Kidney transplantation

Kidney transplantation or renal transplantation is the organ transplant of a kidney into a patient
with end-stage renal disease. Kidney transplantation is typically classified as deceased-donor
(formerly known as cadaveric) or living-donor transplantation depending on the source of the donor
organ.

Common Causes of End-Stage Renal Disease

 Diabetes mellitus
 High blood pressure
 Glomerulonephritis
 Polycystic Kidney Disease
 Severe anatomical problems of the urinary tract

Indications
The indication for kidney transplantation is end-stage renal disease (ESRD), regardless of the
primary cause. This is defined as a glomerular filtration rate < 15 ml/min/1.73 m2.
Common diseases leading to ESRD include malignant hypertension, infections, diabetes mellitus,
and focal segmental glomerulosclerosis; genetic causes include polycystic kidney disease, a number
of inborn errors of metabolism, and autoimmune conditions such as lupus.
Diabetes is the most common known cause of kidney transplantation, accounting for approximately
25% of those in the US. The majority of renal transplant recipients are on dialysis (peritoneal
dialysis or hemodialysis) at the time of transplantation. However, individuals with chronic kidney
disease who have a living donor available may undergo pre-emptive transplantation before dialysis
is needed. If a patient is put on the waiting list for a deceased donor transplant early enough, they
may also be transplanted pre-dialysis.

Contraindications
Contraindications include both cardiac and pulmonary insufficiency, as well as hepatic disease and
some cancers. Concurrent tobacco use and morbid obesity are also among the indicators putting a
patient at a higher risk for surgical complications.

Sources of kidneys
Living donors
Sometimes family members, including brothers, sisters, parents, children (18 years or
older), uncles, aunts, cousins, or a spouse or close friend may wish to donate a kidney.
That person is called a "living donor." The donor must be in excellent health, well informed
about transplantation, and able to give informed consent. Any healthy person can donate a
kidney safely.
 Deceased donors
A deceased donor kidney comes from a person who has suffered brain death. The Uniform
Anatomical Gift Act allows everyone to consent to organ donation for transplantation at the
time of death and allows families to provide such permission as well. After permission for
donation is granted, the kidneys are removed and stored until a recipient has been selected.

Deceased donors can be divided in two groups:

 Brain-dead (BD) donors

 Donation after Cardiac Death (DCD) donors

Transplant Evaluation Process

Regardless of the type of kidney transplant-living donor or deceased donor-special blood

tests are needed to find out what type of blood and tissue is present. These test results help
to match a donor kidney to the recipient.
Blood Type Testing
The first test establishes the blood type. There are four blood types: A, B, AB, and O.
Everyone fits into one of these inherited groups. The recipient and donor should have either
the same blood type or compatible ones, unless they are participating in a special program
that allow donation across blood types. The list below shows compatible types:
 If the recipient blood type is A Donor blood type must be A or O
 If the recipient blood type is B Donor blood type must be B or O
 If the recipient blood type is O Donor blood type must be O
 If the recipient blood type is AB Donor blood type can be A, B, AB, or O
The AB blood type is the easiest to match because that individual accepts all other blood
types.
Blood type O is the hardest to match. Although people with blood type O can donate to all
types, they can only receive kidneys from blood type O donors. For example, if a patient
with blood type O received a kidney from a donor with blood type A, the body would
recognize the donor kidney as foreign and destroy it.
Tissue Typing
The second test, which is a blood test for human leukocyte antigens (HLA), is called tissue
typing. Antigens are markers found on many cells of the body that distinguish each
individual as unique. These markers are inherited from the parents. Both recipients and any
potential donors have tissue typing performed during the evaluation process.
To receive a kidney where recipient's markers and the donor's markers all are the same is a
"perfect match" kidney. Perfect match transplants have the best chance of working for many
years. Most perfect match kidney transplants come from siblings.
Although tissue typing is done despite partial or absent HLA match with some degree of
"mismatch" between the recipient and donor.
 Crossmatch
Throughout life, the body makes substances called antibodies that act to destroy foreign
materials. Individuals may make antibodies each time there is an infection, with pregnancy,
have a blood transfusion, or undergo a kidney transplant. If there are antibodies to the
donor kidney, the body may destroy the kidney. For this reason, when a donor kidney is
available, a test called a crossmatch is done to ensure the recipient does not have pre-
formed antibodies to the donor .
The crossmatch is done by mixing the recipient's blood with cells from the donor. If the
crossmatch is positive, it means that there are antibodies against the donor. The recipient
should not receive this particular kidney unless a special treatment is done before
transplantation to reduce the antibody levels. If the crossmatch is negative, it means the
recipient does not have antibodies to the donor and that they are eligible to receive this
kidney.
Crossmatches are performed several times during preparation for a living donor transplant,
and a final crossmatch is performed within 48 hours before this type of transplant.
Serology
Testing is also done for viruses, such as HIV (human immunodeficiency virus), hepatitis,
and CMV (cytomegalovirus) to select the proper preventive medications after transplant.
These viruses are checked in any potential donor to help prevent spreading disease to the
recipient.
Pre-transplant Period
This period refers to the time that a patient is on the deceased donor waiting list or prior to
the completion of the evaluation of a potential living donor. The recipient undergoes testing
to ensure the safety of the operation and the ability to tolerate the anti-rejection medication
necessary after transplantation. The type of tests varies by age, gender, cause of renal
disease, and other concomitant medical conditions. These may include, but are not limited
to:
 General Health Maintenance: general metabolic laboratory tests, coagulation studies,
complete blood count, colonoscopy, pap smear and mammogram (women) and prostate
(men)
 Cardiovascular Evaluation: electrocardiogram, stress test, echocardiogram, cardiac
catheterization
 Pulmonary Evaluation: chest x-ray, spirometry

