Immediate allograft dysfunction due to atheroembolic disease

Cholesterol Embolization Syndrome After Kidney Transplantation: A Case Series and Systematic Review

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Background.

Cholesterol embolization syndrome (CES) is an uncommon but well-known cause of renal failure in native kidneys, but little is known about CES in kidney transplant recipients. The aim of this study was to determine the incidence, clinical characteristics, histopathology, and prognosis of CES after kidney transplantation.

Methods.

CES cases in both transplanted and native kidneys (control group) were identified by searching the databases of the divisions of Nephrology and Pathology of our institution. Clinical data were retrospectively collected. Biopsies were classified according to the latest Banff 2019 Update. Second, a systematic literature search was performed (December 01, 2020) of Ovid MEDLINE, EMBASE, the Cochrane Central Register of controlled trials, Google Scholar, and Web of Science.

Results.

CES was observed in for-cause biopsies of 11 out of 2350 (0.47%) kidney transplant recipients transplanted between January 1, 2006, and December 31, 2018 (0.0009 cases per person-year). All patients had ≥1 cardiovascular risk factor, and 9 donors were expanded criteria donors. Graft loss occurred in 27.3% of the patients diagnosed with CES. Eight transplant biopsies with CES were also classified as biopsy-proven acute rejection. Transplant biopsies showed signs of inflammation (arteritis, n = 7; interstitial inflammation, n = 5; tubulitis, n = 7). One patient with CES in a native kidney was identified. The biopsy of the native kidney only showed arteritis and classified as an isolated “v” lesion. The literature search resulted in 188 unique articles of which 20 were included. A total of 47 cases of CES after kidney transplantation was reported. Cholesterol emboli were found in <1% of all kidney transplant biopsies. In 57.8% of the kidney transplant biopsies with CES described in literature, concomitant inflammation was present.

Conclusions.

CES is an uncommon cause of kidney transplant failure, although the incidence of CES may be underestimated. CES may mimic rejection as it can be accompanied by arteritis.

Urological Complications in Kidney Transplant Recipients: Analysis of the Risk Factors and Impact on Transplant Outcomes in the Era of “Extended Criteria Donors”

Urological complications (UC) following kidney transplantation (KT) are associated with increased morbidity. The aim of this study is to evaluate the risk factors for UC in the era of “extended criteria donors” (ECD) and their impact on patient and graft survivals. A retrospective monocentric study of all patients undergoing KT from 2010 to 2019 with a follow-up ≥30 days was performed. Out of 459 patients (males: 296 (64.5%); age: 57 (19–77) years) enrolled, 228 (49.7%) received ECD organs, moreover, 166 (67.2%) grafts had a cold ischemia time ≥10 h. UCs were reported in 32 (7%) patients. In 21 (65.6%) cases UC occurred within 3 months post-KT and 24 (5.2%) were associated with early urinary tract infection (UTI). The overall 5 year patient and graft survival rates were 96.5% and 90.6%, respectively. UC decreased graft survival (UC-group: 75.0% vs. noUC-group: 91.8%, p < 0.001), especially if associated with early UTI (UC-group: 71.4% vs. noUC-group: 77.8%, p < 0.001). At multivariate analysis, early UTI after KT (OR: 9.975, 95%-IC: 2.934–33.909, p < 0.001) and delayed graft function (DGF) (OR: 3.844, 95%-IC: 1.328–11.131, p: 0.013) were significant risk factors for UC, while ECD graft did not increase the risk of post-transplant UC. ECD grafts are not associated with UC. DGF and early UTI post-KT increase the risks of UC and reduce graft survival in the long-term. Therefore, aggressive management of early post-transplant UTI and strategies to reduce DGF incidence, such as machine preservation, are essential to prevent UC after KT.

