Rare Complication Of Renal Transplantation Research Articles

MO993: Incidence of Ptld and Its Relationship with Cmv-Serostatus Positivity Among Childhood and Adulthood Population: A Registry Data Study

Abstract BACKGROUND AND AIMS It is unknown how the epidemiology of post-transplant lymphoproliferative disease (PTLD) and its relationship with CMV infection differ between adult and pediatric kidney transplant recipients. In addition, with current advancements in immunosuppressive therapy, the incidence of PTLD has changed dramatically. The aim of our study is to elucidate the relationship between PTLD and CMV infection. Moerover, to assess the incidence of PTLD among Adult and pediatric renal transplant patients in the current era. METHOD All renal transplant patients registered in the Organ Procurement and Transplantation Network between 2005 and 2019 were retrospectively reviewed. Patient were followed up till December 2020. Patients who had multiple organ transplant or those with previous renal transplants were excluded from the study. Data about recipient factors (age, sex ethnicity, diabetes, CMV serostatus, and EBV serostatus), donor factors (living or deceased), transplant factors (PRA, Cold ischemia time, HLA mismatches, induction and immunosuppressive therapy) were reviewed. Incidence rate of PTLD at one year and five years post-transplant were calculated among the Adult and Pediatric population. Univariate and Multivariate cox-hazard regression models were performed to assess the relationship between CMV serostatus and occurrence of PTLD. RESULTS About 10 947 pediatric renal transplant patients were included. About 315 pediatric patients developed PTLD during the follow-up time (2.88%). About 50.55% of PTLD occurred within the first-year post-transplant. 60% occurred within two-year post-transplant, while 80.63% of them occurred within five years post-transplant. CMV recipient infection was not associated with PTLD occurrence in the pediatric population (HR = 0.88, Pvalue = 0.81, 95% confidence interval ranged between 0.66 and 1.18). Proportional hazard assumption was not violated with P = 0.55. Among the adult population, 1990/277 955 developed PTLD (0.77%). About 25.77% of PTLD among the adult population occurred within the first-year post-transplant. About 39.39% of PTLD in the adult occurred within two-year post-transplant. About 66.55% of PTLD in the adult occurred within five-years post-transplant. CMV recipient positive serostatus was associated with a protective effect against occurrence of PTLD (HR = 0.82, Pvalue <0.01, 95% confidence interval ranged between 0.73 and 0.94). The most common type of PTLD among the pediatric and adult population was monomorphic PTLD ( 40% and 34%, respectively). CONCLUSION PTLD is a rare complication of renal transplantation in the current era. The risk of development of PTLD is highest during the first-year post-transplant. CMV recipient positive serostatus has a protective effect against development of PTLD.

Renal transplantation in patients with Alport syndrome: patient selection, outcomes, and donor evaluation

Alport syndrome is an inherited disorder of basement membrane collagen IV that frequently results in end-stage renal disease. Patients with Alport syndrome who undergo renal transplantation have generally excellent outcomes. Posttransplant antiglomerular basement membrane nephritis is a rare complication of renal transplantation for Alport syndrome. Because Alport syndrome is a genetic disorder, potential related donors must be carefully evaluated in order to minimize harm.

Complication rare de la transplantation rénale : la pyélonéphrite emphysémateuse

Emphysematous pyelonephritis is a necrotizing infection of the renal parenchyma and peri-renal tissues, characterized by the presence of air within the parenchyma of the urinary tract and peri-renal space. This is a severe complication, which involves the functional prognosis of the kidney and the patient's prognosis. The emphysematous pyelonephritis is a rare complication of renal transplantation. Its gravity is linked particularly to the fragility of immunosuppressed patients. The authors report the case of an emphysematous pyelonephritis having occurred 9 months after transplantation in a patient 58 years. The evolving risks and therapeutic modalities will be outlined and discussed.

Minimally invasive treatment of renal transplant nephrolithiasis.

Urolithiasis is a rare complication of renal transplantation, and there is limited evidence to guide treatment. Management of stones in the transplanted kidney can be challenging. We present our experience in treating upper urinary tract (UUT) allograft lithiasis using minimally invasive procedures, with the aim of demonstrating their efficacy and safety in renal transplant recipients. The records of 1615 patients undergoing kidney transplantation and follow-up in our center between August 2000 and July 2014 were reviewed. The mode of presentation, donor type, onset time, immunosuppression protocol, stone character, therapeutic intervention and outcomes of those with UUT allograft lithiasis were recorded. Extracorporeal shock wave lithotripsy (SWL), flexible ureteroscopy (F-URS) and percutaneous nephrolithotomy (PCNL) were used in the management of these calculi. Stone composition was analyzed after the procedure. Nineteen renal transplant recipients (1.2 %, nine males and ten females) were found to have UUT allograft calculi. Of these, five underwent SWL (26.3 %), four had F-URS combined with lithotomy forceps extraction or holmium laser disruption (21.1 %), six had PNCL (31.6 %), one submitted to F-URS after two failed sessions of SWL (5.3 %), one combined PCNL and F-URS (5.3 %), and two spontaneously of stones (10.5 %). All patients were rendered stone-free with a combination of treatments, and none required a blood transfusion. The incidence of calculi in the transplanted kidney is low. Minimally invasive procedures are safe and effective means of removing allograft calculi.