Potential Reasons of Excluding Transplant Recipient

 Uncorrectable cardiovascular disease
 History of metastatic cancer or ongoing chemotherapy
 Active systemic infections
 Uncontrollable psychiatric illness
 Current substance abuse
 Current neurological impairment with significant cognitive impairment and no surrogate
decision maker
 Procedure
In most cases the barely functioning existing kidneys are not removed, as removal has been shown
to increase the rates of surgical morbidity. Therefore, the kidney is usually placed in a location
different from the original kidney. Often this is in the iliac fossa so it is often necessary to use a
different blood supply:

 The renal artery of the new kidney, previously branching from the abdominal aorta in the donor,
is often connected to the external iliac artery in the recipient.
 The renal vein of the new kidney, previously draining to the inferior vena cava in the donor, is
often connected to the external iliac vein in the recipient.
The donor ureter is anastomosed with the recipient bladder.

Transplant Surgery
The transplant surgery is performed under general anesthesia. The operation usually takes
2-4 hours. This type of operation is a heterotopic transplant meaning the kidney is placed in
a different location than the existing kidneys. (Liver and heart transplants are orthotopic
transplants, in which the diseased organ is removed and the transplanted organ is placed in
the same location.) The kidney transplant is placed in the front (anterior) part of the lower
abdomen, in the pelvis.
The original kidneys are not usually removed unless they are causing severe problems such
as uncontrollable high blood pressure, frequent kidney infections, or are greatly enlarged.
The artery that carries blood to the kidney and the vein that carries blood away is surgically
connected to the artery and vein already existing in the pelvis of the recipient. The ureter, or
tube, that carries urine from the kidney is connected to the bladder. Recovery in the hospital
is usually 3-7 days.
Complications can occur with any surgery. The following complications do not occur often
but can include:
 Bleeding, infection, or wound healing problems.
 Difficulty with blood circulation to the kidney or problem with flow of urine from the kidney.
These complications may require another operation to correct them.

Post operation
The transplant surgery takes about three hours.[45] The donor kidney will be placed in the lower
abdomen and its blood vessels connected to arteries and veins in the recipient's body. When this is
complete, blood will be allowed to flow through the kidney again. The final step is connecting the
ureter from the donor kidney to the bladder. In most cases, the kidney will soon start producing
urine.
Depending on its quality, the new kidney usually begins functioning immediately. Living donor
kidneys normally require 3–5 days to reach normal functioning levels, while cadaveric donations
stretch that interval to 7–15 days. Hospital stay is typically for 4–10 days. If complications arise,
additional medications (diuretics) may be administered to help the kidney produce urine.
 Immunosuppressant drugs are used to suppress the immune system from rejecting the donor
kidney. These medicines must be taken for the rest of the recipient's life. The most common
medication regimen today is a mixture of tacrolimus, mycophenolate, and prednisolone. Some
recipients may instead take ciclosporin, sirolimus, or azathioprine. The risk of early rejection of the
transplanted kidney is increased if corticosteroids are avoided or withdrawn after the
transplantation.[46] Ciclosporin, considered a breakthrough immunosuppressive when first discovered
in the 1980s, ironically causes nephrotoxicity and can result in iatrogenic damage to the newly
transplanted kidney. Tacrolimus, which is a similar drug, also causes nephrotoxicity. Blood levels of
both must be monitored closely and if the recipient seems to have declining renal function or
proteinuria, a biopsy may be necessary to determine whether this is due to rejection [47][48] or
ciclosporin or tacrolimus intoxication .

Post Transplant Period

The post transplant period requires close monitoring of the kidney function, early signs of
rejection, adjustments of the various medications, and vigilance for the increased incidence
of immunosuppression-related effects such as infections and cancer.
Just as the body fights off bacteria and viruses (germs) that cause illness, it also can fight
off the transplanted organ because it is a "foreign object." When the body fights off the
transplanted kidney, rejection occurs.
Rejection is an expected side effect of transplantation and up to 30% of people who receive
a kidney transplant will experience some degree of rejection. Most rejections occur within
six months after transplantation, but can occur at any time, even years later. Prompt
treatment can reverse the rejection in most cases.
Anti-Rejection Medications

Anti-rejection medications, also known as immunosuppressive agents, help to prevent and

treat rejection. They are necessary for the "lifetime" of the transplant. If these medications
are stopped, rejection may occur and the kidney transplant will fail.
Below is a list of medications that might be used after a kidney transplant. A combination of
these drugs will be prescribed dependent on the specific transplant needs.
Anti-inflammatory Medication
Prednisone is taken orally or intravenously. Most side effects of prednisone are related to
drug dosage levels. Prednisone is used at low dosages to minimize side effects. The
possible side effects of prednisone are:
 Changes in physical appearance such as puffiness of the face and weight gain.
 Irritation to the stomach lining.
 Increased risk of bruising and decreased rate of healing.
 Increased sugar level in the blood (steroid-induced diabetes).
 Unexplained mood changes. This may mean depression, irritability, or high spirits.
 General muscle weakness or pain in knees or joints.
 Formation of cataracts. A clouding of the lens of the eye occurs infrequently with long-term
use of prednisone.
 Anti-proliferative Medications
Azathioprine (Imuran®) is taken orally or intravenously. The most common side effects
associated with azathioprine are:
 Thinning of hair
 Irritation of the liver
 Decreased white blood cell count
Mycophenolate mofetil (CellCept®) is taken orally. The most common side effects of
mycophenolate mofetil are:
 Abdominal aches and/or diarrhea
 Decreased white blood cell count
 Decreased red blood cell count
Mycophenolate sodium (Myfortic®) is taken orally. It provides the same active ingredient as
mycophenolate mofetil and generally has the same side effect profile. It is enterically coated
to potentially reduce abdominal aches and diarrhea.
Sirolimus (Rapamune®) is taken orally. The most common side effects of sirolimus are:
 Decreased platelet count
 Decreased white blood cell count
 Decreased red blood cell count
 Elevated cholesterol and triglycerides
Cytokine Inhibitors
Cyclosporine (Neoral®, Gengraf®) is taken orally. The most common side effects of
cyclosporine therapy are:
 Kidney dysfunction
 Tremors
 Irritation of the liver
 Excessive body hair growth
 High blood pressure
 Swollen/bleeding gums
 High potassium in the blood
 Increased sugar level in the blood (drug-induced diabetes)
Tacrolimus (Prograf®) is taken orally. The most common side effects of tacrolimus therapy
are:
 Kidney dysfunction
 High blood pressure
 High potassium in the blood
 Increased sugar level in the blood (drug-induced diabetes)
 Tremors
 Headaches
 Insomnia
Antilymphocyte Medications
Antithymocyte globulin (Thymoglobulin®) is given intravenously. Thymoglobulin can cause:
 Decreased white blood cell and platelet counts
 Sweating
 Itching
 Rash
 Fever
Muromonab-CD3 (OKT3®) is given intravenously and can cause:
 Chills
 Fever
 Diarrhea
 Headache
 Shortness of breath
Anti-interleukin-2 Receptor Antibody (Zenapax® or Simulect®) These two drugs are given
intravenously. These medications rarely cause side effects but can include:
 Chills
 Headache
 Allergic reaction
Alemtuzumab (Campath®)
 Fever
 Chills
 Rash
 Shortness of breath
 Decreased white blood cell counts

Complications
Problems after a transplant may include: Post operative complication, bleeding, infection, vascular
thrombosis and urinary complications

