP, decreased output and pain at the graft site. Rejection usually presents as an unexplained rise in serum creatinine and can be confirmed with biopsy. Q
    6. Typical biopsy findings of acute cellular rejection include a lymphoplasmacytic infiltration of the renal interstitial areas with occasional penetration of the tubular epithelial by these cells.
    7. Renal scan shows increased graft size and decreased renal blood flow, GFR and tubular function.
    8. Most rejection episodes can be treated successfully with a short course of increased steroids or antilymphocyte antibody agents in some cases.
    9. Chronic rejection is most common cause of graft failure and appears to have both immunologic and nonimmunologic components and characterized by gradual decline in renal function.
    10. As a broad classification for progressive graft failure, risk factors include initial poor function of the graft and a history of acute rejection episodes.
Extra Edge: About Renal Transplantation
  1. First autologous renal transplantation was performed by 'Hardy' in 1963
    In 1963, Hardy performed the first renal autotransplantation to resolve on extensive ureteral lesion'.
    1. Most of the organs used for transplantation are obtained from brainstem-dead, heart-beating deceased donors and in the majority of cases multiple organs are procured.
    2. In India, for organ harvesting from brain dead patients, the relatives are formally asked to sign a prescribed form, in contrast to U.K., where the transplant coordinators and nurse just write and sign in the file about the consent given.
    3. After removal from the donor, the kidney is flushed with chilled organ preservation solution and, if necessary, stored briefly on ice until transplanted into the recipient.
    4. Calcineurin blockers are especially useful in renal transplant patients. These include cyclosporine and tacrolimus,
  3. PTLD
    1. PTLD is an abnormal proliferation of B lymphocytes, usually in response to Epstein-Barr virus infection.
    2. PTLD occurs in around 1-3% of kidney and liver transplant recipients and the incidence is considerably higher in children.
    3. Patients at most risk are those who have received aggressive immunosuppression. PTLD is a serious condition with a mortality rate of up to 50%.
    4. If it is identified at an early stage, reduction or cessation of immunosuppressive therapy may cause disease regression and result in a cure.
    5. Chemotherapy is often given and anti-viral therapy, surgery and radiotherapy may also have a role in treating established disease.
  4. Pre Surgery Requirement
    1. Before the donation it is essential to perform imaging (usually MR angiography or CT angiography) to delineate the anatomy of the arterial supply to the kidneys.
    2. If the left kidney has a single renal artery (10% of kidneys have two or more renal arteries) it is usually chosen for transplantation because it has a longer renal vein, which simplifies the transplant operation.
    3. The presence of multiple arteries does not necessarily preclude donation although implantation of living donor kidneys with multiple arteries may increase the chances of vascular complications developing after implantation.
  5. Immunosuppressive drug regimen in renal transplantation
    Combination of glucocorticoid with cyclosporine or tacrolimus, azathioprine or mycophenolate mofetil and sometimes antilymphocyte antibody preparation.

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