|Year : 2022 | Volume
| Issue : 3 | Page : 53-58
Short-term evaluation of renal transplantation complications: A single institute experience
Puneet Aggarwal1, Raghav Talwar2, SC Karan3
1 Cl Spl Surg & Urologist, Department of Urology, Army Hospital R&R, Delhi Cantt, India
2 Conslt Surg & Urologist, Department of Urology, Command Hospital Air Force) Bengaluru, Karnataka, India
3 Conslt Urology, Department of Urology, Narayan Medical College & Hospital Sasaram, Bihar, India
|Date of Submission||07-Feb-2021|
|Date of Decision||07-May-2021|
|Date of Acceptance||26-May-2021|
|Date of Web Publication||01-Apr-2022|
Lt Col (Dr) Puneet Aggarwal
Cl Spl Surg & Urologist, Department of Urology, Army Hospital R&R, Delhi Cantt
Source of Support: None, Conflict of Interest: None
Introduction: Renal Transplant remains one of the pioneer branches of solid organ transplant and surgical complications can affect the outcome. Material and Methods: Present study was done to find out the incidence of surgical complications in Renal Transplant Recipients, their outcome, to compare it with contemporary studies and suggest remedial measures. It was Prospective non-randomized observational study conducted at tertiary centre. All patients who underwent live related or deceased donor transplant over two yrs were recruited. All relevant data was collected. Data were collected and put in a master chart in Microsoft Excel© format and statistical analysis was done using SPSS 17 software®. Student t test was used to compare data with published contemporary series and p value was calculated. Results: one hundred and forty-five cases including 31 (21%) deceased donor recipients were studied. Eleven (7.58%) had surgical complications. Two with arterial complications required graft nephrectomies and one with renal artery stenosis stented successfully. Higher incidence of arterial complications (2.06%) was noted as compared to contemporary studies (0.69%-1.3%) (p>.05) with higher incidence (3.2%) in deceased Donor recipients. No venous complications recorded (contemporary studies 0.15% - 0.55% incidence). One (0.68%) Ureteric stricture was reported, comparable to contemporary studies (0.27%-0.54%) (p>.05) and managed endoscopically. No uretric-vesical anastamosis leak recorded (contemporary studies 0% - 0.97% incidence). Four (2.75%) had Lymphorea, (Three deceased, one live donor) requiring Betadine instillation, significantly lower than contemporary studies (7.14%- 23%) (p<.05). Two (1.4%) had surgical site infection requiring secondary suturing, significantly lower than contemporary studies (3.2%- 15%) (<.05). One (0.68%) had stricture urethra managed conservatively, comparable to contemporary studies (0.83%-1.18%). Conclusion: Overall incidence of surgical complications is reducing. Complication rates are higher in Deceased Donor recipients.
Keywords: Chronic kidney disease, deceased donor recipients, live related recipients
|How to cite this article:|
Aggarwal P, Talwar R, Karan S C. Short-term evaluation of renal transplantation complications: A single institute experience. J Mar Med Soc 2022;24, Suppl S1:53-8
| Introduction|| |
Chronic kidney disease (CKD) remains a major public health problem. The approximate prevalence of CKD in India is 800 cases per million populations whereas end stage renal disease (ESRD) cases are 150–200 cases per million populations.
The management of ESRD involves renal replacement therapy in form of either haemodialysis or peritoneal dialysis and transplantation. Haemodialysis requires a permanent Arterio-venous fistula line and is associated with significantly higher complication. Many clinical trials have consistently shown better quality of life post renal transplantation.
Renal Transplant remains one of the pioneer branches of solid organ transplant worldwide and has less immediate and delayed complications compared to other solid organ transplants. With refinement of surgical techniques the incidence of surgical complications remains low. Surgical complications still remain one of the most important posttransplant complications primarily in early part and usually at a lower rate in late period. Careful assessment of both clinical and investigative parameters can lead to early detection of complications and prompt management which can lead to improved outcome.
The first successful experimental organ transplant was reported by Ullmann in 1902 when he auto-transplanted a dog's kidney to neck. In Boston the first transplant of a kidney from one twin Sister to another with renal failure was performed in 1954. Joseph Murray and John P. Merill is widely credited with the success of these related kidney transplantations.
The first human renal transplantation in India was done at KEM Hospital Mumbai from a cadaveric donor in 1965. The first live-related Renal transplantation was done in CMC Vellore in 1971. An acute shortage of related kidney donor remains main obstacle for successful and widespread application of transplantation surgery.