Long-Term Outcome of Subcutaneous Pyelovesical Bypass in Extended Ureteral Stricture After Renal Transplantation

Extended ureteral stricture is a rare complication of renal transplantation. Its management remains challenging. The aim of our study was to report our 15 years of experience with subcutaneous pyelovesical bypass graft (SPBG) in selected renal transplant patients who presented with extended ureteral stricture and who were not eligible for open ureteral reconstruction. Seven patients were operated on between 1992 and 2007-six men and one woman-with a mean age at surgery of 47 years (range 30-67 y). We report no encrustation or dislodgment with a mean follow-up of 6 years (range 1-14 y). Postoperative mortality was null. During the follow-up, three patients died: Two from an extrarenal cause with a functional SPBG and a stable renal function; one from septic shock after fungic colonization of the prosthesis. Asymptomatic urinary tract infection developed in two other patients, with no renal function impairment. Despite a 47% rate of infection (3/7), SPBG can be a safe and efficient alternative to open surgery to save many years of graft function in renal transplant patients who present with extended ureteral stricture.

Chylous Ascites in a Renal Transplant Recipient Under Sirolimus (Rapamycin) Treatment

Ascites is a rare complication of renal transplantation. Ascites has been reported after kidney transplantation due to rejection, decapsulation of the graft, urinary or vascular leak, lymphocele, transudation, or infection. While technical complications of the procedure are the most frequent cause, portal hypertension and graft rejection are other causes. Ascites can occur after renal transplantation independent of kidney function. Usually, a time relation can be made between the surgical procedure and ascites development. Chylous ascites is still more uncommon; it is usually related to traumatic lymphatic injury. Drugs are rarely associated with the genesis of ascites. Sirolimus has been associated with a high rate of lymphoceles, lymphedema, and pulmonary alveolar proteinosis. The exact mechanisms remain unknown. The risk for lymphocele formation with sirolimus is 12% to 15%. Ascites is an adverse effect with an incidence between 3% and 20%, but no relation between sirolimus and chylous ascites was previously established. We present a clinical report of chylous ascites in a renal transplant patient under sirolimus therapy; our investigation pointed to sirolimus as the cause.

Regression of Kaposi's Sarcoma in Renal Graft Recipients After Conversion to Sirolimus Treatment

Kaposi's sarcoma (KS) is a rare complication of renal transplantation in Poland (in our center 2 of 1000 patients). Neovascularization (typical for KS) is promoted by KS-related vascular endothelial growth factor (t-r-VEGF). Sirolimus may reduce t-r-VEGF synthesis and inhibit PI3K-p70 S6 kinase of endothelial cells. Two men, 58 and 51 years old, were transplantated in 2002. Initial immunosuppression consisted of cyclosporine, azathioprine, and prednisone. In the second patient, at the week 8 the immunosuppression was switched to tacrolimus and mycophenolate mophetil. KS symptoms appeared on hard palate and skin in month 7 in both patients. In the first patient, the X-ray showed enlargement of mediastinal lymph nodes and diffuse interstital infiltrates with nodular changes in both lungs. Serum creatinine of the first patient was increased from 1.6 to 1.9 mg/dL, while in the second it remained stable (∼2.0 mg/dL). Since confirmation of KS immunosuppression has been minimized in both patients; all drugs except prednisone were withdrawn, and sirolimus was introduced (1–2 mg/24 hours blood level 5–8 ng/mL). Within a month the progression of lung and skin disease ceased, and patients' conditions began to improve with lung opacities regressing, the biggest skin lesions diminishing and smaller ones disappearing. Within 1 year renal function improved. Our observation suggests that sirolimus-based immunosuppression proffers the possibility of KS regression with concomitant renal function preservation among renal graft recipients. It is difficult to ascertain whether KS regression may be atributted to sirolimus treatment or to the reduced overall immunosuppression.

REGRESSION OF KAPOSI’S SARCOMA IN RENAL GRAFT RECIPIENTS AFTER CONVERSION TO SIROLIMUS TREATMENT.

