Complication Of Kidney Transplantation Research Articles

Delayed Graft Function in Kidney Transplant: Risk Factors, Consequences and Prevention Strategies.

Background. Delayed graft function is a frequent complication of kidney transplantation that requires dialysis in the first week posttransplant. Materials and Methods. We searched for the most relevant articles in the National Institutes of Health library of medicine, as well as in transplantation, pharmacologic, and nephrological journals. Results. The main factors that may influence the development of delayed graft function (DGF) are ischemia–reperfusion injury, the source and the quality of the donated kidney, and the clinical management of the recipient. The pathophysiology of ischemia–reperfusion injury is complex and involves kidney hypoxia related to the duration of warm and cold ischemia, as well as the harmful effects of blood reperfusion on tubular epithelial cells and endothelial cells. Ischemia–reperfusion injury is more frequent and severe in kidneys from deceased donors than in those from living donors. Of great importance is the quality and function of the donated kidney. Kidneys from living donors and those with normal function can provide better results. In the peri-operative management of the recipient, great attention should be paid to hemodynamic stability and blood pressure; nephrotoxic medicaments should be avoided. Over time, patients with DGF may present lower graft function and survival compared to transplant recipients without DGF. Maladaptation repair, mitochondrial dysfunction, and acute rejection may explain the worse long-term outcome in patients with DGF. Many different strategies meant to prevent DGF have been evaluated, but only prolonged perfusion of dopamine and hypothermic machine perfusion have proven to be of some benefit. Whenever possible, a preemptive transplant from living donor should be preferred.

Pediatric kidney transplant recipients with and without underlying structural kidney disease have a comparable risk of hospitalization associated with urinary tract infections

IntroductionUrinary tract infections (UTIs) are a common and potentially serious kidney transplant complication. Pediatric kidney transplants are potentially at increased risk for UTIs when structural kidney disease is the underlying end-stage kidney disease (ESKD) etiology. The objective of this manuscript is to determine if children with structural kidney disorders are more prone to UTIs post kidney transplant.Materials and methodsHospitalizations for pediatric kidney transplant recipients were retrospectively reviewed over a 4-year period for UTIs in the diagnostic codes. The patient’s age, sex, graft age, underlying diagnosis for cause of ESKD, symptoms at presentation, urinalysis results, and urine culture results were recorded. UTI rates, febrile UTI rates, and UTI rates in the 1st year post-transplant were compared between children with ESKD due to structural vs. non-structural kidney disease.ResultsOverall, 62 of 145 pediatric patients with kidney transplants accounted for 182 hospitalizations for kidney transplant complications over the 4-year study period. UTIs were components of 34% of the hospitalizations. Overall, UTI rates, febrile UTI rates, and UTI rates for the 1st year post kidney transplant were comparable for children with vs. without structural ESKD etiologies.ConclusionUrinary tract infections are frequent components of hospitalizations for pediatric kidney transplant recipients. Children with and without structural kidney disease as an ESKD etiology have similar UTI rates indicating that UTI susceptibility is primarily due to the transplant process and/or medication regimens. UTIs represent a potentially modifiable risk factor for pediatric kidney transplant complications.

Risk Factors for Urologic Complications After Kidney Transplantation and Impact in Graft Survival.

Background and PurposeKidney transplantation (KT) is the best therapy for chronic kidney disease (CKD). Major urologic complications (MUCs) are the second etiology associated to morbidity and graft loss following KT, after rejection episodes. The objective of this study was to estimate the incidence, risk factors and impact on graft survival associated to urological complications in KT patients.Patients and MethodsA retrospective cohort based on electronic patient files of kidney transplant recipients from Colombiana de Trasplantes was created for the period August 2008 to September 2019. Initiation of follow-up was defined as the date of transplantation up to 3 years post-transplantation. Incidence of ureteral stenosis, ureteral obstruction, and ureteral leak was measured. A logistic regression multivariate model was adjusted to determine the associated factors to MUCs (yes/no). Patient and graft survival time were analyzed using a Kaplan-Meier method.ResultsA total of 1584 KT patients were included in the cohort. MUCs were present in 195 (12.6%) KT patients. We found that dialysis duration (OR: 1.004; p = 0.02) remained significant for the incidence of MUCs in KT patients of deceased donors. Probability of graft and patient survival at 3 years of follow-up was 90.5% and 85.5%, respectively. No significant difference was found on graft and patient survival in KT patients with or without MUCs.ConclusionMUCs are frequent complications for KT. We did not observe significant differences in graft or patient survival according to the presence of MUCs. The identification of MUCs and risk factors may guide transplant teams for future surgical and clinical decisions.