At our centre transplant programme started in 2000. On an average about 80–90 cases of live related and Deceased Donor renal transplantations are done every year. As of now more than 1100 live related and Deceased Donor renal transplantations have been done at this centre.
The objective of present study was to find out the incidence of various surgical complications in Renal Transplant Recipients and to compare it with contemporary studies, to find out the possible aetiology of such complications in Renal Transplant Recipients and to study the outcome of such complications and suggest the remedial measures to avoid such complications.
| Materials and Methods|| |
The study was carried out at tertiary care centre. The Study was 2 years prospective observational study carried out for 2 years with minimum 3 months follow up of all patients. A total of 145 patients were studied.
All renal transplant recipient patients who were operated in the 2 years' time period were included in the study. Both Live related and Deceased Donor transplant recipient patients were included in the study. Patients underwent second or subsequent renal transplant, having previous history of stricture urethra and patients lost to follow up were excluded from the study.
Data were collected and put in a master chart in Microsoft Excel© format in this study period. All post-transplant recovery data and surgical complications data were plotted. Statistical analysis was done using SPSS 17 software® (SPSS 17 software, IBM Corp,Armonk,N.Y.,USA). Student's t-test was used to compare data in the present series with published contemporary series. P value was calculated to analyse statistically significant difference. If any statistically significant difference could be detected then reasons were analysed to find out cause for difference in complication rates.
Institutional Ethical Committee written approval was taken before starting the study. Informed written consent of patients were obtained after formal counselling by transplant team.
Donor nephrectomies and recipient surgeries were performed by a single dedicated team of urologists. Transplant recipient patients were admitted 24–48 h prior to surgery and dialysed day before surgery.
All patients were operated in general anaesthesia. As a protocol injection cefoperazone + sulbactam 1 g was given intravenously at the onset of procedure. Under strict asepsis all patients were catheterized with 18Fr 3 ways Foley's.
A modified Gibson's incision was made in right lower quadrant of abdomen. External iliac artery and vein were prepared by ligating the lymphatics with 3'0' silk to reduce the incidence of lymphocele. In some patients internal iliac artery was prepared instead of external iliac artery after sparing the first branch.
For bladder preparation a serosal incision was made. Detrusor muscle was incised over a length of 3–4 cm carefully to expose the bladder mucosa.
The renal vein was anastomosed end-to-side, to the external iliac vein using a continuous 6–0 monofilament vascular suture. After de-clamping any significant bleeding area was sutured with a vascular suture but most of the needle puncture sites stopped bleeding with a gentle compression with swab.
Renal artery was anastomosed end to side with external iliac artery using 7–0 monofilament vascular suture or sometimes end to end with internal iliac artery. In case of accessory renal vessel it was anastomosed separately with external iliac artery or inferior epigastric artery.
After anastomosis clamps were released and perfusion to the kidney was checked. Before proceeding for Ureteric anastomosis a 6 Fr DJ stent was inserted. An extravesical Modified Lich-Gregoir Ureteric re-implantation was performed with 4'0' Vicryl suture/PDS. Then a muscular backing of the tunnel was created with same suture. Kidney was placed in the fossa without any kink or tension on anastomosis. Drain was placed and wound was closed.
Patient was closely monitored for hourly intake and Urine output. Patient hydration status, blood pressure, central venous pressure was checked. Drain output was measured 24 hourly. By institution protocol if patient had otherwise smooth postoperative recovery with decreasing serum creatinine and good urine output then on 5th postoperative day Foley catheter was removed. If drain output remains low drain was removed and patient was discharged home.
DJ stent was removed 2 weeks after transplantation along with abdominal sutures removal. Patient came for routine initial monthly follow up in urology outpatient department for 3 months.
| Results|| |
A total 145 patients were included in this study comprising of both live-related and cadaveric organ donor cases that were performed in a 2 years study period and all patients were followed up for minimum 3 months. Being a defence setup none of the patients lost to follow-up.
In our study majority of Transplant recipients were male (73.10%), compared to female recipients (26.9%). The majority of the donors were wives (24.1%) followed by deceased donors (21.3%) and mothers (20.0%). But male donors like Fathers (13.1%), Brothers (3.4%), Son (1.3%) and Husbands (9.6%) also contributed a substantial no of cases. Majority of the donors belonged to 36–50 years age group. Eleven donor patients had double renal artery out of which 4 had right double artery and 7 had left double renal artery.
A total of eleven posttransplant surgical complications were recorded in present series of 145 cases (7.58%) [Figure 1]. Of these complications three arterial complications, one stricture urethra, one Ureteric complication, four lymphorea and two surgical site infection (SSI) were recorded. Of these 6 complications were seen with live related donors n = 114 (5.2%) and 5 with deceased donors n = 31 (16.12%).
Three patients had arterial complications. In these three two had end to side anastomosis with external iliac artery and one had end to end anastomosis with internal iliac artery. One had transplant renal artery stenosis, one had transplant arterial thrombosis and one had Transplant renal artery aneurysm. all three patients underwent emergency colour Doppler ultrasonography based on clinical suspicion of low urine output and rising serum creatinine. Renal artery stenosis patient underwent conventional renal angiogram followed by successful stenting of renal artery. patient with renal artery aneurysm was managed with Stenting but was unsuccessful and later on underwent graft nephrectomy. The transplant arterial thrombosis patient underwent emergency re-exploration but had a nonviable graft and subjected to emergency graft nephrectomy.
All transplant renal artery complications were noted in donor with single renal artery (2.02%). No arterial complications were seen in 11 patients with double renal artery. Arterial complications rate was higher in cadaveric series (3.2%) compared to live-related donors (1.75%).
In the present series only one ureteric complication was recorded. Patient developed Vesico-ureteric junction (VUJ) stricture which was managed successfully with laser resection and endo-pyelotomy stenting. It was recorded in live-related case (0.87%).
One case of Stricture urethra was recorded. RGU revealed short segment sub-meatal stenosis. The patient was managed with serial dilatation and self-calibration and it was recorded in live related case (0.87%).
Four cases of Lymphorea were recorded. Patients had persistent drain of more than 100 ml/24 h after 14 days of surgery and drain fluid creatinine ranging from 1 to 2 mg/dl. All required Betadine instillation in which fresh bottle of 10% betadine was taken and was diluted to 1% and 25 ml to 50 ml instilled through drain under aseptic conditions with gravity only. If drain remained high instillation repeated after 3 days. None of the patient required betadine instillation more than two times. No case of lymphocele was noted. Out of these 4 patients 1 (0.87%) was recorded with live-related donor and 3 (9.6%) with deceased donor.
A total of two surgical site related complications were recorded in the study one each in live-related (0.8%) and deceased donor (3.2%) group. One patient had Superficial and one had Deep SSI. The body mass index (BMI) ranged from 21 to 26 kg/m2 (23.25 kg/m2). None of these were diabetic. The SSI was managed by culture swab based antibiotic treatment and wound dressings. One patient has to undergo secondary suturing.
On analysis of medical complications, it was recorded that twelve had Acute Tubular Necrosis (8.45%), three had acute rejections (2.0%), and one patient went into septicaemia followed by death (0.68%). One patient died on 3rd postoperative day following a cadaveric kidney transplant possibly due to sudden cardiac arrest.
| Discussion|| |
Renal Transplantation is an established mode of therapy for ESRD patients with good overall quality of life characteristics.
In the study of 720 patients done by Rana et al. deceased donor contributed only 5.2% but deceases donors contribute 23.7% in study of 1843 patients by Aktas et al. Deceased donors contributed a significant no in our study 21.30% (n = 31). The possible reasons for this high contribution from deceased donors could be due to increasing awareness among the public regarding organ donation.
In our study wives were the highest group of donors (35 cases, 24.1%) followed by mothers (31 cases, 21.30%) and compare favourably with study done by Rana et al.
In age of donors varied from 20 to 62 years with majority of the donors belonged to 36–50 years age group with female donor predominance. Fifteen patients (out of total 114 Live Related donors or 13.15%) were above the age of 50 years. Of these fifteen donors three patients had preexisting well controlled Hypertension on single drug. Follow up of these donors till 1 year did not show any target organ damage which compare favourably with study done by Rastogi et al. The recipient age varied from 11 to 60 years with mean age of 36 years which is comparable with the mean age of recipient of 33 years and 42 years reported by Rana et al. and Srivastava et al. respectively.
The arterial complications were 3 out of 145 cases studied (2.06%). This compared to the study by Srivastava et al., Rana et al. and Atkas et al. showed a P = 0.24, 0.13 and 0.28 respectively which was statistically insignificant (P > 0.05) [Table 1]. On analysing it was observed that the study done by Srivastava et al. included only live-related transplantations and study done by Rana et al. had only 5% deceased donors compared to 21% deceased donors in present study and 23% in study by Atkas et al. Several mechanisms causing vascular complications have been postulated such as faulty suture technique producing incomplete intimal re-approximation with secondary intraluminal fibrosis, postoperative hypotension, hypercoagulable state, atherosclerosis of the donor or recipient vessels, trauma to the donor artery during perfusion, wide disparity in vessel size, torsion of graft during anastomosis, kinking of artery and angulation of the vein owing to improper location of the graft.
|Table 1: Comparison arterial complications with other contemporary series|
Click here to view
The arterial complications rate was higher in deceased series (3.2%) compared to live-related cases (1.75%). The possible reason for higher incidence of arterial complications in deceased donors could be technical although the number is too small for statistical analysis.
