POST OPERATIVE COMPLICATIONS OF RENAL

TRANSPLANT

BYMOHD HABROL AFZAM BIN ABD WAHAB

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Can be classified into• Urologic complications

– Urine leak and urinomas– Urinary obstruction

• Peri – transplant fluid complications– Hematomas– Abscesses and infections– Lymphoceles

• Vascular complications– Renal artery sclerosis– Infarction– Arteriovenous fistula and pseudoaneurysms– Renal vein thrombosis

• Calculous disease• Neoplasms• Gastrointestinal and herniation complications• Post – transplantation lymphoproliferative disorders

Urologic complicationsUrine leak and urinomas• Relatively rare complications of

transplantation and usually constitute an early postoperative problem.

• Due to ureteral necrosis caused by vascular insufficiency or increased urinary pressures caused by obstruction.

Urinary obstruction• Occurs in approximately 2% of

transplantations ( within the first 6 months )

• At any location but is most frequent at the site of implantation of the ureter into the bladder.

• More than 90% of ureteral stenosis occur within the distal third of the ureter.

• Narrowing at the ureterovesical junction may be caused by scarring secondary to ischemia or rejection, by technical error during the ureteroneocystostomy, or by kinking.

Retrograde pyelogram shows the area of narrowing at the site of ureteral implantation into the bladder (arrow).

Peri Transplant Fluid ComplicationsHematomas• Hematomas are common in the immediate postoperative period, but they may also

develop spontaneously or as a consequence of trauma or biopsy. They are usually small and resolve spontaneously. Large hematomas can displace the transplanted kidney and produce hydronephrosis.

Abscesses and infections• More than 80% of renal transplant recipients suffer at least one case of infection during

the first year after transplantation. • First weeks ------ such as pneumonia, surgical wound infections, and urinary tract

infections, are similar to those that typically develop in nonimmunocompromised patients who have undergone surgery.

• Infections with opportunistic pathogens and cytomegalovirus often develop 1–6 months after surgery, and infections common in the general population are seen after 6 months.

Lymphoceles • Lymphoceles are the most common fluid collection that causes transplant hydronephrosis.

Patients with a failing allograft may develop ipsilateral lower extremity edema caused by compression of the femoral vein. In rare cases, lymphoceles may develop in the scrotum and lymphatic drainage may occur through the wound.

• occurring within 1–2 months after transplantation

Vascular complications• Renal artery stenosis

– Occurs usually in the first year after transplantation. – May be located before the anastomosis (because of atherosclerotic disease in the donor

vessel), at the anastomosis (secondary to vessel perfusion injury, faulty suture technique, or reaction to suture material), or after the anastomosis (due to rejection, turbulent flow from kidney malposition, or arterial twisting, kinking, or compression).

– About 80% of patients with end-stage renal disease are hypertensive, and after renal transplantation two-thirds of these groups experience a reduction in hypertension.

• Infarction– Renal artery thrombosis may result from hyperacute rejection, anastomotic occlusion,

arterial kinking, or intimal flap. Segmental infarcts in the renal transplant may be focal or diffuse and may occur as part of rejection or as a result of an unassociated vascular thrombosis. Vasculitis may induce small segmental infarcts.

– Signs ------ absence of urinary output and often with swelling and tenderness over the graft and anuria.

• Renal vein thrombosis– Renal vein thrombosis is an unusual complication of transplantation; ( less than 5% ). – C / O ----- an abrupt cessation of urinary function and swelling and tenderness over the graft.

Hypovolemia, venous compression from a peritransplant fluid collection, dysfunctional anastomosis, and slow flow secondary to rejection or other allograft disease can also precipitate renal vein thrombosis.

Others complicationsCalculous Diseases Neoplasms

Renal transplant calculus in a 34-year-old patient with hematuria. (a) US image demonstrates hydronephrosis with a shadowing echogenic focus seen in the upper middle renal pole (arrow). (b) US image of the distal ureter shows an echogenic focus with shadowing (arrow) a finding consistent with an obstructing calculus.

Renal transplant adenocarcinoma. CT scan shows a cystic mass (arrow) arising from the renal transplant that proved to be renal cell carcinoma.

Prolonged immunosuppression following renal transplantation places the transplant recipient at about 100 times the normal risk for developing cancer.

Other complicationsGIT & Herniation Post-transplant LP Disorders

Renal transplant herniation. CT scan demonstrates multiple distended small bowel loops around the transplanted kidney, findings compatible with obstruction. Small bowel had herniated through the peritoneal defect related to the renal graft, a diagnosis that was surgically proved.

Posttransplantation lymphoproliferative disease in a 25-year-old renal allograft recipient who presented with abdominal pain. (a) Contrast-enhanced CT scan demonstrates circumferential thickening of the jejunum (arrows). (b)Contrast-enhanced CT scan obtained at a lower level shows encasement of the superior mesenteric artery by lymphadenopathy (arrowheads), in addition to the jejunal thickening (arrow).