Post-transplant renal failure

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

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

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

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 viral load
- If viral load of 10,000 copies/mL or greater, decrease immunosuppression and trend every 2 to 4 weeks
If above fails,