 Transplant rejection (hyperacute, acute or chronic)

 Infections and sepsis due to the immunosuppressant drugs that are required to decrease risk of
rejection
 Post-transplant lymphoproliferative disorder (a form of lymphoma due to the immune
suppressants)
 Imbalances in electrolytes including calcium and phosphate which can lead to bone problems
 Proteinuria[48]
 Hypertension
 Other side effects of medications including gastrointestinal inflammation and ulceration of the
stomach and esophagus, hirsutism(excessive hair growth in a male-pattern distribution) with
ciclosporin, hair loss with tacrolimus, obesity, acne, diabetes mellitus type
2, hypercholesterolemia, and osteoporosis.
The average lifetime for a donated kidney is ten to fifteen years. When a transplant fails, a patient
may opt for a second transplant, and may have to return to dialysis for some intermediary time.
Infections due to the immunosuppressant drugs used in people with kidney transplants most
commonly occur in mucocutaneous areas (41%), the urinary tract (17%) and the respiratory tract
(14%).[52] The most common infective agents are bacterial (46%), viral (41%), fungal (13%), and
 protozoan (1%).[52] Of the viral illnesses, the most common agents are human
cytomegalovirus (31.5%), herpes simplex (23.4%), and herpes zoster (23.4%).[52] BK virus is now
being increasingly recognised. Infection is the cause of death in about one third of people with renal
transplants, and pneumonias account for 50% of the patient deaths from infection.[5

Living Donor Kidney Transplantation

Living donor kidney transplants are the best option for many patients for several reasons.
 Better long-term results
 No need to wait on the transplant waiting list for a kidney from a deceased donor
 Surgery can be planned at a time convenient for both the donor and recipient
 Lower risks of complications or rejection, and better early function of the transplanted
kidney
Any healthy person can donate a kidney. When a living person donates a kidney the
remaining kidney will enlarge slightly as it takes over the work of two kidneys. Donors do not
need medication or special diets once they recover from surgery. As with any major
operation, there is a chance of complications, but kidney donors have the same life
expectancy, general health, and kidney function as most other people. The kidney loss does
not interfere with a woman's ability to have children.
Potential Barriers to Living Donation
 Age < 18 years unless an emancipated minor
 Uncontrollable hypertension
 History of pulmonary embolism or recurrent thrombosis
 Bleeding disorders
 Uncontrollable psychiatric illness
 Morbid obesity
 Uncontrollable cardiovascular disease
 Conronic lung disease with impairment of oxygenation or ventilation
 History of melanoma
 History of metastatic cancer
 Bilateral or recurrent nephrolithiasis (kidney stones)
 Chronic Kidney Disease (CKD) stage 3 or less
 Proteinuria > 300 mg/d excluding postural proteinuria
 HIV infection
If a person successfully completes a full medical, surgical, and psychosocial evaluation they
will undergo the removal of one kidney. Most transplant centers in the United States use a
laparoscopic surgical technique for the kidney removal. This form of surgery, performed
under general anesthesia, uses very small incisions, a thin scope with a camera to view
inside of the body, and wand-like instruments to remove the kidney. Compared with the
large incision operation used in the past, laparoscopic surgery has greatly improved the
donor's recovery process in several ways:
 Decreased need for strong pain medications
 Shorter recovery time in the hospital
 Quicker return to normal activities
 Very low complication rate
The operation takes 2-3 hours. Recovery time in the hospital is typically 1-3 days. Donors
often are able to return to work as soon as 2-3 weeks after the procedure.
Occasionally the kidney needs to be removed through an open incision in the flank region.
Prior to the use of the laparoscopic technique, this surgery was the standard for the removal
of the donated kidney. It involves a 5-7 inch incision on the side, division of muscle and
removal of the tip of the twelfth rib. The operation typically lasts 3 hours and the recovery in
the hospital averages 4-5 days with time out of work of 6-8 weeks.
Although laparoscopy is increasingly used over open surgery, from time to time, the
surgeon may elect to do an open procedure when individual anatomic differences in the
donor suggest that this will be a better surgical approach.
The quality and function of the kidneys recovered with either technique work equally well.
Regardless of technique all donors will require lifelong monitoring of their overall health,
blood pressure and kidney function.

