Complications of Transplanted Kidney

After receiving a kidney transplant, patients face various complications ranging from organ rejection to infections and surgical problems. Understanding these challenges and maintaining careful follow-up care is essential for long-term transplant success.

Table of contents

• Rejection of the Transplanted Kidney
• Surgical Complications
• Early Post-Transplant Complications
• Risk of Infections
• Effects of Immunosuppressive Medications
• Long-Term Health Complications
• Graft Failure and Return to Dialysis
• Warning Signs After Transplant

Rejection of the Transplanted Kidney

The immune system is the body’s way of protecting against things that don’t naturally belong, such as viruses, bacteria, and foreign tissue. After a kidney transplant, your immune system recognizes the transplanted kidney as a foreign object and tries to attack it in an attempt to destroy what doesn’t belong. This process is called rejection^[2].

To prevent rejection, transplant patients must take special immunosuppressant or anti-rejection medicines for the rest of their lives. Without these drugs to suppress the immune system, it would attack the transplanted organ^[2]. The most important thing you can do to prevent a rejection episode is to make sure you take your medicines every day as directed.

There are different types of rejection depending on when they occur. Acute rejection happens within the first 12 months after transplant, most commonly within the first several weeks. About 15% to 20% of people who receive a new kidney will experience some type of rejection^[13]. Chronic rejection typically happens slowly over several years, as your immune system constantly fights the new kidney, leading to gradual kidney damage^[13].

Sometimes a rejection episode can occur even when you have done everything correctly. During a rejection episode, the transplant kidney may not function as well as it should. This does not necessarily mean it will stop working completely or that you will lose the new kidney. When recognized and treated early, it is possible to stop the rejection with little or no damage to the kidney^[2].

To confirm rejection, a kidney biopsy is usually necessary. After applying numbing medicine, a needle is guided through the abdominal wall and into the kidney to remove a tiny piece of tissue. By looking at the tissue under a microscope, doctors can tell if rejection is the source of the problem^[2]. If rejection is confirmed, patients receive strong anti-rejection medicine, usually through an IV, for three to 10 days.

Surgical Complications

Post-surgical complications occur in approximately 12.7% to 15-17% of kidney transplant patients and are associated with significant illness^[4]. These complications can be classified as surgical or medical problems.

Surgical complications include problems with blood vessels, urological complications, lymphocele, wound infection, and herniation^[4]. One common issue is bleeding, which can happen immediately after surgery. There is also a risk of post-operative formation of blood clots, called arterial thrombosis. These clots may get dislodged from the operative site and travel through the body^[7].

Abdominal surgery weakens the abdominal muscles and may lead to abdominal hernias over the site of the incision, called incisional hernia. People who are obese, diabetic, or experiencing rejection are at higher risk^[7]. Some patients may also develop abscesses within the abdominal walls, which is more likely in old, obese, and diabetic patients^[7].

Ureteral complications are among the most common surgical problems, affecting approximately 9% of patients^[10]. These include obstruction, urine leak, and vesicoureteral reflux (backward flow of urine). The ureter is a tube that drains urine from your transplanted kidney to the bladder. An incision is made in the bladder so the ureter can be stitched to the bladder^[6].

If the bladder becomes too full before the incision has healed, the ureter can pull away from the bladder and urine can leak out. If a urine leak occurs, the urine draining from your catheter will stop, usually abruptly. As urine drains into the area around the kidney, you may develop pain. The only treatment for this problem is an operation to reconnect the ureter^[6]. Urine leak usually occurs in the early postoperative period, and nearly 60% of patients can be successfully managed with a pelvic drain and urinary decompression^[10].

Early Post-Transplant Complications

Acute Tubular Necrosis (ATN) or delayed graft function is a common early complication. In most cases, the transplanted kidney begins to make urine right away. Sometimes though, the kidney may have delayed function after surgery. This can occur as a result of factors related to the donor, such as low blood pressure during CPR, or if the kidney has been stored for many hours after removal from the donor. It may also happen if the transplant recipient has unexpected bleeding during surgery or during a biopsy^[6].

There is no specific treatment for delayed graft function. You will just need to patiently wait for your kidney to start working. Dialysis may be required for a few weeks or as long as three months^[6]. Delayed graft function is suspected when the creatinine (a waste product that healthy kidneys filter out) does not fall quickly after transplant.

Primary non-function is when the transplanted kidney never starts working. This is rare, but it can happen. It is a very discouraging event for the patient and the transplant team. Dialysis is usually required in the first 48 hours after surgery and will continue to be required on a regular basis. Patients with primary non-function have a kidney biopsy that reveals irreversible damage. In most cases, the transplanted kidney needs to be removed. Primary non-function does not prevent you from having another transplant^[6].

After a transplant, there might be lots of swelling (oedema) around the legs and groin area. This normally settles as the kidney starts passing good amounts of urine. For a straightforward transplant, a hospital stay might be seven to ten days, but if there are complications, the hospital stay might be up to a few weeks^[19].