Long-Term Complications of Kidney Transplantation

Long-Term Complications of Kidney Transplantation

Cardiovascular Risk after Kidney Transplantation: Causes and Current Approaches to a Relevant Burden.

Background. Cardiovascular disease is a frequent complication after kidney transplantation and represents the leading cause of mortality in this population. Material and Methods. We searched for the relevant articles in the National Institutes of Health library of medicine, transplant, cardiologic and nephrological journals. Results. The pathogenesis of cardiovascular disease in kidney transplant is multifactorial. Apart from non-modifiable risk factors, such as age, gender, genetic predisposition and ethnicity, several traditional and non-traditional modifiable risk factors contribute to its development. Traditional factors, such as diabetes, hypertension and dyslipidemia, may be present before and may worsen after transplantation. Immunosuppressants and impaired graft function may strongly influence the exacerbation of these comorbidities. However, in the last years, several studies showed that many other cardiovascular risk factors may be involved in kidney transplantation, including hyperuricemia, inflammation, low klotho and elevated Fibroblast Growth Factor 23 levels, deficient levels of vitamin D, vascular calcifications, anemia and poor physical activity and quality of life. Conclusions. The timely and effective treatment of time-honored and recently discovered modifiable risk factors represent the basis of the prevention of cardiovascular complications in kidney transplantation. Reduction of cardiovascular risk can improve the life expectancy, the quality of life and the allograft function and survival.

Early Postoperative Kidney Transplant Complications Related to Immunomodulator Regimen in Pediatric Recipients.

Calcineurin inhibitors (cyclosporine and tacrolimus) are widely used in kidney transplant to prevent acute transplantrejection; however,the effects of these medications on graft sequelae after transplant remain unclear. We aimed to compare early complications, including graftrejectionandinfectionrates after kidney transplant, in childrenbetween the cyclosporine and tacrolimus immunomodulator regimens. In this prospective cohort study, 105 pediatric patients who were candidates to receive kidney transplant in the age range of 4 to 18 years were included. There were 28 patients who received cyclosporine, and 77 patients who received tacrolimus. Participants were routinely tested for cytomegalovirus, BK virus, and bacterial infection on a monthly basis for the first 3 months and once every 3 months thereafter for the first year. The graft rejection rate was also assessed and compared between the 2 treatment regimens. There were no significant differences between the 2 groups receiving cyclosporine or tacrolimus in graft rejection rate (P = .719), cytomegalovirus viremia (P = .112), BK viremia (P = .278), and bacterial infection (P = .897). Graftfailure was significantly more frequent in male than in female patients (30.9% vs 8.2%; P = .004). The rates of graft failure in study patients with and without previous history of graftfailure were found to be statistically similar (16.7% vs 20.4%; P = .825). History of infection in donors did not affect the graft complications posttransplant in recipients. The use of either tacrolimus or cyclosporine leads to similar consequences in terms of graft rejection or posttransplant viral and bacterial infection, so either drug may be exchanged for the other if needed for tolerability.

Transplant Renal Artery Stenosis in Living Donor Kidney Transplant Recipients: A Single Center Experience from Nepal

