Post-transplant renal failure - Revision history

Aidan at 17:57, 15 February 2022

2022-02-15T17:57:07Z

← Older revision		Revision as of 17:57, 15 February 2022
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	* Viral infections, including [[BK virus]] and [[CMV]], and, rarely, [[adenovirus]]		* Viral infections, including [[BK virus]] and [[CMV]], and, rarely, [[adenovirus]]
	* New glomerular disease		* New glomerular disease
			**Atypical HUS (>50%)
			**Membranoproliferative GN, including type 1 (20-50%) and type 2 (>50%)
			**Focal segmental glomerulosclerosis (20-40%)
			**IgA nephropathy (10-25%)
			**Membranous nephropathy (5-30%)
			**ANCA-associated GN (15-20%)
			**Lupus (5-30%)
			**Anti-GBM disease (<5%)
	* Less commonly, retained ureteral stent and arteriovenous fistula after kidney allograft biopsy		* Less commonly, retained ureteral stent and arteriovenous fistula after kidney allograft biopsy

Aidan at 17:50, 15 February 2022

2022-02-15T17:50:01Z

← Older revision		Revision as of 17:50, 15 February 2022
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	** Chronic allograft dysfunction, with slowly worsening renal function		** Chronic allograft dysfunction, with slowly worsening renal function
	** Delayed graft function, where dialysis is required within the first week of transplantation		** Delayed graft function, where dialysis is required within the first week of transplantation
			*May also be classified as:
			**Immediate or hyperacute (<1 week post-transplant)
			**Early (within 6 months post-transplant)
			**Late (6 or more months post-transplant)

	== Differential Diagnosis ==		== Differential Diagnosis ==

	=== Immediate ~~(<1 week)~~ ===		=== Immediate Dysfunction ===

			* Hyperacute rejection, often diagnosed intraoperatively on reperfusion of transplant
	* Postischemic acute tubular necrosis		*Postischemic acute tubular necrosis causing delayed graft function
	* Hyperacute rejection
	* Volume depletion		* Volume depletion
			* Surgical complications:
⚫	* ~~Surgical complications: vascular thrombosis, fluid~~ collections (lymphocele, urinoma, perinephric hematoma)~~, multiple renal arteries~~
			**Vascular thrombosis (either transplant renal artery or vein)
			***RAT: painless anuria and AKI, high risk of graft loss
		⚫	**Fluid collections (lymphocele, urinoma, perinephric hematoma)
			**Multiple renal arteries
	* Atheroembolism		* Atheroembolism
	* Calcium oxalate deposits		* Calcium oxalate deposits

	=== Early and Late ===		=== Early and Late Dysfunction ===

	* Acute rejection, usually within the first 12 months		* Acute rejection, usually within the first 12 months
			** Either cellular (usually after the first week) or antibody-mediated
	** Often with fever, oliguria, and graft pain or tenderness
	* Calcineurin inhibitor nephrotoxicity, usually within the first three months		* Calcineurin inhibitor nephrotoxicity, usually within the first three months
			*Fluid collections (usually early)
			**Urinoma (within first few weeks)
			**Lymphocele (usually 2 to 6 weeks, but can be up to one year)
	* Thrombotic microangiopathy		* Thrombotic microangiopathy
	* Recurrent primary disease		* Recurrent primary disease
	* Transplant renal artery stenosis		* Transplant renal artery stenosis (usually late), caused by recurrent infections, rejection, or [[BK virus]]
			* Urinary obstruction, from bladder or ureteric obstruction, which can result from fluid collections, [[urolithiasis]], bladder dysfunction (especially in [[diabetes]]), or [[benign prostatic hypertrophy]]
	* Urinary obstruction
	* Viral infections, including [[BK virus]] and [[CMV]], and, rarely, [[adenovirus]]		* Viral infections, including [[BK virus]] and [[CMV]], and, rarely, [[adenovirus]]
	* New glomerular disease		* New glomerular disease
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	* BK level		* BK level
	* dd-cfDNA level		* dd-cfDNA level
			*US with Dopplers of renal artery and vein, looking for collections, thombosis, and patency of ureter

	== Management ==		== Management ==
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	* If above fails, check dd-cfDNA and [[BK virus\|BK viral load]]		* If above fails, check dd-cfDNA and [[BK virus\|BK viral load]]
	** If viral load of 10,000 copies/mL or greater, decrease immunosuppression and trend every 2 to 4 weeks		** If viral load of 10,000 copies/mL or greater, decrease immunosuppression and trend every 2 to 4 weeks
	* If above fails,		* If above fails, allograft biopsy is needed

			== Further Reading ==

			* Acute and Chronic Allograft Dysfunction in Kidney Transplant Recipients. ''Medical Clin North America''. 2016;100(3):487-503. doi: [https://doi.org/10.1016/j.mcna.2016.01.002 10.1016/j.mcna.2016.01.002]

Aidan: Created page with "== Background == * Common complication of renal transplant * May be broadly classified as: ** Acute allograft dysfunction, with increase in serum creatinine, failure of creat..."

2022-02-15T17:32:48Z

Created page with "== Background == * Common complication of renal transplant * May be broadly classified as: ** Acute allograft dysfunction, with increase in serum creatinine, failure of creat..."

New page

== Background ==

* Common complication of renal transplant
* May be broadly classified as:
** Acute allograft dysfunction, with increase in serum creatinine, failure of creatinine to decrease after transplantation, or proteinuria within about 1 to 3 months
** Chronic allograft dysfunction, with slowly worsening renal function
** Delayed graft function, where dialysis is required within the first week of transplantation

== Differential Diagnosis ==

=== Immediate (<1 week) ===

* Postischemic acute tubular necrosis
* Hyperacute rejection
* Volume depletion
* Surgical complications: vascular thrombosis, fluid collections (lymphocele, urinoma, perinephric hematoma), multiple renal arteries
* Atheroembolism
* Calcium oxalate deposits

=== Early and Late ===

* Acute rejection, usually within the first 12 months
** Often with fever, oliguria, and graft pain or tenderness
* Calcineurin inhibitor nephrotoxicity, usually within the first three months
* Thrombotic microangiopathy
* Recurrent primary disease
* Transplant renal artery stenosis
* Urinary obstruction
* Viral infections, including [[BK virus]] and [[CMV]], and, rarely, [[adenovirus]]
* New glomerular disease
* Less commonly, retained ureteral stent and arteriovenous fistula after kidney allograft biopsy

== Investigations ==

=== Acute Allograft Dysfunction ===

* Tacrolimus or cyclosporine levels
* BK level
* dd-cfDNA level

== Management ==

=== Acute Allograft Dysfunction ===

* For patients >1 week post transplantation
* If fever, abdominal pain, or graft tenderness, assess for [[pyelonephritis]]
* If hypovolemic, increase oral fluid and follow creatinine
* If recent medication change, change it back and follow creatinine
* If CNI is supratherapeutic, decrease it and follow creatinine and CNI levels
* If above fails, check dd-cfDNA and [[BK virus|BK viral load]]
** If viral load of 10,000 copies/mL or greater, decrease immunosuppression and trend every 2 to 4 weeks
* If above fails,