Complications of kidney transplantation are disorders etiologically associated with nephrotransplant transplantation. In the early period, hyperthermia, oligoanuria, arterial hypertension, pain in the graft area are manifested. Late complications of kidney transplantation are asymptomatic for a long time, and subsequently signs of renal failure and disorders in the work of other organs prevail. Pathology is diagnosed by blood and urine tests, ultrasound, ultrasound, kidney MRI, puncture biopsy. Immunosuppressants, antibiotics, antiplatelet agents, anticoagulants are used for treatment, surgical revision of the wound, surgical interventions on the ureters, nephrotransplantectomy are performed.
ICD 10
Z94.0 T86.1
Meaning
The survival rate of patients who underwent kidney transplantation during the first postoperative year reaches 94-98%, however, the development of complications significantly affects the functionality of the transplanted organ and the quality of life of recipients. In the early and late posttransplantation period, both urological diseases and damage to other organs can occur, which can provoke the death of the patient.
According to the results of observations, 33.2% of deaths after kidney transplantation are caused by cardiac causes, of which 11.3% — acute myocardial infarction, 17.8% — infectious diseases, 11.9% — tumor process, 6.9% — cerebrovascular accident, 30.3% — other factors. During the first 12 months after the intervention, from 6 to 12% of nephrotransplants are rejected, which requires the resumption of renal replacement therapy and re-transplantation. Up to 36% of recipients carry urinary tract infections and opportunistic infections.
Causes
Despite the accumulated experience and the introduction of effective standards for the operation, the technical complexity of its implementation and the use of an allograft increase the risk of a complicated course of the postoperative period. Specialists in the field of modern urology, nephrology and transplantology distinguish the following groups of causes that provoke complications after nephrotransplantation:
- Age and health status of the recipient. In addition to absolute contraindications, in which transplantation in most cases ends with an unfavorable outcome, there are relative ones that significantly increase the likelihood of complications. The risk group includes patients older than 65-70 years, as well as those suffering from a number of concomitant diseases — active hepatitis, cirrhosis of the liver, SLE, vasculitis, hemolytic-uremic syndrome, systemic diseases in the active phase, diabetes mellitus, acute infectious processes, CHF IIB art.
- Features of the transplanted kidney. Complications of kidney transplantation occur more often with AB0 and HLA incompatibility of tissues, presensitization of the recipient. Organ engraftment worsens with prolonged (more than 24 hours) cold ischemia of the kidney, according to the results of some observations, this factor turns out to be more significant than histocompatibility. The functionality of a cadaveric kidney depends on the causes of death of the donor, electrolyte disorders, the degree and duration of hypotension, and other features of the agonal period. The technique of organ harvesting also affects the course of the post-transplant period.
- Medical factors. The outcome of transplantation depends on the completeness of the preoperative examination of the recipient and the lifetime donor, the correctness of the assessment of the identified contraindications, pretransplantation preparation when histological incompatibility of tissues is detected. The quality of kidney engraftment is influenced by the technical accuracy of transplantation, compliance with the requirements of asepsis and antiseptics, prevention of ischemic organ damage, the quality of patient monitoring, the choice of the optimal immunosuppression regimen (IST).
- Immunodeficiency. A number of post-nephrotransplantation complications are associated with drug-induced suppression of the recipient’s immunity. The appointment of immunosuppressive drugs is an important condition for the prevention of transplant rejection. However, against the background of immunodeficiency, the likelihood of early and long-term infectious diseases increases. In addition, immunosuppression is a risk factor for oncogenesis. In some patients, disorders of humoral and cellular immunity stimulate the occurrence of allergic and autoimmune reactions.
Pathogenesis
The mechanism of development of complications of kidney transplantation depends on the etiological factors that provoked the pathological condition. Often, the disorder is based on immune or infectious inflammation. In the first case, rejection of the nephrotransplant is observed due to a T-cell response or a humoral reaction of the antigen-antibody type. When infectious agents enter the wound, inflammatory destruction of tissues occurs under the action of bacterial endo- and exotoxins.
The situation is often aggravated by ischemic disorders that have arisen against the background of microcirculation disorders, arterial occlusion, venous thrombosis. A separate role in the pathogenesis of post-nephrotransplantation complications is played by immunosuppression, which reduces or distorts the normal protective reaction of the body to the action of damaging factors. In the long term, the processes of sclerosis of the renal parenchyma prevail.