Iloprost in Acute Post-kidney Transplant Atheroembolism: A Case Report of Two Successful Treatments

Cholesterol embolization (CE) is a rare and alarming post-transplant complication, responsible for primary non-function (PNF) or delayed graft function (DGF). Its incidence is expected to rise due to increasingly old donors and recipients and the extended criteria for donation. Therapy with statins and steroids has not been shown to be effective, while agonism of prostaglandin I₂ has been reported to be useful in systemic CE. We report two cases of acute post-transplant CE in which intravenous iloprost (0.05 mg/kg/day) was added to standard statin and steroid therapy. In the first instance, CE was due to embolization from the kidney artery resulting in embolization of the small vessels; after a long DGF and 15 days of iloprost therapy, renal function recovered. The second instance is a case of embolization from the iliac artery of the recipient, where CE manifested as a partial renal infarction. After 5 days of iloprost administration, creatinine levels improved. Iloprost acts on vasodilation and on different inflammatory pathways, improving the anti-inflammatory profile. Post-transplant CE is difficult to diagnose and, if not treated, can lead to loss of function. Iloprost added to standard therapy could be beneficial in accelerating renal function recovery immediately after transplant.

Complications of kidney transplantation with grafts from expanded criteria donors

PURPOSE

The limited availability of kidneys for transplantation has been addressed by expanding the criteria for allowing a donor kidney to be transplanted, but this tendency may cause suboptimal kidneys to be implanted and could be associated with greater risk of complications.

METHODS

A retrospective study of 407 kidney transplantations was done to compare complications of transplantation with non-expanded (n = 244) and expanded criteria donors (n = 163). Expanded criteria donors were donors older than 60 years, or donors aged 50-60 years who had ≥ 2 of the following risk factors: hypertension, diabetes mellitus (type 2), creatinine >1.5 mg/dL, or death caused by stroke.

RESULTS

Compared with transplant recipients from non-expanded criteria donors, transplant recipients from expanded criteria donors had significantly greater frequency of graft loss, delayed graft function, pneumonia, overall surgical complications, early reoperation, wound eventration, hydronephrosis, postoperative hemorrhage, and wound infection. When analyzing surgical complications types, a significant greater frequency of urologic, wound, vascular, early and late surgical complications was found. In terms of severity, expanded donor criteria transplantation was related to Clavien I, III, and IV complications.

CONCLUSIONS

Transplantation of kidneys from expanded criteria donors is associated with a significant higher risk of medical and surgical complications than kidneys from non-expanded criteria donors.

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.

“Old-for-Old” Cadaveric Renal Transplantation: Surgical Findings, Perioperative Complications and Outcome

OBJECTIVE

To evaluate the surgical findings and outcome of locally allocated, blood-group-compatible but HLA-unmatched cadaveric kidneys in first renal transplantation of donor/recipient pairs aged 65 years and above (Eurotransplant Senior Program=ESP).

METHODS

26 patients of the study group (donor age 70.4 +/- 3.6/recipient age 67.7 +/- 2.8) were compared to 30 controls aged 60 and above (mean recipient age 62.6 +/- 2.3/mean donor age 43.8 +/- 15.3). For controls kidney allocation included HLA matching.

RESULTS

Cold ischemic time (ESP vs. controls 501 vs. 883 min; p<0.05) and mean number of HLA mismatches (4.2 +/- 1.36 vs. 1.6 +/- 1.62; p<0.05) differed significantly. Delayed graft function was lower in the study group (12% vs. 43%; p<0.05), rejection episodes in the ESP group were numerous but did not differ significantly from the controls (46% vs. 30%; p=0.21). More intraoperative complications and a higher incidence of donor organ arteriosclerosis (p<0.05) were seen in the ESP group. Three-year graft survival uncensored and censored for death with functioning graft did not differ, even though mean creatinine and creatinine clearance differed significantly beginning at month three. Three-year patient survival (55% vs. 81%) differed in favour of the control group, even though the difference was not significant due to small number of patients.

CONCLUSION

"Old-for-old" kidney transplantation with local allocation yields graft survival rates comparable to HLA-matched young grafts and is a good approach to extend the donor and recipient pool. Careful patient selection is advised.