P852 Kaposi’s sarcoma (KS) is a rare complication of renal transplantation in Poland (in our center it appeared in 2 out of 1000 renal graft recipients). Substantial proportion of tumor structure consists of newly developed vascular capillaries. Neovascularization is usually promoted by tumor - related vascular endothelial growth factor (t-r-VEGF). Experimental studies provided evidence, that sirolimus (Sir) treatment led to reduction in t-r-VEGF synthesis and inhibited intracellular PI3K-p70S6 kinase signalling pathway, required for VEGF stimulation of endothelial cells. The classic approach to treatment of immunocompromised KS patient is reduction of immunosuppressive therapy (IST), which carries a risk of graft rejection. Here we present clinical data, suggesting that immunosuppressive therapy including Sir, may be associated with KS regression. We report 2 patients diagnosed with KS, maintained initially on standard triple IST. The 58, and 51 year old men underwent cadaveric renal transplantation in 2002. Initial IST consisted of cyclosporine A (CsA), azathioprine (Aza), and prednisone (P). Due to acute rejection in 2-nd patient, since 8-th week after transplantation, IST was switched to tacrolimus (Tac) and mycophenolate mophetil (MMF). The onset of KS symptoms appeared 7 months after engraftment in both patients. The first patient presented with brown – blue polyp – like, and plane lesions on the hard palate. In the 12-th month rapidly growing brownish nodular sheling skin lesions, localized on the internal surface of both calves, over the ankles, were noted. Smaller lesions were spread all over the skin. The second patient presented with nearly the same skin and mucous lesions. In the 1-st patient repeated X-ray films showed increasing shadows in lungs with enlargement of mediastinal lymph nodes. It was associated with increasing respiratory insufficiecy. Bronchoalveolar lavage gave no consistent data. In the 1-st patient graft function deteriorated slightly (serum creatinine raised from 1,55 to 1,85 mg/dl), while in the 2-nd patient it remained nearly stable (creatinine ∼2,0 mg/dl). In both patients skin biopsy proved KS. Since confirmation of the diagnosis. IST had been minimized (Aza, CsA or MMF were withdrawn) and switched to sirolimus (1-2 mg/24h) with prednisone (10 mg/24h). Serum levels of sirolimus were maintained within 5-8 ng/ml range. Within one month the progression of lung and skin disease has stopped, and patients condition began to improve: regression of lung opacities, reduction of the biggest nodular skin lesions and disappearance of smaller ones were noted. In one year observation renal function remained stable. Conclusions: It is difficult to ascertain whether KS regression can be atributted to sirolimus treatment or to immunosuppression reduction. Our observation may suggest, that sirolimus based IST brings the possibility of KS regression with concomitant renal function preservation in renal graft recipients.

Brucellosis arthritis—a rare complication of renal transplantation: a case report

Brucellosis arthritis—a rare complication of renal transplantation: a case report

Caliceal fistula in kidney transplantation. The role of magnetic resonance imaging

Abstract Caliceal fistula is a rare complication of renal transplantation, which often raises some diagnostic problems. We report the case of a patient in which this complication occurred and in whom the diagnosis could be clearly demonstrated by using magnetic resonance imaging (MRI). On the T1-weighted images, a perirenal collection was depicted by a low signal intensity. On T2-weighted images, the collection appeared with a high signal intensity, and a linear hyperintensity was observed on the internal graft's labium at the level of the inferior pole corresponding to a caliceal fistula arising from the lower pole of the graft. In this setting, the use of MRI is compared with the other diagnostic techniques (sonography, CT scan, nephrogram, scintigraphy). MRI constitutes a progress in imaging of the renal graft by its high definition and the lack of nephrotoxicity. Its place remains, however, to be more precisely defined in the evaluation of a renal graft's complications.

Post renal transplant thrombotic microangiopathy: A single centre experience

SUMMARY: Thrombotic microangiopathy (TMA) is a rare complication of renal transplantation. This study is a review of our experience of seven cases of TMA occurring between 1986 and 1995, an incidence of 0.8%. One patient had a recurrence of TMA in her graft having an episode of haemolytic uraemic syndrome as the cause of her original kidney failure. the other six patients had a rejection episode either at the time of diagnosis of TMA or a mean of 12 days prior to the diagnosis of TMA. All patients were treated with plasma exchange and those on cyclosporin had their dose reduced. Two patients had graft loss while the remainder had successful outcomes with stable graft function 3–11 years post diagnosis of TMA. We conclude that, in our experience rejection played a prominent role in the disease pathogenesis and that cyclosporin could be continued successfully albeit at a reduced dosage.

