Nonimmunologic Complications After Kidney Transplantation
Differential diagnosis for post-transplant allograft dysfunction depends on many factors; importantly, the timing after transplantation (please see Table 30-1).
For allograft dysfunction in the early perioperative period, urologic and vascular surgical complications should be investigated and the possibility of rejection considered; other common etiologies include hypovolemia, hyperglycemia, drug toxicity (commonly calcineurin inhibitor [CNI] toxicity), and infection.
Acute rejection, recurrent disease, chronic allograft nephropathy, CNI toxicity, BK virus nephropathy (BKVN), and transplant renal artery stenosis are transplant-specific causes of renal dysfunction. However, it is important to recognize that renal failure can also ensue from all causes affecting nontransplant patients.
TABLE 30-1 DIFFERENTIAL DIAGNOSIS OF RENAL ALLOGRAFT DYSFUNCTION
Postoperative complications range between 5% and 10% (please see Table 30-2)
Arterial surgical complications include bleeding, renal artery thrombosis, and renal artery stenosis
Venous surgical complications include bleeding and renal vein thrombosis
Ureteral surgical complications include urinary leak and ureteral obstruction
Other complications are lymphocele, seromas, and infections
A wide spectrum of potential pathogens infects immunocompromised hosts; many are infrequent pathogens in normal individuals.
Fever and physical signs of infection (e.g., erythema) are often diminished.
Risk factors for infections include:
Prior therapies (chemotherapy or antimicrobials)
Immunosuppressive therapy: type, temporal sequence, and intensity
Mucocutaneous barrier integrity (catheters, lines, drains)
Neutropenia, lymphopenia, hypogammaglobulinemia (often drug induced)
Technical complications (graft injury, fluid collections, wounds)
Underlying immune defects (e.g., genetic polymorphisms, autoimmune disease)
Metabolic conditions: uremia, malnutrition, diabetes, alcoholism, cirrhosis, advanced age
Viral infection (e.g., herpesviruses, hepatitides B and C, HIV, respiratory syncytial virus [RSV], influenza)
It is the human herpesvirus 5 (HHV-5).
Seroprevalence of CMV is around 60% in the general population and it varies according to the age and race.1
Transmission is through blood, sexual intercourse, and transplanted organs.
Active infection in kidney transplant recipients is 30% to 70% without prophylaxis at 1 month from transplant with the highest rate in patients with donor CMV IgG positive into recipient CMV IgG negative.2
CMV infection leads to increased morbidity, mortality, and allograft failure.
Risk factors for CMV infection:
Highest risk: CMV donor positive into recipient-negative serostatus
Lack of CMV prophylaxis
CMV infection is uncommon in CMV negative into recipient-negative serostatus.
Often considered as a disease of overimmunosuppression.
TABLE 30-2 SURGICAL COMPLICATIONS AFTER TRANSPLANTATION: CAUSES, SYMPTOMS, AND MANAGEMENT