Introduction: Transplant renal artery stenosis (TRAS) is the most common preventable vascular complication in kidney transplantation with significant rates of graft loss and mortality. We aimed to study the demographics, prevalence, clinical presentation, and outcome of TRAS. Methods: We retrospectively reviewed medical records of all living donor kidney transplant recipients at Tribhuvan University Teaching Hospital from August 2008 to May 2021. Cases diagnosed with TRAS by ultrasound Doppler and/or renal CT angiogram were included. Data on demographics, clinical presentation, management, and outcomes were collected and analyzed. Among patients who underwent revascularization, pre and post-procedure creatinine, blood pressure (BP), and antihypertensive medicine burden were compared. Results: Among 620 living donor kidney transplantation, TRAS was present in 17 recipients (Male:Female = 16:1) (2.6%); mean age was 35.47±12.71 years. The median duration at diagnosis was one- month post-transplant (range: 5 days-9 months). The most common clinical features of TRAS were graft dysfunction and uncontrolled hypertension. Diagnosis of TRAS was confirmed with CT angiography in 13 patients. Ten patients underwent revascularization. Pre and post-revascularization mean serum creatinine was 356±210.49 μmol/L and 122.8±30.48 μmol/L (p=0.007) respectively, mean systolic BP was 200±12.47 mmHg and 133±13.38 mmHg (p=0.005) respectively and mean diastolic BP was 105±15.09 mmHg and 80±9.43 mmHg(p=0.005) respectively. Significant reduction in anti- hypertensive pill burden was achieved. Conclusion: Prevalence of TRAS was 2.6%. Most cases presented early with hypertension and graft dysfunction. Revascularization of significant stenosis had a favorable outcome in terms of BP control, antihypertensive pill burden, and preservation of renal function.

Delayed Graft Function Under the Microscope: Surveillance Biopsies in Kidney Transplantation.

Delayed graft function (DGF) is a common complication of kidney transplantation and frequently leads to the necessity of surveillance biopsies. The purpose of this study is to describe the histological findings in surveillance biopsies of deceased donor kidney transplant recipients and evaluate the risk factors for graft outcomes. This is a monocentric, retrospective study including kidney transplant recipients that underwent a graft biopsy during the DGF period between January 2006 and July 2019. 356 biopsies were performed in 335 deceased donor transplant recipients. Biopsies were analyzed according to the Banff classification. The main histological findings were: acute tubular necrosis in 150 biopsies (42.1%), acute rejection in 96 biopsies (26.9%), and borderline findings in 91 biopsies (25.5%). In the multivariate analysis, recipient age (p = 0.028) and DGF duration (p = 0.005) were associated with rejection, antibody-induction with anti-thymocyte globulin (ATG) was protective (p = 0.001). The occurrence of rejection was associated with lower death-censored graft survival (log-rank; p = 0.009). Surveillance biopsies of kidney grafts experiencing DGF remain an essential tool for the care of kidney transplant recipients. The recipient's age and duration of DGF are independent risk factors for acute rejection, while antibody-induction therapy with ATG is associated with protection from its occurrence.

Mammalian Target of Rapamycin Inhibitors and Wound Healing Complications in Kidney Transplantation: Old Myths and New Realities.

Mammalian target of rapamycin inhibitors (mTOR-I) lacks nephrotoxicity, has antineoplastic effects, and reduces viral infections in kidney transplant recipients. Earlier studies reported a significant incidence of wound healing complications and lymphocele. This resulted in the uncomfortable willingness of transplant clinicians to use these agents in the immediate posttransplant period. As evidence and experience evolved over time, much useful information became available about the optimal use of these agents. Understandably, mTOR-I effects wound healing through their antiproliferative properties. However, there are a lot of other immunological and nonimmunological factors which can also contribute to wound healing complications. These risk factors include obesity, uremia, increasing age, diabetes, smoking, alcoholism, and protein-energy malnutrition. Except for age, the rest of all these risk factors are modifiable. At the same time, mycophenolic acid derivatives, steroids, and antithymocyte globulin (ATG) have also been implicated in wound healing complications. A lot has been learnt about the optimal dose of mTOR-I and their trough levels, its combinations with other immunosuppressive medications, and patients' profile, enabling clinicians to use these agents appropriately for maximum benefits. Recent randomized control trials have further increased the confidence of clinicians to use these agents in immediate posttransplant periods.

A Novel Method for Urinary Tract Reconstruction in Transplanted Embryonic Kidneys Using the Hybrid Stent: A Pig Study.

A Novel Method for Urinary Tract Reconstruction in Transplanted Embryonic Kidneys Using the Hybrid Stent: A Pig Study.

