Urological Complications after Renal Transplantation: A Single Center Review on 1100 Cases

A retrospective review of 1100 cases of consecutive live-donor renal transplants done between 1989 and 2002 in the Department of Urology and Renal Transplantation SGPGIMS, Lucknow was carried out by Drs. H. Chaudhary; A. Arivastava; R. Sridhar and A. Kumar. It was done to determine the incidence and management of urological complications assess the possible risk factors and the effect on patient and graft survival.

The overall incidence of urological complications was 12.81% and occurred at a mean interval of 10.2 days (1-264 days) after renal transplantation.  Uretero-neocysostomy was stented in 893 cases. It was found that urinary leaks and obstruction occurred in only 0.56% and 0.11% when stents were used as copared to 4.8% and 0.22% in non-stunted cases respectively. Would infections occur in 5.8% cases. Other complications included lymphocele in 9% and urethral stricture in 2.1%. Risk of these complications was not found to correlate with donor or recipient factors. Also these complications and their surgical treatment did not after the graft and patient survival. In Conclusion, it was found that routine use of stents in uretero-neocystostomy significantly lowered the incidence of urological complications. Also routine ultrasound in the postoperative period was important for early detection of problems.

Incidence of Malignancy in Renal Transplant Reciepients

Long- Term immunosuppression is known to malignancy. Drs.K.D.Gohel, S.gang, L.J.Shah, A.Gunju, M.M.Rajpurkar and V.N.Acharya, Muljibhai Patel Urological Hospital, Nadiad, Gujarati undertook a retrospective analyse os the incidence and type of malignancy in 850 renal allograft recipients. These recipients had their transplants between April 1980 and October 1988. Out of the 850 recipients, 559 (65.%) were on 3-drug immonosuppression (Cy A+ Aza+Pred) and 291 (34.2%) were on 2-drug immunosuppression (Aza+Pred). The incidence of malignancy was 9/850 (1.06%) with 6 cases (66.7%) being detected in triple immunosuppression (<5years=4 cases, > 5years=2 cases) and 3 cases (33.3%) being detected in dual immunosuppression (<5years=0 cases, >5years=3cases). No specific type of malignancy was found to be prominant. Also skin cancer, although reported in the literature, was notable by its absence. Details of the detected malignancies are given below in the table:

*R=Related, DR=Unrelated, Er= Emotionally related, **?LFU=Left for Follow up.

                 Incidence of Malignancy in Renal Transplant Receipts

Pediatric Renal Transplantation – the Bangalore Experience

Should renal transplantation be the treatment of choice for children with end-stage renal disease (ESRD)?  Drs. K. D. Phadke and P. Anil Kumar of the Children’s Kidney Care Centre, Department of Paediatrics, St. Johns’s Medical College Hospital, Bangalore analyzed their experience with 16 renal transplantations performed over the last three years in children between the ages of 4-18 years (mean = 12.25 years). The weight of the children ranged from 10-40 kg (mean =24.62 kg). The male to female ratio was 4.3:1, 11 children had tubulointerstitial disease and five children had glomerular disease. The donors were mother (13), father(1), maternal uncle (1) and cadaver (1). Triple immnunosuppression including cyclosporine, azathioprine and steroids was used in all patients. Cyclophosphamide was used in the first month instead of azathioprine in one patient later had a recurrence of the same, which responded to plasmapheresis. One patient developed immune thrombocytopenia on cyclosporine and so cyclosporine was replaced by mycophenolate mofetil.

During the follow-up period of 3 months to 3 years, one patient had graft loss due to vascular thrombosis. Acute rejection was seen in one patient after one-and-a-half years, probable precipitated by infection. Chronic rejection was seen in two patients. 13 out of 16 children had normal renal functions.  Acute tubular neurosis (ATN) was seen in four patients. The recovery period of ATN ranged from four days to one month. Significant infections included urinary tract infection (4) and herpes zoster (1). Graft survival at one year was 88.88%. The analysis showed that renal transplantation was lifesaving to children with ESRD while also giving them good quality of life and, therefore, should be the treatment to choice. 

