Early common surgical complications in 1500 kidney transplantations

Postoperative Events in Incompatible Living Donor Kidney Transplant Recipients Undergoing Prior Desensitization

BACKGROUND

Living donor kidney transplantation (LDKT) is one of the best options for patients with chronic renal failure, but approximately one-third of cases are limited by incompatibility ABO and/or HLA between recipient and donor. This study aims to analyze the surgical complications and bleeding events presented in ABO-incompatible (ABOi) and HLA-incompatible (HLAi) patients within a pre-transplant desensitization program compared with ABO-compatible (ABOc) recipients.

MATERIAL AND METHODS

We performed a retrospective analysis of ABOi and HLAi recipients undergoing LKDT between 2009 and 2019, resulting in a total of 62 patients that we compared with the same number of ABOc performed consecutively before 2019. The following variables were analyzed: surgical complications, presence, size and rate of reintervention of peri-graft hematomas, and number of transfusions received in the postoperative period.

RESULTS

No statistical differences were shown in donor and recipient age, BMI, or sex; in the case of pre-surgical hematocrit, the ABOi group presented slightly lower figures. In the incompatible group (ABOi + HLAi), we found a greater number of postoperative surgical complications when analyzing the number of hematomas, size, need for surgical reintervention, and the number of blood units transfused; incompatible patients showed higher rates of hematomas, need for surgical reinterventions, and transfused units (P < .05).

CONCLUSION

Desensitized patients need more transfusions, have a greater number and size of hematomas, and have higher reintervention rates. Although these are present in greater numbers, we did not observe statistically significant differences in the number of surgical complications.

Urologic considerations and complications in kidney transplant recipients

Urologic considerations during the kidney transplantation process, starting with initial recipient evaluation and continuing through the post-transplant, long-term follow-up, are critical for minimizing urologic complications and improving graft survival. Appropriate, targeted, preoperative urologic evaluation of the recipient allows for an optimized urinary tract to accept the graft, whereas post-transplant urologic follow-up and monitoring decrease the risk of graft lost secondary to a urologic cause, particularly in patients with a urologic reason for their kidney failure and in those patients with concomitant urologic diagnoses. Urologic complications comprise the second most common adverse post-transplant event, occurring in 2.5% to 14% of patients and are associated with high morbidity, graft loss, and mortality. Early and late urologic complications, including hematuria, hematoma, lymphocele, urine leak, ureteral stricture, nephrolithiasis, and vesicoureteral reflux, and their causes and treatment options are explored. A multidisciplinary team approach to kidney transplantation, including transplant surgery, urology, and nephrology, optimizes outcomes and graft survival. Although the current role of the urologist in kidney transplantation varies greatly by institution, appropriate consultation, participation, and monitoring in select patients is essential.

An update on ABO-incompatible kidney transplantation

ABO-incompatible kidney transplantation is nowadays a well-established procedure to expand living donor transplantation to blood group incompatible donor/recipient constellations. In the last two decades, transplantation protocols evolved to more specific isohaemagglutinin elimination techniques and established competent antirejection protection protocols without the need of splenectomy. ABOi kidney transplantation associated accommodation despite isohaemagglutinin reappearance, C4d positivity of peritubular capillaries as well as the increased incidence of bleeding complications is currently under intense investigation. However, most recent data show excellent graft survival rates equivalent to ABO-compatible kidney transplantation outcome.

Recipient and donor risk factors for surgical complications following kidney transplantation

OBJECTIVE

The aim of this study was to evaluate recipient and donor risk factors that are related to surgical complications after renal transplantation.

MATERIAL AND METHODS

In total, 419 kidney transplantations were analysed with regard to the influence of recipient and donor risk factors on the main postoperative surgical complications.

RESULTS

The mean follow-up for the entire group was 72.8 months (± 54.2 SD). Vascular complications were independently associated with donor age; and urological complications with recipient age >65 years and cyclosporine rather than tacrolimus therapy. Wound complications were independently associated with recipient age, preoperative dialysis time, recipient body mass index (BMI) and cyclosporine rather than tacrolimus therapy. Collections were independently associated with retransplantation, type 2 diabetes mellitus and wound complications. Overall surgical complications were associated with donor age and delayed graft function. In terms of severity, grade I complications were independently associated with recipient age and surgical revision, grade II with recipient age >50 years, grade III with recipient BMI, and grade IV with donor age.

CONCLUSIONS

Recipient characteristics are the primary determinants of wound, urological and minor (Clavien grades I, II and III) complications; however, graft or donor characteristics are the primary risk factors for vascular, overall and major (Clavien grade IV) surgical complications.