As the incidence of Venous thrombosis in present study was nil, the statistical significance with other studies could not be compared. Transplant renal vein thrombosis has been noted in up to 6% patients. Presentation of renal vein thrombosis has been dramatic with acute graft tenderness, haematuria. Timely suspicion and diagnosis is very important as there is chance of turgidity of the graft and rupture with severe haemorrhage and hypotensive shock. Incidence of vein thrombosis is higher on right Donor Kidneys because of thin calibre and short length of right renal vein. Other precipitating factors may be antithrombin 3, protein-C, and protein-S deficiency. In series of 720 cases, Rana et al. had four cases of graft renal vein thrombosis of which two grafts could be saved by emergency thrombectomy.
The incidence of ureteric stricture in the present study was 01 (0.68%) out of 145 cases studied which was statistically insignificant as compared to study by Shringarpure et al. and Rana et al. which showed a P = 0.69 and 0.42 respectively (P > 05) [Table 2].
|Table 2: Comparison of ureteric stricture with other contemporary series|
Click here to view
Double J Stenting is known to reduce the incidence of early Ureteric leak. But it has no role in late development of Ureteric strictures. Risk factors for ureteral stenosis include advanced donor age, delayed graft function, and kidneys with more than two arteries. Our patient had live-related transplant. He had Acute Tubular Necrosis episodes after transplantation and had received pulse dose of Injection Methyl Prednisolone. Acute Tubular necrosis is known predisposing factors of lower Ureteric stricture due to segmental ischemia. He presented within 3 months of transplant with slow rise of serum creatinine and ultrasonography (USG) abdomen showed moderate to gross hydronephrosis of graft kidney. DTPA renogram revealed obstructed drainage pattern.
Patient was managed initially with ultrasound-guided percutaneous nephrostomy. nephrostogram showed ureteroneocystostomy site short segment stricture and antegrade DJ stenting was done [Figure 2]. His underwent laser resection of uteteroneocystostomy stricture and endo-pyelotomy stent placement. He recovered well and followed up with serial USG abdomen and DTPA renogram after endopyelotomy stent removal at 6 weeks.
In this series there was no Ureteric leak complication. This may be due to routine practice of DJ Stenting and keeping it in place for 2 weeks which may have reduced incidence of early urinary leak. Since there was no urinary leak on our study and study done by Shringarpue et al. as compared to 0.97% incidence in study done by Rana et al. statistical comparison was not possible.
Four cases of Lymphorea were recorded. All patients required Betadine installation once or twice. Of these four patients three patients received a cadaveric kidney [Table 3].
|Table 3: Comparison of lymphatic complication with other contemporary series|
Click here to view
The incidence of lymphocele formation in present study was 4 out of 145 cases studied (2.75%). This study compared to study by Shringarpure et al. showed a P = 0.07 which was statistically insignificant. However, compared to the study by Birkin et al., the P = 0.0009 which was statistically significant.
Lymphocele or lymphorea has a reported incidence rate of 0.6%–20%. Risks for Lymphocele development include acute rejection, lymphatic vessel connection, high-dose steroid therapy, large peri vascular dissection, and increased tissue trauma with conventional surgical procedures instead of minimally invasive surgery. Collection is usually minimal and resolves spontaneously without clinical signs.
In our series incidence of lymphocele/lymphorea was significantly lower than contemporary studies. The possible reasons could be firstly, majority of transplants done in present series are live related donor transplantation compared to other series like Bikran et al. in which series 17 out of 26 cases had cadaveric transplants. In our series 3 out of 4 lymphorea patients had received deceased donor kidney. It is possibly due to en-block removal of kidneys. Secondly, incidence of acute tubular necrosis (12 cases, 8.2%) and graft acute rejection (3 cases, 2.06%) remained low in our series. ATN and acute graft rejection are associated with higher incidence of lymphocele formation. Lastly, all donor kidney retrieval were done with meticulous ligation of lymphatics.