Dehydration can be a problem after transplant. As a dialysis patient, you were trained to avoid extra fluid. When you have a functioning kidney, restricting fluid can lead to dehydration. During summer months, it is especially important to drink plenty of fluids because water loss from heat and perspiration can cause dehydration and your creatinine to rise^[6].

Risk of Infections

Infection is a constant risk to transplant recipients. The immunosuppressive medications that you take to prevent rejection cause you to be at increased risk for infections^[6]. Patients with kidney transplants are particularly susceptible to infections such as urinary tract infections or pneumonia^[15].

Immunosuppressants work by diminishing the ability of immune cells to function. These drugs can weaken the immune system and may make the person vulnerable to infections. Over the long term, immune suppressants may also raise the risk of certain cancers^[7].

You will take antibiotics to prevent infection for the first 3-6 months after your transplant^[6]. Common infections that can occur include urine infections, and patients should notify their transplant team immediately if they experience symptoms such as pain or burning during urination, or a noticeable decrease in the amount of urine^[2].

Effects of Immunosuppressive Medications

Complications are also associated with the use of immunosuppressing medications such as azathioprine, ciclosporin, mycophenolate mofetil, sirolimus, tacrolimus, or prednisolone^[7]. The majority of patients are discharged on a regimen consisting of tacrolimus and an antimetabolite, with most on a triple regimen that includes a corticosteroid^[15].

Steroid drugs have a host of side effects including puffiness of face, increase in weight, high blood sugar and blood pressure, bone disease, cataracts, stomach acidity, skin changes, acne, and facial hair^[7]. When used over time, these drugs may also cause liver or kidney damage in some patients^[7].

Taking medications as prescribed is critical. Medication adherence becomes an integral part of life after kidney transplant. These medicines play a crucial role in preventing your body from rejecting the newly transplanted kidney. Immunosuppressants are designed to decrease the activity of your immune system so it can accept the new organ^[17].

Before prescribing any new medications, it is important to check for potential interactions with immunosuppression drugs^[15]. Always discuss any issues or concerns about your medication regimen with your healthcare team.

Long-Term Health Complications

Most complications after kidney transplant are due to two factors. First, many people having a transplant have other health problems in addition to kidney failure, such as diabetes, high blood pressure, heart disease, or other complications of being on dialysis. Secondly, the body recognizes a transplant as an invader and tries to destroy it, requiring anti-rejection drugs that interfere with the immune system’s good functions^[5].

Patients with kidney transplants have a significant disease burden due to a high number of pre-existing conditions and use of immunosuppression medications. These patients are at higher risk of developing conditions such as hypertension, high cholesterol levels, and post-transplant diabetes^[15]. The anti-rejection drugs can cause complications such as high blood pressure, high cholesterol, and diabetes. All of these can lead to a heart attack or a stroke^[5].

Cancer is another long-term risk. Over the long term, immune suppressants may raise the risk of certain cancers, most commonly skin cancer^[5][7]. Patients may also develop post-transplant lymphoproliferative disorder (PTLD), a complication related to immunosuppression.

Within one year of any transplant, about 3% (three out of one hundred) of people die, which is no greater than the percentage that would have died if they had remained on dialysis^[5]. Long-term survival depends very much on not getting heart problems and cancer. On average, about 70% (seven out of ten) transplant recipients are alive ten years after a transplant^[5].

Graft Failure and Return to Dialysis

The number of kidney transplant recipients returning to dialysis after graft failure is steadily increasing over time. Patients with a failed kidney transplant have been shown to have a significant increase in death rate compared with patients with a functioning graft or patients starting dialysis for the first time^[9].

The risk for infectious complications, cardiovascular disease, and cancer is greater than in the dialysis population due to the frequent maintenance of low-dose immunosuppression, which is required to reduce the risk of developing antibodies against donor tissue (allosensitization), particularly in patients with the prospect of another transplant from a living donor^[9].

Currently, 4.8% of post-transplantation patients have returned to dialysis^[4]. Graft survival at one year is approximately 82.4% with a 91% one-year patient survival^[4]. Early identification and treatment of surgical complications are critical for patient and graft survival^[4].

Warning Signs After Transplant

Although rejection can occur without any symptoms, you should notify the transplant team immediately if any of the following warning signs occur^[2]:

• Fever over 100 degrees Fahrenheit (38 degrees Celsius). Fever is usually a sign that the immune system is trying to fight off infection, but it can also be a sign of rejection.
• Other flu-like symptoms, such as chills, headache, body aches, fatigue, or dizziness
• Pain or tenderness over the site of the transplanted kidney
• Sudden weight gain or swelling of hands, feet, legs, or eyelids
• Difficulty breathing
• Pain or burning during urination or a noticeable decrease in the amount of urine
• Bloody urine (hematuria)
• Elevated blood pressure

In addition to taking medicines as directed, it is important to keep all follow-up clinic appointments so that the transplant team can detect any signs of rejection through changes in your physical exam or in kidney function lab tests^[2]. Your healthcare provider can usually recognize and treat a kidney rejection before it causes any major or irreversible damage^[13].