Transplantation Complication

While organ transplantation offers life-saving treatment for people with failing organs, it comes with significant challenges that require careful management and lifelong attention.

Table of contents

• Understanding Transplantation Complications
• Rejection of the Transplanted Organ
• Infection Risks
• Effects of Immunosuppression
• Surgical Complications
• Organ-Specific Complications
• Long-Term Survival and Outcomes

Understanding Transplantation Complications

Organ transplantation involves major surgery and carries the possibility of serious complications, including infection, transplant rejection, and even death. However, for people whose vital organs have failed, transplantation may offer the only chance of survival^[5]. Most complications after transplant happen due to two main factors. First, many people receiving a transplant already have other health problems such as diabetes (a condition where the body cannot properly control blood sugar levels), high blood pressure, heart disease, or other complications from being on dialysis (a treatment that filters waste from blood when kidneys don’t work)^[1].

The second major cause of complications is that the body recognizes a transplant as an invader, similar to how it would recognize a germ. This means the body will try to destroy the transplant through a process called rejection^[1]. Although rejection can be prevented with drugs, these medications interfere with the good things the immune system (the body’s defense system) does, as well as preventing rejection^[1].

Complications after transplant are fairly common. Between 30 to 60 percent of patients experience some type of complication, which are associated with increased illness and death in this population^[14]. Post-operative complications occur in about 15 to 17 percent of all cases and are associated with significant illness^[9].

Rejection of the Transplanted Organ

The immune system protects a person from things that don’t naturally belong in the body, such as viruses, bacteria, or foreign tissue like a transplanted organ from someone else^[2]. After transplant, doctors prescribe special immunosuppressant or anti-rejection medicines (drugs that weaken the immune system). Without these drugs, the immune system would recognize the transplanted organ as foreign and attack it^[2].

The most important thing you can do to prevent rejection is to make sure you take your medicines every day exactly as directed. Sometimes rejection can occur even when you have done everything correctly^[2]. During a rejection episode, the transplant organ 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 organ. When recognized and treated early, it is possible to stop the rejection with little or no damage to the organ^[2].

Warning signs of rejection can include fever over 100 degrees, flu-like symptoms such as chills, headache, body aches, fatigue or dizziness, pain or tenderness over the site of the transplanted organ, sudden weight gain or swelling, difficulty breathing, changes in urination patterns, bloody urine, or elevated blood pressure^[2]. If rejection is suspected, a biopsy (removal of a small piece of tissue for examination) is usually necessary to confirm the diagnosis^[2].

Infection Risks

Infection is a constant risk for transplant recipients. The immunosuppressive medications taken to prevent rejection cause patients to be at increased risk for infections^[4]. Patients will be at risk for bacterial, fungal, and viral infections for several months after transplant. These infections are a major risk in the early recovery period until the new organ grows and the body makes white blood cells to fight infection. Some infections will still be a risk while the immune system recovers during the first two years after transplant^[12].

Fever is one important sign of infection. If you develop a fever, chest x-rays will be obtained, and urine and blood cultures will be done. Antibiotics will be given through an IV to help the body fight the infection. Nearly all patients develop fever during the first two weeks after transplantation, but most infections are treated successfully with antibiotics^[12]. Patients typically receive anti-viral medicines to help prevent any viral infection they had in the past from coming back after the transplant. These can include cold sores, recurrence of genital herpes, shingles, cytomegalovirus, and other infections affecting the lungs or gut^[12].

Patients will take antibiotics to prevent infection for the first three to six months after transplant^[4]. Neurological complications related to infection, including meningitis, encephalitis, and abscess, have significant illness and death rates in transplant patients. Symptoms can range from non-specific ones such as headache, fever, and altered mental status to focal neurologic problems and coma^[14].

Effects of Immunosuppression

The drugs used to prevent rejection interfere with both the harmful and helpful functions of the immune system. As a result, infections and cancers occur as side effects^[1]. In addition to increasing infection and cancer risk, anti-rejection drugs cause complications such as high blood pressure, high cholesterol, and diabetes. All of these can lead to a heart attack or stroke^[1].