Long-term clinical outcomes of patients with nonsignificant transplanted renal artery stenosis

BackgroundTransplant renal artery stenosis (TRAS) is the main vascular complication of kidney transplantation. For research and treatment purposes, several authors consider critical renal artery stenosis to be greater than 50%, and percutaneous intervention is indicated in this scenario. However, there are no reports in the current literature on the evolution of patients with less than 50% stenosis.MethodThis retrospective study included data from all patients who underwent kidney transplantation and were suspected of having TRAS after transplantation with stenosis under 50% independent of age and were referred for angiography at a single centre between January 2007 and December 2014.ResultsDuring this period, 6,829 kidney transplants were performed at Hospital do Rim, 313 of whom had a clinical suspicion of TRAS, and 54 of whom presented no significant stenosis. The average age was 35.93 years old, the predominant sex was male, and most individuals (94.4%) underwent dialysis before transplantation. In most cases in this group, transplants occurred from a deceased donor (66.7%). The time between transplantation and angiography was less than one year in 79.6% of patients, and all presented nonsignificant TRAS. Creatinine levels, systolic blood pressure, diastolic blood pressure and glomerular filtration rate improved over the long term. The outcomes found were death and allograft loss.ConclusionAge, sex and ethnic group of patients were factors that did not interfere with the frequency of renal artery stenosis. The outcomes showed that in the long term, most patients evolve well and have improved quality of life and kidney function, although there are cases of death and kidney loss.

Histologic acute graft pyelonephritis after kidney transplantation: Incidence, clinical characteristics, risk factors, and association with graft loss.

Histologic acute graft pyelonephritis (HAGPN) after kidney transplantation (KT) has been assessed less frequently than urinary tract infections (UTIs) or clinical acute graft pyelonephritis. Risk factors for HAGPN, its association with graft loss, and measures that might prevent it are not known. We performed a retrospective review of HAGPN cases identified from KT occurring between January 2008 and December 2017 at our institution. We compared the HAGPN cases to a randomly selected control group of KTs to identify risk factors using univariate and multivariate Cox regression models. The association between HAGPN and graft loss was also assessed, similarly. HAGPN was identified in 46 of 1391 patients (cumulative incidence, 5% [95% CI, 3%-7%]) undergoing KT at a single center from January 2008 through December 2017 (median time to diagnosis, 241days after KT; interquartile range, 122-755 days). Indications for biopsy were follow-up of treated rejection (n=20 [43%]), KT protocol biopsy (n=19 [41%]), and acute kidney injury (n=7 [15%]). Histologic rejection, UTI, and asymptomatic bacteriuria (ASB) were present in 23 (50%), 9 (20%), and 16 (35%). Multivariate Cox proportional hazards models comparing KT recipients with or without HAGPN (n=46 and n=138, respectively) showed that HAGPN was associated with urologic complication by day 30, delayed graft function, previous UTI or ASB, and a history of rejection. In the univariate and multivariate analyses, HAGPN was associated with an increased risk of graft loss. HAGPN is an infrequent, unanticipated, and clinically significant complication of KT.

The kidney transplant rate is outpaced bytherate of readmission for complications.

Hospital readmissions experienced by kidney transplant recipients may be secondary to a range of conditions, including infections and rejection episodes. The objective was to identify trends in patients with kidney transplant complications, in regard to hospital discharges, ED visits, and charges over the years available from 1993to2015. Using the Healthcare Cost and Utilization Project database, trends were identified in hospitalizations, emergency department visits, and charges from 1993 to 2015 for complications following kidney transplantation. Hospital discharges have significantly increased over time and at a faster rate than the increase in number of kidney transplants performed, while emergency department visits numbers and rates remain unchanged. The type of kidney transplant complications experienced were analyzed by incidence and proportion of total charges. Rejection made up the largest proportion of hospitalizations and of total cost in patients suffering from kidney transplant complications. Improved immunosuppression regimens have resulted in longer allograft survival. We speculate that the overlap between infection and rejection is compounding and contributing to graft injury and thus, it is important to try to prevent and/or properly identify those episodes as well in order to improve graft survival.

A1100 - Outcomes and complications in kidney transplantation from Donors after Circulatory Death (DCD): Differences between type II-uncontrolled and type III-controlled DCD

A1100 - Outcomes and complications in kidney transplantation from Donors after Circulatory Death (DCD): Differences between type II-uncontrolled and type III-controlled DCD

Long-Term Infectious Complications of Kidney Transplantation.