Total ureteral replacement by subcutaneous pyelovesical bypass in ureteral necrosis after renal transplantation

Abstract Objectives: Ureteral necrosis is a rare complication of renal transplantation, and is seldom cured by endoscopic management alone. To avoid the potential hazard to the graft created by an open ureteral reconstruction in cases of renal transplant ureteral necrosis, we have appiled a new minimally invasive technique of total ureteral replacement, initially described for the palliative treatment of ureteral obstructions. The subcutaneous bypass technique is based on the use of a silicone-PTFE-bonded tube tunnelled underneath the skin. Methods: Total ureteral replacement by subcutaneous pyelovesical bypass was performed in three renal transplant patients (two men and one woman; mean age 41 years, (range 23–58) years with ureteral necrosis after failure of primary endoscopic treatment. The ureteral lesion was distal necrosis in two patients, and a total necrosis in the other. Under general anaesthesia and fluoroscopic guidance, a percutaneous tract was created and progressively dilated. The ureteral prosthesis was introduced into the pyelocaliceal cavities through a 30 F Amplatz sheet, then subcutaneously tracked down to the suprapubic area, and introduced into the bladder via a short incision. Results: There was no operative or postoperative morbidity. There was no obstruction, dislodgement or encrustation of the prosthesis. There were no bladder-related symptoms, or clinical reflux, and no abdominal wall complications. An asymptomatic episode of lower urinary tract infection (Staphylococcus epidermidis) was observed in the female patient. All the grafts were functioning with fine pyelocaliceal cavities, with a mean follow-up of 32 months (13–69 months). Conclusion: Total ureteral replacement by subcutaneous pyelovesical bypass is a simple and safe technique of ureteral reconstruction in renal transplantation. Late encrustation of the prosthesis may occur, and the prosthesis may need to be changed in such cases. Subcutaneous pyelovesical bypass can be regarded as an alternative to an open procedure to treat ureteral necrosis after renal transplantation.

NATIVE PERIPHERAL VASCULAR DISEASE CONTRIBUTES TO RENAL TRANSPLANT RENOVASCULAR DISEASE

288 Renal transplant artery stenosis (RTAS) is a relatively rare complication of renal transplantation, especially with the current techniques for vascular anastomoses. However, older patients (pts) prone to peripheral vascular disease (PVD), are more frequently being considered as candidates for renal transplantation. PVD involving the iliac system in this context can mimic RTAS(pseudoRTAS) and detrimentally affect graft function. We retrospectively analyzed 819 pts who underwent primary and non-primary kidney transplantation alone between 1993 and 1997 to determine the extent of pseudoRTAS. The population consisted of 506 M and 313 F. 92 pts (11.2%), suspected of having RTAS with new onset lower extremity edema and an increase in serum creatinine(Cr) underwent angiography (Agram) or magnetic resonance angiography (MRA). 4 pts underwent Agram or MRA involving the transplant renal artery for other reasons. RTAS or pseudoRTAS was defined as one or more hemodynamically significant lesions in the renal transplant artery or iliac system diagnosed by Agram or MRA. PseudoRTAS or RTAS was evident in 44 pts (5.4%), including 5 pts with pseudoRTAS and RTAS, 15 with pseudoRTAS, and 24 with RTAS. The recipient factor most significantly associated with RTAS and pseudoRTAS was increased weight at time of transplant (p < 0.0009). Other recipient factors that were associated with RTAS or pseudoRTAS included:TableThere was no significant association between RTAS or pseudoRTAS and race, pre-transplant dialysis modality, use of cyclosporine, FK506 or MMF, CMV infection, PRA, or HLA matching. In evaluating donor variables, available for 491 cadaveric transplants in this group, only older donor age was significantly associated with RTAS or pseudoRTAS (p < 0.0005). These data suggest that ischemic renal disease in renal transplant recipients may be increasing in incidence, taking on a new guise encompassing RTAS and pre-existing PVD that acts as pseudoRTAS.

Cyclosporine-Induced Thrombotic Microangiopathy Resulting in Renal Allograft Loss and Its Successful Reuse: A Report of Two Cases

Cyclosporine-induced thrombotic microangiopathy is a rare complication of renal transplantation. It commonly leads to graft loss. The mechanism of this entity is unknown. Factors intrinsic to the donor kidney appear to play an important role. We describe two cases of renal transplant patients who lost their first grafts secondary to cyclosporine-induced thrombotic microangiopathy. These patients were successfully retransplanted with an immunosuppressive protocol that included long-term cyclosporine. We conclude that graft loss from this entity is not a contraindication to subsequent successful transplantation with cyclosporine.

Renal Scintigraphic Findings in a Case of Transplant Renal Vein Thrombosis

Renal vein thrombosis is a rare complication of renal transplantation. The scintigraphic features of a documented case of renal vein thrombosis studied with Tc-99m DTPA and the differential diagnosis relevant to these findings are discussed.