1. NON SURGICAL COMPLICATIONS
IN RENAL TRANSPLANT
Dept of Urology
Govt Royapettah Hospital and Kilpauk Medical College
Chennai
1
2. Moderators:
Professors:
• Prof. Dr. G. Sivasankar, M.S., M.Ch.,
• Prof. Dr. A. Senthilvel, M.S., M.Ch.,
Asst Professors:
• Dr. J. Sivabalan, M.S., M.Ch.,
• Dr. R. Bhargavi, M.S., M.Ch.,
• Dr. S. Raju, M.S., M.Ch.,
• Dr. K. Muthurathinam, M.S., M.Ch.,
• Dr. D. Tamilselvan, M.S., M.Ch.,
• Dr. K. Senthilkumar, M.S., M.Ch.
Dept Of Urology, KMC and GRH, Chennai 2
11. Hyperacute Rejection
• it is produced by preformed cytotoxic antibodies against
the graft.
Nowadays this is rare - pretransplantation crossmatches
It is typically manifest shortly after vascular anastomosis is
established.
Early changes are prominent margination of neutrophils,
within the glomerular and peritubular capillaries
followed by widespread vascular thrombosis - neutrophils
incorporated in the thrombi.
kidney is - cyanotic, slightly edematous, and flaccid
urine production suddenly ceases
Dept Of Urology, KMC and GRH, Chennai 11
12. extensive tubular necrosis ensues, followed after 24 hours
by numerous cortical and medullary infarcts.
Immunofluorescence may disclose capillary and arterial
wall IgG or IgM, C3, and fibrin, with fibrin also in the
thrombi.
Peritubular capillary C4d deposition occurs after 24 to 72
hours if the kidney remains viable during this time.
DDs - physical perfusion-related injury to vascular
endothelium and injury caused by cold-reacting IgM
antibodies against blood cells.
It is only in hyperacute rejection, however, that neutrophils
are typically and regularly incorporated in the thrombi.
Dept Of Urology, KMC and GRH, Chennai 12
58. PTLD
• often is a reflection of a more immunosuppressed state
• a key component of treatment is the reduction of
immunosuppression - this does increase the risk for rejection
• require additional interventions, including rituximab,
chemotherapy, surgery, and/or radiation oncology.
• Although PTLD is often EBV associated, there is no role for
antivirals.
• CMV has been identified as a potential cofactor for the
development of PTLD
Dept Of Urology, KMC and GRH, Chennai 58
69. MRI in rejection
• blood oxygenation level-dependent (BOLD) imaging and DWI,
endogenous substances such as deoxyhemoglobin and water
molecules are used as intrinsic ―contrast agents, respectively
• BOLD imaging capitalizes on the direct relationship between oxygen
consumption and deoxyhemoglobin concentration to create a signal
map from the susceptibility produced by deoxyhemoglobin, such
that areas of increased oxygen consumption show high signal.
• In renal allograft dysfunction, the oxygen consumption decreases
while the deoxyhemoglobin concentration decreases, with
consequent loss of signal.
• In DWI, restricted water molecules generate high signal.
• ischemic areas result in restricted diffusion of water molecules with
consequent gain of signal.
Dept Of Urology, KMC and GRH, Chennai 69
70. • diffusion tensor imaging (DTI) provides microstructural
information inferred from diffusion and its anisotropy, or
direction of diffusion.
• Normally functioning kidneys have an organized, radial
orientation of tubules, collecting ducts, and blood vessels in
the medulla, and DTI tractography reveals these tightly
packed tracts.
• in impaired allografts, DTI shows a reduced number and
density of these tracts.
• Ferumoxytol-enhanced MRA provides long-acting,
nonnephrotoxic, nongadolinium imaging of the entire
arterial and venous system, enabling a reliable assessment
of blood flow and vascular structural abnormalities.
Dept Of Urology, KMC and GRH, Chennai 70
71. Core Needle Biopsy of the
Transplanted Kidney
• commonly done to distinguish ATN from acute rejection and
nephritis.
• may be done at predetermined intervals after transplantation
(protocol biopsies) as part of routine surveillance for
subclinical rejection.
• kidney is more superficial and does not move with respiration
• renal graft can be potentially localized by palpation but USG
guidance is preferred
• cortex of the upper or lower pole of the renal graft is targeted
for biopsy since the evaluation is centered around the
glomerulus.
Dept Of Urology, KMC and GRH, Chennai 71
72. • a dermatotomy is made to facilitate passage of a 17-gauge
introducer into the renal cortex
• an automatic spring-loaded 18-gauge core needle biopsy device is
inserted coaxially to retrieve cortical tissue.
• Two tissue samples are usually adequate.
• follow-up USG is performed approximately 5 minutes after
hemostasis to detect any bleeding.
• Postbiopsy - bed rest for 3 to 6 hours with observation of vital signs
every 15 minutes for at least 2 hours and then hourly for several
hours.
• Macroscopic hematuria occurs approximately 3% of renal biopsies.
• Severe complications are more common after ― “for cause
biopsies” compared to “protocol biopsies”
Dept Of Urology, KMC and GRH, Chennai 72