Infections remain a common complication of solid-organ transplantation. Most infections in the first month after transplant are typically health care-associated infections, whereas late infections, beyond 6-12 months, are community-acquired infections. Opportunistic infections most frequently present in the first 12 months post-transplant and can be modulated on prior exposures and use of prophylaxis. In this review, we summarize the current epidemiology of postkidney transplant infections with a focus on key viral (BK polyomavirus, cytomegalovirus, Epstein-Barr virus, and norovirus), bacterial (urinary tract infections and Clostridioides difficile colitis), and fungal infections. Current guidelines for safe living post-transplant are also summarized. Literature supporting prophylaxis and vaccination is also provided.

Allograft Vesicoureteral Reflux after Kidney Transplantation.

Allograft vesicoureteral reflux (VUR) is a leading urological complication of kidney transplantation. Despite the relatively high incidence, there is a lack of consensus regarding VUR risk factors, impact on renal function, and management. Dialysis vintage and atrophic bladder have been recognized as the most relevant recipient-related determinants of post-transplant VUR, whilst possible relationships with sex, age, and ureteral implantation technique remain debated. Clinical manifestations vary from an asymptomatic condition to persistent or recurrent urinary tract infections (UTIs). Voiding cystourethrography is widely accepted as the gold standard diagnostic modality, and the reflux is generally graded following the International Reflux Study Committee Scale. Long-term transplant outcomes of recipients with asymptomatic grade I-III VUR are yet to be clarified. On the contrary, available data suggest that symptomatic grade IV-V VUR may lead to progressive allograft dysfunction and premature transplant loss. Therapeutic options include watchful waiting, prolonged antibiotic suppression, sub-mucosal endoscopic injection of dextranomer/hyaluronic acid copolymer at the site of the ureteral anastomosis, and surgery. Indication for specific treatments depends on recipient’s characteristics (age, frailty, compliance with antibiotics), renal function (serum creatinine concentration < 2.5 vs. ≥ 2.5 mg/dL), severity of UTIs, and VUR grading (grade I-III vs. IV-V). Current evidence supporting surgical referral over more conservative strategies is weak. Therefore, a tailored approach should be preferred. Properly designed studies, with adequate sample size and follow-up, are warranted to clarify those unresolved issues.

Higher Viral Load of Polyomavirus Type BK but not JC among Renal Transplant Recipients in Comparison to Donors.

Background & Objective:Polyomaviruses types BK and JC and Cytomegalovirus (CMV) have been shown to be related to kidney transplantation complications. This study aimed to assess the prevalence of these viruses in patients receiving kidney transplantation. Methods:This cross-sectional study was performed on 40 kidney transplant recipients and 44 donors. Urine samples were used for the extraction of viral DNA. The prevalence of JC and BK viruses and their viral loads were determined by real-time polymerase chain reaction.Results:JC and BK viruses were identified in 31% and 92.3% of all subjects, respectively. The frequency of JC and BK cases was not statistically different between the recipient and donor groups (P>0.05). All patients in the donor group and 96.8% of the recipients were positive for CMV IgG antibody. The mean viral load of BK in donors and recipients was 4.5×1010 and 3.3×1011 copies, respectively. The mean viral load of JC was 8.6×107 copies in donors and 2.9×108 copies in recipients. The distribution of BKV was significantly higher in recipients than donors (P=0.001), while no difference was observed between the two studied groups for JCV. Conclusion:This study showed a relatively high prevalence of BK and JC viruria in both renal transplant donors and recipients. The viral load for BKV, but not JCV, was higher in recipients than in donors.

Development and Validation of Nomogram for Predicting Delayed Graft Function After Kidney Transplantation of Deceased Donor.