Classification
The systematization of variants of complications after kidney transplantation was created taking into account the time of occurrence, causes, mechanism of development and clinical symptoms of the disorder. This approach corresponds to the principles of timely diagnosis and adequate etiopathogenetic therapy of post-nephrotransplantation disorders. Complications of nephrotransplantation may be early, acute during surgery or in the first months after transplantation, and late, with a gradual increase in symptoms. There are the following forms of pathology:
- Rejection of a kidney graft. The use of modern immunosuppressive therapy allowed to increase the survival rate of the transplanted kidney within a year after the intervention to 88-94%, followed by a deterioration of 3-8% per year. Most cases of rejection are observed in the first 3-4 posttransplantation months, due to reactions of cellular and humoral immunity.
- Surgical complications. They occur during the transplantation process or in the early postoperative period. Usually caused by a violation of the technique of surgery, norms of asepsis, antiseptics. They are manifested by bleeding of varying intensity up to hemorrhagic shock, renal artery stenosis, vascular thrombosis of the transplanted kidney, the development of wound infection, the formation of lymphocele.
- Urological complications. The ureter is at the greatest risk of damage. If it is damaged due to non-compliance with the transplantation technique, it is possible to develop complete necrosis, obstruction of the ureteral lumen, obstruction from the outside with a suture or ligature, point necrosis with the formation of urinoma. In some cases, the failure of the created neoureterocystoanastomosis is observed.
Concomitant damage to other organs. Kidney transplantation and the appointment of immunosuppressive therapy can provoke activation of bacterial, viral and fungal infections, gastrointestinal bleeding, calcium metabolism disorders, secondary diabetes mellitus, increased atherosclerotic processes. Recipients have an increased risk of malignant neoplasia.
Symptoms
Early acute disorders are usually characterized by a violent clinical picture. Shortly after transplantation, the patient has a pronounced intoxication syndrome with high fever, chills, joint and muscle pain, nausea, vomiting, itching, and severe weakness. With internal bleeding, dizziness, pallor of the skin is observed, loss of consciousness is possible.
In most recipients, the appearance of complications is indicated by a significant decrease in urination up to its complete cessation in combination with high blood pressure. A painful seal may be palpated in the area of the transplanted kidney. A common sign of infectious inflammation is the presence of abundant wound discharge. When the peritoneum is involved in the inflammatory process and the development of peritonitis, there is a sharp pain in the abdominal cavity, the abdomen becomes tense, plank-like, there is an increase in pulse, a sharp drop in blood pressure, often there is no stool.
The manifestation of late complications usually becomes a progressive decrease in the filtration capacity of the kidneys. Clinical symptoms are absent for a long time. Subsequently, the patient begins to complain of fatigue, decreased performance. The daily diuresis decreases. In the morning, swelling appears on the face mainly in the eyelid area, which, as kidney failure develops, persists throughout the day and spreads to other parts of the body. Blood pressure often rises.
Symptoms of uremia arise and increase — lethargy, apathy, pallor and grayish skin tone, intense itching, thirst, sleep disorders, low body temperature, lack of appetite, nausea, vomiting, diarrhea. With a combined lesion of other organs and systems, the corresponding symptoms are noted. Due to the suppression of immunity, recipients often suffer from acute respiratory viral infections, they develop severe long-term bronchitis, pneumonia. Various forms of pyoderma are possible.
Violation of calcium absorption leads to osteoporosis, hyperplasia of the parathyroid glands. Anemia is often formed due to insufficient synthesis of erythropoietins. Patients taking immunosuppressants for a long time may be diagnosed with oncological diseases. At the same time, neoplasms of presumably viral origin prevail — squamous and basal cell carcinomas, lymphoproliferative disease (mainly B-cell non-Hodgkin’s lymphoma), anogenital neoplasia, including cervical cancer, Kaposi’s sarcoma.
Diagnostics
Diagnostic search in case of suspected complication of kidney transplantation is aimed at clarifying the nature of the disorder, assessing the viability and functional viability of a kidney transplant, identifying critical organ and metabolic disorders that threaten the recipient’s life. The most informative survey methods are:
- Blood test. The probable development of acute complications is confirmed by a significant increase in the level of white blood cells, a drop in platelet count, and an acceleration of ESR. In the long-term period, there is often a decrease in the concentration of erythrocytes, hemoglobin, against the background of immunosuppression, leukopenia may occur.
- Ultrasound of the kidney transplant. Kidney echography is a safe screening method that allows detecting changes in the size of the transplanted organ, destruction of the parenchyma, and the presence of pathological changes in the paranephral space. The study is complemented by ultrasound of renal vessels for a comprehensive assessment of the state of blood flow.
- Biochemical blood analysis. The violation of the filtration function of the glomeruli is indicated by an increase in the levels of creatinine, residual nitrogen, urea, and potassium. The lesion of the glomerular apparatus is confirmed by the data of the Rehberg test, a nephrological complex. A high level of LDH, C-reactive protein is characteristic.
