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Renal transplant complications

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  • 1. Renal transplant offers the best therapy for end-stage renal disease. However, these patientscan have many different medical complications. They range from side effects of potentimmunosuppressive drugs or from drug interactions, renal tract problems, respiratoryinfections, fever, post-surgical complications, cardiovascular, gastrointestinal, neurologic,endocrine and electrolyte imbalance. Emergency physicians need to be aware of thecomplications and special factors associated with renal transplant patients.In general, a single kidney is transplanted in the right or left lower quadrant of the abdomen.Living donor transplants function immediately, while 30% of cadaver transplants undergodelayed graft function due to prolonged cold ischemic preservation. The renal transplantrecipient will now require long term immunosuppression to prevent rejection. The currentregimen is based on a triple therapy approach that includes cyclosporine-microemulsion ortacrolimus, mycophenolatemofetil or azathioprine and corticosteroids. Antilymphocyteantibodies are also widely used with the triple therapy regimen. While the currentimmunosuppressive regimens are more potent which leads to less rejection, there is a greaterincidence of medication-related problems.Rejection is the only unique cause for renal failure in kidney transplant patients. Two commoncauses of acute renal failure are acute cyclosporine or tacrolimus nephrotoxicity and acuterejection. Elevated blood levels of cyclosporine or tacrolimus favor nephrotoxicity. Keep inmind the best time to draws a drug level is 1-3 hours before a dose is scheduled making theselevels unreliable at times in the ED. Renal transplant recipients that present with fever andallograft tenderness and increased creatinine make acute rejection the likely diagnosis. Urinarytract infections occur in less than 10% of patients in the first post transplant year and are similarto that in the general population. Therefore, the most common pathogen to cause urinary tractinfections in renal transplant recipients is E. coli. Remember, to avoid aminoglycosides, anephrotoxic agent, when treating urinary tract infections.Pneumonia is the most common pulmonary issue in renal transplant recipients presenting to theED. Non-opportunistic infections occur in the first month post-transplant, followed byopportunistic infections in the first year and community-acquired respiratory infectionsafterward. Macrolides should be avoided in the treatment of pneumonia. The macrolidesinhibit the hepatic enzyme system that metabolizes the immunosuppressants.Fever in renal transplant patients is a common problem. Immunosuppressed patients aresusceptible to opportunistic infections that can become fulminant, however, they areuncommon in the first post-transplant month. The highest incidence of opportunistic infectionsoccurs between the second and sixth month post-transplant. Opportunistic infections varygeographically, therefore, it is important that ED physicians understand what pathogens areprevalent in renal transplant patients at their institution and provide appropriate treatment.Cytomegalovirus (CMV) disease is an opportunistic infection common in renal transplantpatients and with no variation in geographic prevalence. A renal transplant patient presenting 2months after kidney transplant with high fever, elevated liver function tests and leukopenia
  • 2. likely has CMV disease. CMV is diagnosed with PCR and most commonly presents between oneto six months post transplant. Patients presenting with a fever in the first year after transplantgenerally will require admission.Surgical complications associated with the allograft include acute occlusion of the transplantrenal artery or vein, peritransplant hematoma, urinary leak, lymphocele, obstructive uropathyand bleeding after renal allograft biopsy. A renal transplant recipient that presents in the firstweek post transplant with acute renal failure and oligoanuria likely has acute occlusion of thetransplant renal artery. Peritransplant hematoma occurs as an early postoperative complicationor in perioperative anticoagulation. Patients present with severe pain over the allograft,decrease in hemoglobin or hematocrit level and an increasing serum creatinine level. Urinaryleak presents in the first post-transplant month and is caused by disruption of the uretericanastomosis to the bladder. This leads to extravasation of urine and acute renal failure.Lymphocele occurs within the first 3 months post-transplant and is caused by severage of thelymphatics during the transplant operation and leading to a lymph leak. Large lymphoceles cancause allograft pain, acute renal failure, urinary frequency, ipsilateral lower extremity edema,iliac vein thrombosis or pulmonary embolism. Causes of obstructive uropathy include technicalproblems with ureteric anastomosis or lymphocele which can be followed by stenosis of thetransplanted ureter. Ultrasound can be important to evaluate for fluid collections orhydronephrosis which may require a nephrostomy tube. Finally, 3% of patients present withgross hematuria after an allograft biopsy. Severe hematuria may require angiographic occlusionand blood transfusions. All the allograft complications discussed will require surgicalexploration and interventions as needed.The risk of cardiovascular disease is threefold to fivefold higher in renal transplant recipientscompared with the general population. If diltiazem, verapamil or amiodarone is used beware ofthe immunosuppressive agents, cyclosporine, tacrolimus or sirolimus. The antiarrhythmicagents inhibit the hepatic P-450 enzyme system, subsequently, elevating theimmunosuppressive levels. Hypertensive urgencies or emergencies can be treated withparenteral or oral antihypertensives. Gastrointestinal disorders are common and their severitymay be blunted by immunosuppressants, therefore radiologic studies are required. Neurologiccomplications can result from side effects of immunosuppressive drugs, opportunistic infectionsor malignancy. Headaches in the renal transplant patient warrant a lumbar puncture andimaging studies of the brain. Anemia, leukopenia and thrombocytopenia may be caused byimmunosuppressants, antibiotics, anti-virals or corticosteroids. Corticosteroids can also causeosteoporosis, avascular necrosis or tendon rupture affecting the Achilles or quadriceps.Osteoporosis tends to affect the feet for unclear reasons. Cyclosporine and tacrolimus causehyperkalemia and hypomagnesaemia. The above-mentioned immunosuppressants along withcorticosteroids can cause de novo diabetes in 5-20% of renal transplant recipients. Lastly the
  • 3. combination of anemia, thrombocytopenia, and acute renal failure suggests hemolytic uremicsyndrome.The renal transplant recipient is prone to a number of medical complications. It is importantthat emergency physicians understand these medical complexities, including drug regimens anddrug interactions, and make sure to effectively communicate with the transplant physician.References :- Review by Jose Vega, MD ( Column Organized by Evan Schwarz, MD of Division of Emergency Medicine of Washington University )