Post-transplant renal failure
From IDWiki
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
- 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
Immediate Dysfunction
- Hyperacute rejection, often diagnosed intraoperatively on reperfusion of transplant
- Postischemic acute tubular necrosis causing delayed graft function
- Volume depletion
- Surgical complications:
- 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
- Vascular thrombosis (either transplant renal artery or vein)
- Atheroembolism
- Calcium oxalate deposits
Early and Late Dysfunction
- Acute rejection, usually within the first 12 months
- Either cellular (usually after the first week) or antibody-mediated
- 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
- Recurrent primary disease
- 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
- Viral infections, including BK virus and CMV, and, rarely, adenovirus
- 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
Investigations
Acute Allograft Dysfunction
- Tacrolimus or cyclosporine levels
- BK level
- dd-cfDNA level
- US with Dopplers of renal artery and vein, looking for collections, thombosis, and patency of ureter
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 viral load
- If viral load of 10,000 copies/mL or greater, decrease immunosuppression and trend every 2 to 4 weeks
- 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: 10.1016/j.mcna.2016.01.002