Special Programs For Living Donor Transplantation

Many patients have relatives or non-relatives who wish to donate a kidney but are not able
to because their blood type or tissue type does not match. In such cases, the donor and
recipient are said to be "incompatible."
See also: National Kidney Registry
Live Donor to Deceased Donor Waiting List Exchange
This program is a way for a living donor to benefit a loved one, even if their blood or tissue
types do not match. The donor gives a kidney to another patient who has a compatible
blood type and is at the top of the kidney waiting list for a "deceased donor" kidney. In
exchange, that donor's relative or friend would move to a higher position on the deceased
donor waiting list, a position equal to that of the patient who received the donor's kidney.
For example, if the donor's kidney went to the fourth patient on the deceased donor waiting
list, the recipient would move to the fourth spot on the list for his or her blood group and
would receive kidney offers once at the top of the list.
Paired Exchange Kidney Transplant (or "Family Swap")
This program is another way for a living donor to benefit a loved one even if their blood or
tissue types do not match. A "paired exchange" allows patients who have willing but
incompatible donors to "exchange" kidneys with one another-the kidneys just go to different
recipients than usually expected.
An example of how this works would be if Mary wanted to give her sister Susan a kidney,
but differences in blood type made it impossible, and Kevin wanted to give his sister Sarah
a kidney, but differences in blood type made that impossible (see picture below). A paired
exchange would be arranged so that Mary would donate to Sarah and Kevin would donate
to Susan. The two pairs can thus "exchange" kidneys so that both donors give kidneys and
both patients receive kidneys.
That means that two kidney transplants and two donor surgeries will take place on the same
day at the same time.
Blood Type Incompatible Kidney Transplant
This is a program that lets patients receive a kidney from a living donor who has an
incompatible blood type. To be able to receive such a kidney, patients must undergo
several treatments before and after the transplant to remove the harmful antibodies that can
lead to rejection of the transplanted kidney.
A special process called plasmapheresis, which is similar to dialysis, is used to remove
these harmful antibodies from the patient's blood.
Patients require multiple treatments with plasmapheresis before transplant, and may require
several more after transplant to keep their antibody levels down. Some patients may also
need to have their spleens removed at the time of transplant surgery to lower the number of
cells that produce antibodies. The spleen, a spongy organ about as big as a person's fist,
produces blood cells. Located in the upper left part of the abdomen under the rib cage, the
spleen can be removed laparoscopically.
Positive Crossmatch and Sensitized Patient Kidney Transplant
This program makes it possible to perform kidney transplants in patients who have
developed antibodies against their kidney donors-a situation known as "positive
crossmatch."
The process is similar to that for blood type-incompatible kidney transplants. Patients
receive medications to decrease their antibody level or they may undergo plasmapheresis
treatments to remove the harmful antibodies from their blood. If their antibody levels to their
donors are successfully reduced, they can then go ahead with the transplants.
Blood type-incompatible kidney transplants and positive crossmatch/sensitized patient
kidney transplants have been very successful in the United States and internationally.
Success rates are close to those for transplants from compatible living donors and are
better than success rates for deceased donor transplants.
Deceased Donor Kidney Transplantation

When an individual does not have a living donor but is an acceptable transplant candidate,
he/she will be placed on a waiting list. In 1984, Congress passed the National Organ
Transplant Act. This act prohibited the sale of human organs and mandated a national
Organ Procurement and Transplantation Network (OPTN) to oversee organ recovery and
placement and equitable organ distribution policies. The United Network for Organ Sharing
(UNOS) is an independent, non-profit organization. It was awarded the national OPTN
contract in 1986. It is the only organization ever to operate the OPTN.
Organ Procurement Organizations (OPO) are non-profit agencies operating in designated
service areas covering whole states or just parts of a state. OPOs are responsible for:
approaching families about the option of donation, evaluating suitability of potential donors,
coordinating the recovery and transportation of donated organs and educating the public
about the need for organ donation.
Most deceased donor kidneys are transplanted to recipients in the same service area as the
deceased donor. Although there are recommended guidelines for organ allocation, each
OPO may request a "variance" to fit the special needs to the patients waiting for kidney
transplantation in their service area.
Whenever a donor is identified within an OPO the HLA tissue typing results are entered into
the UNOS national computer system. UNOS has the HLA tissue typing information of all
patients awaiting kidney transplantation in the United States. If a waiting list patient has the
identical HLA tissue type as the donor the kidney will be given to him/her regardless of the
geography.
Unfortunately, many more patients are medically suitable for transplants than organs
available. The waiting times are many years and growing longer. Many patients develop
medical and surgical complications while waiting which may prevent them from receiving a
deceased donor kidney transplant in the future.
Transplant Success Rates

The success rate of kidney transplantation varies depending on whether the donated organ
is from a living donor or a deceased donor as well as the medical circumstances of the
recipient. Kidneys from living donors generally last longer. Most kidney losses are due to
rejection, but infections, circulation problems, cancer, and return of the original kidney
disease can also cause kidney loss.

