Complications after kidney

transplantation
part 1
Course topics
Part 1
Urological complications after kidney transplantation
Cardiovascular complications
Infection in renal transplant recipients
Part2
Vascular complications
Liver disease in renal transplant recipients
Neurological complications
Nonmalignant and malignant skin lesions in renal
transplant patients
Urological complications after kidney
transplantation

Ureteral Complications
- Ureteral Leak
-Ureteral Stenosis
Use of Prophylactic Ureteral Stents
Urinary Retention
Erectile Dysfunction
Ureteral leak or obstruction is typically caused
by either technical errors or ischemia.

The native ureter derives its blood supply
from renal and pelvic sources, but the
transplant ureter must rely on branches from
the anastomosed renal artery.
The ureter becomes more ischemic the more distal it is
from the kidney.
One of the advantages of placing a renal allograft into
the pelvis is the short distance to the bladder - it allows
a minimal length of transplant ureteral length.
The other surgical principle to ensure optimal ureteral
perfusion is preservation of the blood supply.
This is accomplished during procurement by removing
theureter complete with a significant margin of
periureteral tissue, avoiding a stripped ureter
During the back table preparation of the
kidney, it is important to preserve the
perirenal fat bordered by the ureter and lower
pole of the kidney (the golden triangle)


Ureteral Leak
Ureteral leaks are reported in 1% to 3% of renal transplants.
The two most common causes are ureteral ischemia with
necrosis and surgical technical error.
Technical errors include misplacement of ureteral sutures
and insufficient ureteral length with tension on the
anastomosis.
Leaks resulting from technical errors often occur within the
first 24 hours, whereas leaks from necrosis usually occur
within the first 14 days.
Ureteral leak repair techniques
Psoas hitch and Boari flap techniques
Ureteral Stenosis
Stenosis of the transplant ureter occurs in
approximately 3% of transplant recipients.
The obstruction can be extraluminal
(compression from lymphocele or spermatic
cord), ureteral (ischemia), or intraluminal (stone,
fungal ball, sloughed renal papilla, foreign body).
Ureteral stenosis may occur months or years
after an otherwise successful transplant.
Most commonly, ureteral stenosis is gradual
and asymptomatic, with an unexplained
increase in creatinine leading to discovery of
hydronephrosis on ultrasound or computed
tomography
Stents can reduce the incidence of ureteral
leaks and early ureteral stenosis and make the
early management of leaks easier.
URINARY RETENTION
After renal transplantation, urinary retention may be
due to bladder outflow obstruction or a neurogenic
noncontractile bladder.
Bladder outflow obstruction after transplantation is
almost exclusively seen in men and may be due to
urethral stricture, benign prostatic hypertrophy, or
bladder neck contracture
Patients with a noncontractile bladder usually have a
preexisting history of voiding problems or neurological
disorders ( Parkinsons disease, multiple sclerosis,
diabetes with peripheral neuropathy)
ERECTILE DYSFUNCTION

With an aging transplant population, erectile dysfunction is
a prevalent and increasingly identified problem.
Factors contributing to erectile dysfunction are often the
same factors responsible for renal failure, including
diabetes, hypertension (and its medical treatment),and
vasculopathy.
Dialysis patients may have elevated serum prolactin, which
can depress testosterone and lead to erectile dysfunction;
this may explain partly the 20% of patients whose erectile
dysfunction improves after transplant.
The use of internal iliac artery for anastomosis should be
avoided in men receiving a second transplant, in whom
vasculogenic impotence can occur as a result in 25%.
Cardiovascular complications
Pretransplant Measures to Reduce
Cardiovascular Disease
Screening for Ischemic Heart Disease before
Transplantation
Perioperative Blockade
Post-Transplant Measures to Reduce
Cardiovascular Disease
Prophylactic Anticoagulation
Aspirin Prophylaxis
Cigarette Abstinence
Hypertension treatment
Dyslipidemias control
Diabetes treatment
Antioxidant Vitamins
Infection in renal transplant recipients
Transplant recipients are susceptible to a broad
spectrum of infectious pathogens, manifest diminished
signs and symptoms of invasive infection, and may
develop systemic signs (e.g., fever) in response to
noninfectious processes (e.g., graft rejection, drug
toxicity) with multiple processes often present.
Immunocompromised patients tolerate invasive,
established infection poorly with high morbidity and
mortality, lending urgency to the need for an early,
specific diagnosis to guide antimicrobial therapy
Given the T lymphocyte dysfunction inherent
to transplantation immunosuppression, viral
infections in particular are increased.
These viral infections not only contribute to
graft dysfunction, graft rejection, and systemic
illness but also enhance the risk for other
opportunistic infections (e.g., Pneumocystis
and Aspergillus) and virally mediated cancers
The risk of infection in a renal transplant recipient
is determined by the interaction of two key
factors:
1. The epidemiological exposures of the patient,
including the timing, intensity, and virulence of
the organisms
2. The patients net state of immunosuppression
which reflects a measure of all host factors
contributing to the risk for infection
Factors contributing to the net state of
immunosupression
The timeline of infection after
transplantation