Depending on the type of complication, an increase or decrease in specific density, the presence of erythrocytes, leukocytes, cylinders, and bacteria may be detected in the general urine analysis. To exclude rejection of the nephrotransplant, it is recommended to conduct an extended complex immunological examination, puncture biopsy followed by histological analysis of the obtained material. Studies with the introduction of X-ray contrast (intravenous urography , CT, MSCT of the kidneys) are performed with caution due to the possible aggravation of the clinical situation due to the development of contrast-induced nephropathy.
As additional methods, MRI may be prescribed to identify possible structural disorders in the graft tissues and nephroscintigraphy, which allows to clarify the functionality of the transplanted kidney. To monitor the patient’s condition in the early posttransplantation period, the volemic status (hemohydrobalance, CVD level), electrolyte state (potassium, sodium, acid-base equilibrium levels), coagulogram are evaluated, diuresis control is provided, daily blood pressure monitoring is performed, ECG is performed regularly.
Differential diagnosis is usually carried out between different types of complications. With late urological consequences of transplantation, the development of recurrent glomerulonephritis, recurrent lupus nephropathy, pyelonephritis, hydronephrosis is excluded. According to the appointment of a nephrologist or urologist, the patient is advised by a transplant specialist, an anesthesiologist, an abdominal surgeon, an infectious disease specialist, a rheumatologist, an immunologist, an oncologist.
Treatment
The main medical tasks are the speedy correction of the disorders that have arisen and the maintenance of the recipient’s basic vital functions. In the absence of acute surgical complications, treatment is usually represented by complex drug therapy. Taking into account the revealed violations, patients who have undergone kidney transplantation are prescribed:
- Correction of immunosuppressive therapy. The use of pulse methods, changing the dosage of calcineurin inhibitors, antimetabolites, glucocorticoids, interleukin inhibitors, biological anti-lymphocytic agents, replacing some drugs with others often makes it possible to stop an episode of rejection. Correction of prescriptions may also be required if complications are associated with immunosuppressants taken.
- Treatment of transplanted kidney ischemia. When vascular and thrombotic disorders occur, disaggregants, anticoagulants, antihypoxants, cytoprotectors, synthetic prostaglandins are used. With their help, it is possible to effectively improve renal blood flow, microcirculation, tissue perfusion. Hyperbaric oxygenation may be prescribed to increase the oxygen capacity of the blood.
- Antibacterial drugs. The indication for active antibiotic therapy is the presence of infectious and inflammatory complications. Antibacterial agents with minimal risk of nephrotoxic effect are preferred — quinolones, combinations of diaminopyrimidines with synthetic sulfonamides. In the treatment of opportunistic infections, the sensitivity of microorganisms is taken into account.
Infusion therapy under the control of diuresis is carried out in the event of acute, life-threatening conditions, metabolic disorders. Taking into account the clinical picture, colloidal and crystalloid solutions, individual electrolytes, whole blood and its components can be infused into the recipient of the kidney. With increasing signs of renal insufficiency, replacement therapy is resumed (hemodialysis, peritoneal dialysis, hemofiltration, hemodiafiltration). The treatment of diseases provoked by kidney transplantation is carried out according to the protocols for the corresponding pathology.
Surgical methods of treatment are required in the detection of surgical complications, destruction of the ureter or kidney transplant. The volume of interventions depends on the characteristics of the complication. Revision and drainage of the wound, suturing of damaged vessels, laparoscopic marsupialization of the lymphocele can be performed. If the ureter is damaged, endoscopic dissection of the ureterocele, ureteroplasty, ureterocutaneostomy, and neoureterocystoanastomosis may be performed. Irreversible destruction of the transplanted kidney serves as an indication for nephrotransplantectomy, followed by the appointment of RRT and possible re-transplantation of the organ.
Prognosis and prevention
The occurrence of complications of kidney transplantation significantly worsens the survival rates of patients, however, timely detection and competent correction of disorders make the prognosis more favorable. Prevention of possible complications begins with a comprehensive examination of the patient before surgery to determine all absolute and relative contraindications, assess histocompatibility with the donor. With the upcoming AB0-incompatible transplantation, preoperative desensitization is required. According to indications, preventive antibiotic therapy may be prescribed at the pretransplantation stage.
Taking into account the likely compromise of wound healing against the background of immunosuppressive therapy, precision surgical technique, increased attention to detail, strict adherence to aseptic rules, and thorough hemostasis are important. After transplantation, the right choice of induction and maintenance IST, postoperative monitoring of the recipient’s condition plays a key role.