Success Rate of Kidney Transplantation

Type of Donor 1 Year 3 Years 5 Years 10

Years

Living Donor Graft survival 95% 88% 80% 57%

Patient survival 98% 95% 90% 64%

Deceased Donor Graft survival 90% 79% 67% 41%

Patient survival 95% 88% 81% 61%

Complications of kidney transplant include rejection, side effects of immunosuppressants and so

forth.
Rejection

The immune system of the body perceives the kidney as a foreign object or tissue and
mounts a reaction against it. This may lead to massive damage to the new kidney. Early
signs of rejection include fever and soreness at the site of the new kidney and reduction
in the amount of urine production. To prevent rejection reaction immune suppressing
medications are prescribed right after the operation.
Rejection may be of various types depending on their timing.

 Hyperacute: occurs within minutes of insertion. This is rare these days due to
matching of tissues before donation. This means the donated kindey should be
removed immediately.

 Accelerated: This occurs within a few days in patients previously sensitised.

There may be fever, swollen new kidney and high rise of levels of creatinine in
blood. High dose steroids are given to combat this but may fail and removal may
be needed.

 Acute cellular rejection – This occurs in a quarter of all patients usually in 1-3
weeks but can occur up to 12 weeks. There may be fluid retention, rising blood
pressure and rapid increase in blood creatinine.

 Chronic rejection – In this type there is a gradual rise in serum creatinine and
excretion of protein in urine along with high blood pressure. This type of rejection
is not corrected by increasing immunosuppression therapy.

Side Effects of Immunosuppressants

Complications are also associated with the use of immune suppressing medications like
azathioprine, ciclosporin, mycophenolate mofetil, sirolimus, tacrolimus, or prednisolone.

Immunosuppressants work by diminishing the ability of immune cells to function. These

can weaken the immune system and may make the person vulnerable to infections.

Steroid drugs have a host of side effects like:

 puffiness of face

 increase in weight

 high blood sugar and blood pressure

  bone disease

 cataracts

 stomach acidity

 skin changes

 acne

 facial hair etc.

Over long term immune suppressants may also raise risk of certain cancers. When
used over time, these drugs may also cause liver or kidney damage in a few patients.

Early complications of kidney transplant

Early complications include risk of abscesses within the abdominal walls. This is more
likely in old, obese and diabetic patients.

Bleeding is another common complication immediately after surgery. Bleeding in uerine

or hematuria may also be seen in some patients.

A major abdominal surgery weakens the abdominal muscles and may lead to a risk of
abdominal hernias over the site of the incision called incisional hernia. Obese, diabetics,
those with rejection are more at risk.

Some patients may develop infectious tracts or canals called urinary fistulae.

There is a risk of post-operative formation of blood clots or arterial thrombosis. These

may get dislodged from the operative site and travel up to the lungs or brain leading to
life threatening complications.
Late complications of kidney transplant

 Late complications include narrowing of the ureters and obstruction to flow of

urine from kidney into the bladder. This is called ureteric stenosis.

 Pyelonephrritis or infection of the kidneys after surgery is another complication to

be watching out for.

 Some infections are common especially due to use of immunosuppressant

mediations. These are termed opportunistic infections and include herpes
simplex infection in the first four weeks and then cytomegalovirus infection.
Fungal and bacterial infections are also seen.

 Kidney stones may be transplanted with the donor kidney or may form later in the
new kidney. There may be manifestations of blood in urine (hematuria),
infections and obstruction.

 Renal artery stenosis or narrowing of the renal arteries is a late complication.

There may be development of other blood vessel abnormalities like
arteriovenous fistulae and pseudo aneurysms (balloon like swelling of segments
of the renal arteries). Some patients may also develop lymph channel
abnormalities called lymphoceles.

 Over long term there may be a risk of cancers of skin or lymphomas. This could
be due to the use of immunosuppressant mediations. Common cancers include
Kaposi sarcoma, kidney cancer and in women cervical cancer.

 Heart disease like high blood pressure, high cholesterol etc. are common after
kidney transplant.

 Recurrence of the original kidney dysfunction that damages the new kidney is
another complication of kidney transplant.