BackgroundDelayed graft function (DGF) is a major complication of kidney transplantation (KT), especially in patients receiving donor of decease (DD) KT. Therefore, the kidney donor pool is rare worldwide, it is critical to evaluate the risk coefficient of DGF using preoperative data of donors and recipients and provide a reference for clinical decision-making and resource allocation.Method and AnalysisA total of 238 DD recipients were performed in our center. Finally, 211 patients were included. The clinical database was divided into 34 clinical blood indicators (CBIs) and 6 demographics indexes (DIs). CBIs and DIs were screened for variables with P<0.05 and demonstrated the best cut-off value using multivariable logistics regression. The selected CBIs were passed through the least absolute shrinkage and selection operator (LASSO) to obtain the predictive factors and synthesized into a Riskscore, forming a nomogram with the selected DIs. We used receiver operating characteristic (ROC), calibration, and decision curve analysis (DCA) to verify the discrimination and clinical effects of this nomogram. Finally, 10-fold cross-validation was conducted internally to show the effect of the model.ResultsThe 34 CBIs of the database finally screened out 12 predictors, which were synthesized into Riskscore. The 6 DIs selected 3 variables. Riskscore and 3 DIswere constructed into a nomogram, and the ROC of the nomogram has an AUC value of 0.725. Calibration and DCA showed excellent verification effects on the nomogram. The 10-fold crossover internal validation also demonstrated the model’s excellent discrepancy.ConclusionThe nomogram has an excellent ability to predict DGF and provides an essential reference for decision-making and resource allocation in a clinical setting.

Value of Plasmatic Villin-1 in the prediction of early graft dysfunction in kidney transplant recipients among Egyptian population

Abstract Background One of the main complications of kidney transplantation is delayed graft function (DGF). There has been enormous growing research interest in the potential for the rapidly expanding fields of medical technology to generate new biomarkers with the aim of early prediction of DGF and modifying its therapy accordingly. Villin-1 has been detected in urine of patients with AKI. Additionally, it is redistributed during AKI from the brush borders of the proximal tubular cells toward the basolateral membrane which positions villin-1 closer to the renal vasculature and suggests that it could be released in the blood as well, so can be as a novel biomarker for DGF. Methods Of 70 patients with end-stage renal disease with one or more risk factor for developing delayed graft function attending renal transplantation preparation clinics in ASUSH, IMC and NILE Badrawi hospital in Egypt from May 2016 to July 2019, 41 patients were eligible and assigned into two groups according to the correlation with the serum creatinine levels in the first two days post-transplantation after signed informed consent for participation in our study into group 1 (DGF group) and group 2 (NGF group). We measured the presence of villin-1 by ELISA technique (quantitative) in comparison to serum creatinine levels in plasma at the time of declamping (zero level), 1st, 3rd, 5th, 7th, 12th, 24th, 48th, 72th 96th, 120th hour post declamping, also samples from normal population and chronic kidney disease stage V patients have been collected to establish reference range guide for plasmatic villin-1 in both groups. Results Statistically significant differences were noted in the comparison between both groups as regard the plasmatic villin-1 levels at the same measurement points in both groups, also plasmatic villin-1 started to rise above its reference range in the ESRD patients at the 5th hour post declamping while its peak was at the 7th hour in the DGF group’s recipients then started to decrease after that but didn’t settle down between the reference range guide during the regular follow up of its level till the 120th hour post declamping. the reference range guide was from 0.08 and 0.35 ng\ml in males and from 0.055 to 0.35 ng\ml in females in normal population while from 0.38 and 1.4 ng\ml in males and from 0.28 to 1.1 ng\ml in females in the ESRD patients. Conclusions Plasmatic villin-1 is a promising novel biomarker for detection of early graft dysfunction in kidney transplant. Due to restrictions of the study design these observations need further confirmation by prospective studies.

Kidney Transplantation in Sensitized Patients

Dreaded complication of kidney transplantation in a sensitized patient is hyper-acute rejection immediately after vascular anastomosis. Although pretransplant complement-dependent cytotoxic cross match (CDC) has been the gold standard for many years, this assay is not perfect. The Luminex-based anti-HLA antibody detection assay is more sensitive and specific. While performing live-related kidney transplantation, luminex cross match is routinely performed but in a situation like deceased donor transplantation, in view of time constraints, we do CDC cross match and go ahead with transplantation if the result is negative (Cell lysis &lt;10%). Here, we present two cases of deceased donor transplantation where CDC cross match was negative, based on this report, we went ahead with kidney transplantation but report of Luminex cross match turned out to be positive after the transplantation was already over. Both the recipients had the features of hyper acute rejection. One patient could be salvaged but the other lost the graft.