Research is being done worldwide to develop anti-rejection treatments that do not cause all these complications, but this research has not been fully successful yet. However, the drugs available now are better than a few years ago, and the numbers of complications that occur have been reduced markedly^[1].

Cancer is one of the main complications of transplantation, most commonly skin cancer^[1]. Long-term survival depends very much on not getting heart problems and cancer^[1]. The immunosuppressive regimens alter both the typical presentation and types of organisms observed in infections^[14].

Surgical Complications

Several surgical complications can occur after transplantation. Acute tubular necrosis (ATN), also called delayed graft function, happens when the transplanted kidney does not begin making urine right away after surgery. This can occur due to factors related to the donor, such as low blood pressure during CPR, if the kidney has been stored for many hours after removal from the donor, or if the recipient has unexpected bleeding during surgery or during a biopsy. There is no specific treatment for this problem. Patients just need to patiently wait for the kidney to start working. Dialysis may be required for a few weeks or as long as three months^[4].

Primary non-function is when the transplanted organ never starts working. This is rare but can happen. It is a very discouraging event for both the patient and the transplant team. Dialysis is usually required and will continue to be needed on a regular basis. In most cases, the transplanted kidney needs to be removed. Primary non-function does not prevent you from having another transplant^[4].

A urine leak can occur when the tube that drains urine from the transplanted kidney to the bladder (called the ureter) pulls away from the bladder. This happens if the bladder becomes too full before the surgical connection has healed. If a urine leak occurs, the urine draining from the catheter will stop, usually abruptly. As the urine drains into the area around the kidney, pain may develop. The only treatment for this problem is an operation to reconnect the ureter^[4].

Other surgical complications can include problems with blood supply or urine drainage, bleeding (due to low platelet counts), and dehydration (excessive loss of body fluids). After dialysis, patients were trained to avoid extra fluid, but when they have a functioning kidney, restricting fluid can lead to dehydration. During summer months it is especially important to drink plenty of fluids^[4].

Organ-Specific Complications

Complications can occur in various organs even after a successful transplant. The kidneys filter blood and make urine to send waste products out of the body. The chemotherapy given before transplant can affect how well kidneys work. This is temporary, but waste products may remain in the blood until kidney function improves^[12].

The liver removes harmful substances from body fluids, absorbs nutrients, and produces bile to help digest food. Side effects on the liver include problems with digestion. A more serious problem is when the liver may no longer remove breakdown products of the body, and jaundice develops. In some patients, small blood vessels in the liver are injured in a condition called veno-occlusive disease (VOD). These vessels can become blocked so that blood cannot flow, causing the liver to become enlarged and damaging liver cells^[12].

The lungs can develop complications such as pneumonia or other infections. The heart can experience various problems, and cardiovascular disease remains a major concern for long-term survival^[1]. Anemia (low red blood cell count) can cause weakness and fatigue. Patients will be given red blood cell transfusions as necessary^[12].

Long-Term Survival and Outcomes

Within one year of any transplant, a small percentage of people die, about three out of one hundred in most units. However, this is no greater than the percentage that would have died if they had remained on dialysis^[1]. Long-term survival depends very much on not getting heart problems and cancer. There are many patients who have had a functioning transplant for over 20 years and who are very well. However, on average, about 70 percent (seven out of ten) transplant recipients are alive ten years after a transplant^[1].

For kidney transplants specifically, according to national averages, one-year patient survival is 87 percent for patients receiving a deceased donor organ and 92 percent for those transplanted with an organ from a living donor. Five-year patient survival rates are 76 percent for deceased donors and 81 percent for living donors^[20].

The time a transplant lasts depends on many factors. Transplant recipients directly contribute to the success of their transplant. Failure to comply with the immunosuppression medical regimen is the number one cause of organ failure. Close follow-up with your transplant team and primary-care physician can help ensure a good outcome. Careful attention to medication schedules, lifestyle changes, and infection-avoidance techniques are all important ways to prolong life after transplantation^[20].

Most patients can return to work within three to six months after a transplant. Playing sports and getting healthy exercise, socializing, and traveling for business and pleasure are all possible. The expectation is that people who undergo organ transplantation can and do go on to lead normal lives^[20].