Cardiovascular Disease after Renal Transplantation

Cardiovascular disease is the main cause of mortality after transplantation.  258 patients were evaluated retrospectively to assess the incidence of cardiovascular disease and its relation to risk factors like hypertension, hyperlipidemia, polycythemia and acute rejection. The average follow-up period was 42.4 months. Incidence of ischemic heart disease (IHD) among all patients (with or without pre-transplant (IHD) was seen in 32 patients (12.4%), peripheral vascular disease in 20 patients (7.7%) and cerebrovascular even in 2.3%. Incidence of pre-transplant IHD was found in 12 patients who were otherwise asymptomatic. Incidence of Post-transplant IHD was seen in 20 patients, two patients underwent angioplasty, while 18 patients were managed conservatively of whom two patients had sudden cardiac death post-transplant. Hypertension was seen in 241 patients. 156 patients had well controlled hypertension but significant cardiovascular disease was found in 59.4% of these patients and serum creatinine > 1.4 mg% in 27.5% of them. Of the 85 (32.9%) patients who had uncontrolled hypertension, 40.6% showed cardiovascular disease and serum creatinine was >1.4mg% in 83.5% of them:

Of the 106 patients who had lipid profiles available, 62 patients (53.4%) had dyslipidemia, four out of the 62 patients (6.4%) had cardiovascular disease while 1.1% with normal lipid profile had cardiac event.

Post-transplant polycythemia was seen in 45 patients of whom six patients had cardiovascular event. Acute rejection was seen in seven out of 32 patients with cardiocvascular disease and were treated with methyl red/ IORT3 or OKT3. This evaluation, which was done by Drs. A. Kaul, R. K. Sharma , A. Gupta, N. Sinha, S. Gulati and A. P. Sharma of the Department of Nephrology & Cardiology, SGPGIMS, Lucknow, pointed out the need for aggressive identification of risk factors for cardiovascular disease to decrease its incidence in the post transplant period.

Blood Group Compatibility and Graft Survival

A retrospective study to evaluate the impact of blood group match on graft survival in renal allograft recipients was done by Drs. Manjusha, K. V. Dakshinamurthy, Neela Prasad and D.S.B. Raju, Department of Nephrology. Nizam’s Institute of Medical Sciences, Hyderanad. The data of 139 recipients who had renal allografts between 1992 and 2003 and who had had at least one-year follow up was studied. Out of the 139 recipients, six were cadaveric allografts and the remaining 133 were live allograft. All patients received triple immunosuppressive therapy. Various aspects of patient’s data were analysed and a comparison was done between identical and non-identical blood group matches. It was found that the male-female ratio was 114:25. The mean age of the recipients was 34.9+10.9 years ( range=12-57 years). The mean age of the donor was 38.9+4 years (range=19-56 years). The donors were parents in 51 cases, siblings in 46 cases, spouse in 13 cases, distant relation in 13 cases, childen in 9 cases and cadaver in 6 cases.   

The sex distribution of the donor and the recipient pairs was as follows: Mjuf:6, FjuM:56, MjuM:39, FjuF:17. The blood group distribution was : (Donor recipient) OjuO(70), OjuA(3), OjuB(6), AjuA(22), BjuB(33), ABjuAB(4)%, The mean creatinine at 5 years in different groups was OjuO-1.63+0.97mg%, BjuB-1.42+0.53mg%, AjuA-1.62+0.97mg%, AjuAB1.65+1mg%, OjuA-1.76+0.84mg%, OjuB-1.1+0.34mg%. The total number of rejection episodes in these groups was 48 (38.4%) in the 5 year followup. The distribution wa :OjuO-27(56.25), AjuA-11 (22.91%), ABjuAB-1 (2.08%), BjuB-9(18.75%). Overall graft and patient survival was as follows: