Nonimmunologic complications of kidney transplantation

Abstract

•Lymphoceles may be more common in patients treated with target of rapamycin (TOR) inhibitors •Urine leaks (1% to 3% incidence)•Ureteral obstruction (strictures, ureteral rejection, BK polyoma infection) •Bleeding•Thrombosis (1% to 2% incidence)•Mycotic aneurysms•Late arterial stenosis •Caused by surgery or trauma 1.Valente JF, Schulak JA: Surgical considerations in kidney transplantation, in Hricik DE (ed): Kidney Transplantation: State of the Art. London, UK, Remedica Publishing, 2003, pp 79–962.Langer RM, Kahan BD: Incidence, therapy, and consequences of lymphocele after sirolimus-cyclosporine-prednisone immunosuppression in renal transplant recipients. Transplantation 74:804–808, 2002 •Most common cause of mortality (40% to 50%) after kidney transplantation •Hypertension (≥60% prevalence)•Hyperlipidemia (≥60% prevalence, severity influenced by type of immunosuppression)•Diabetes mellitus/glucose intolerance ▪Worsening glycemic control in previous diabetics▪New-onset diabetes mellitus in 10% of patients (with wide variations depending on risk factors: advanced age, African-American or Hispanic ethnicity, type of immunosuppression)•Smoking•Obesity •Anemia•Role of impaired renal function•Proteinuria•Hyperhomocysteinemia 1.Kasiske BL: Epidemiology of cardiovascular disease after kidney transplantation. Transplantation 72:S5-S8, 2001 (suppl 6)2.Woodward RS, Schnitzler MA, Baty J, et al: Incidence and cost of new onset diabetes mellitus among U.S. waitlisted and transplanted renal allograft recipients. Am J Transplant 3:590–598, 20033.Meier-Kriesch HU, Arndorfer JA, Kaplan B: The impact of body mass index on renal transplant outcomes: A significant independent risk factor for graft failure and patient death. Transplantation 73:70–74, 20024.Djamali A, Becker YT, Simmons WD, Johnson CA, Premasathian N, Becker BN: Increasing hematocrit reduces early posttransplant cardiovascular risk in diabetic transplant recipients. Transplantation 76:816–820, 20035.Meier-Kriesch HU, Baliga R, Kaplan B: Decreased renal function is a strong risk factor for cardiovascular death after renal transplantation. Transplantation 75:1291–1295, 2003 •Herpes viruses: ▪Cytomegalovirus ○Prophylaxis and treatment regimens▪Herpes simplex ○Herpes zoster•Hepatitis B and C•Emerging viruses: ▪BK polyoma, Parvovirus, West Nile virus •Prophylaxis and treatment regimens 1.Rubin R: Temporal aspects of transplant infectious disease. Transpl Infect Dis 5:63–64, 20032.Fishman J: Prevention of CMV in transplant patients. Transpl Infect Dis 1:35–39, 1999 (suppl 1)3.Myonakis E, Goes N, Rubin RH, Cosimi AB, Colvin RB, Fishman J: BK virus in solid organ transplantation: An emerging syndrome. Transplantation 72:1587–1592, 20014.Fishman J, Rubin RH, Koziel MJ, Periera BJ: Hepatitis C virus and organ transplantation. Transplantation 62:147–154, 1996 •Incidence varies widely from center to center•Immune and nonimmune mechanisms •Immune causes (cellular versus humoral acute rejection)•Nonimmune causes: ▪Prerenal azotemia▪Calcineurin inhibitor nephrotoxicity▪Obstructive uropathy▪Hemolytic uremic syndrome (secondary to calcineurin inhibitors)▪Vascular obstruction •Chronic allograft nephropathy ▪Immune mechanisms (role of humoral immunity and indirect allopeptide recognition)▪Nonimmune mechanisms (drug nephrotoxicity, effects of hypertension and hyperlipidemia, ischemia-reperfusion injury, viral infection)•Recurrence of native kidney disease•De novo kidney disease (eg, membranous nephropathy, diabetic nephropathy) 1.Burdmann EA, Andoh TF, Yu L, Bennett WM: Cyclosporine nephrotoxicity. Semin Nephrol 23:465–476, 20032.Waaga AM, Gasser M, Laskowski I, Tilney NL: Mechanisms of chronic rejection. Curr Opin Immunol 12:517–521, 20003.Ramos EL, Tisher CC: Recurrent diseases in the kidney transplant. Am J Kidney Dis 24:142–154, 1994 Neoplastic disorders occurring with higher frequency than in the general population •Role of Epstein-Barr virus •Increased incidence with time posttransplantation•Relatively high ratio of squamous to basal cell carcinoma •Cervical and vulvar carcinoma•Kaposi’s sarcoma Influence of Immunosuppressive Drugs on the Metastatic Potential of Solid Tumors 1.Penn I: Cancers in renal transplant recipients. Adv Ren Replace Ther 7:147–156, 20002.Dampanich E, Kasiske BL: Risk factors for cancer in renal transplant recipients. Transplantation 68:1859–1864, 1999 •High fracture incidence after transplantation ▪Underlying renal osteodystrophy▪Persistent hyperparathyroidism▪Hypogonadism▪Drug-induced osteopenia (corticosteroids, calcineurin inhibitors) Aseptic Necrosis 1.Shane E, Epstein S: Transplantation osteoporosis. Transplant Rev 15:11–32, 2001 •Pharmacokinetic or pharmacodynamic •Antiproliferative agents •Cushingoid features with corticosteroids, hirsutism and gingival hyperplasia with cyclosporine, alopecia with tacrolimus and antiproliferative agents •Corticosteroid-induced acne and ecchymoses •Corticosteroids, antiproliferative agents •Hyperkalemia, hypomagnesemia associated with calcineurin inhibitors; sodium retention associated with corticosteroids and calcineurin inhibitors •Calcineurin inhibitors 1.Danovitch GM: Immunosuppressive medications and protocols for kidney transplantation, in Danovitch GM (ed): Handbook of Kidney Transplantation. (ed 3). Philadelphia, PA, Lippincott Williams & Wilkins, 2001, pp 62–110