The incidence of SSI was 2 out of 145 cases studied (1.4%) which compared to the study by Shrinarpue et al. and Harris et al. is significantly lower (P < .05) [Table 4]. These cases were managed by Swab culture-based antibiotics with resolution of infection. One patient required secondary suturing after resolution of infection.
|Table 4: Comparison of surgical site infection with other contemporary series|
Click here to view
The risk factors for SSI include reoperation, chronic glomerulonephritis, acute graft rejection, delayed graft function, diabetes, lymphocele and high BMI. In our series the possible reason for low incidence of SSI was low incidence of acute rejection (2.0%) and lymphocele (2.7%) as compared to contemporary studies. More so none of the recipients had BMI > 30 kg/m2 which is the risk factor for SSI.
In our study there was one (0.68%) case of stricture urethra. He was managed conservatively with serial dilatation [Table 5]. This study compared to the study by Rana et al. and Xie et al. showed P = 0.66 and 0.83 respectively which was statistically insignificant. As per Xie et al. most common site of stricture in renal transplant recipients is bulbo-memberanous junction followed by submeatal stricture and the common etiological factors are urinary tract infection and cystoscopy. The most likely cause in our case was cystoscopy while Double J stent removal.
|Table 5: Comparison of urethral stricture with other contemporary series|
Click here to view
On mean follow-up for 7 months of 11 patients with various surgical complication 9 recipients were off dialysis, one underwent 2nd transplant and off dialysis one recipient continued on dialysis.
| Conclusion|| |
The incidence of major vascular complications remained low both in live-related and deceased donor transplant cases. Graft loss is imminent in case of Renal artery thrombosis/aneurysm and renal artery stenosis can be managed with endovascular intervention in transplant kidney. Renal vein complications are rarity and lymphorea/lymphocele can be significantly reduced with meticulous lymphatic ligation. Ureteric complications can be minimised with careful ureter handling during graft retrieval and meticulous uretero-vesical anastomosis. Surgical Complication rates were noted to be higher in deceased donor transplant group compared to live related cases. Early diagnosis and effective management of surgical complications were associated with both better Graft and patient survival after 3 months of follow-up in this study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Trivedi HL. Nephrology and kidney transplantation in India: Past, present and future, Indian J Transplant 2014;8:10-3.
Shringarpure S, Venkatraman BM, Sivaraman CP, Thachil JV, Khakhar A. An institutional based study of post-operative surgical complications of live related renal transplant recipients. Indian J Transplant 2013;4:46.
Barker CF, Markmann JF. Historical overview of transplantation. Cold Spring Harb Perspect Med 2013;3:a014977.
Rana YP, Singh DV, Gupta SK, Pradhan AA, Talwar R, Harkar S, et al
. Urological and vascular complications in 720 renal transplantations- lessons learned. Indian J Transplant 2012;6:3.
Aktas S, Boyvat F, Sevmis S, Moray G, Karakayali H, Haberal M. Analysis of vascular complications after renal transplantation. Transplant Proc 2011;43:557-61.
Rastogi A, Yuan S, Arman F, Simon L, Shaffer K, Kamgar M, et al.
Blood pressure and living kidney donors: A clinical perspective. Transplant Direct 2019;5:e488.
Srivastava A, Kumar J, Sharma S, Abhishek, Ansari MS, Kapoor R. Vascular complication in live related renal transplant: An experience of 1945 cases. Indian J Urol 2013;29:42-7.
] [Full text]
Bozkurt B, Gurkan Dumlu E, Tokac M, Kılıc M, Deniz Ayli M. Incidence of lymphoceles in patients undergoing Renal transplantation and the effect of Povidone Iodine in treatment. Indian J Transplant 2013;7:70-3. [Full text]
El Zorkany K, Bridson JM, Sharma A, Halawa A. Transplant renal vein thrombosis. Exp Clin Transplant 2017;15:123-9.
Kumar S, Ameli-Renani S, Hakim A, Jeon JH, Shrivastava S, Patel U. Ureteral obstruction following renal transplantation: Causes, diagnosis and management. Br J Radiol 2014;87:20140169.
Duty BD, Barry JM. Diagnosis and management of ureteral complications following renal transplantation. Asian J Urol 2015;2:202-7.
Ranghino A, Segoloni GP, Lasaponara F, Biancone L. Lymphatic disorders after renal transplantation: New insights for an old complication. Clin Kidney J 2015;8:615-22.
Harris AD, Fleming B, Bromberg JS, Rock P, Nkonge G, Emerick M, et al.
Surgical site infection after renal transplantation. Infect Control Hosp Epidemiol 2015;36:417-23.
Xie L, Lin T, Wazir R, Wang K, Lu Y. The management of urethral stricture after kidney transplantation. Int Urol Nephrol 2014;46:2143-5.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]