| Abstract|| |
A total of 147 kidney transplant recipients are on regular follow-up in our center including 12 who were transplanted in our hospital since the start of the transplantation program in June 1994. Fifty eight patients received cadaveric kidneys (mainly in the United States), 13 received living-related transplants (of which seven were performed in our hospital), and 76, received living non-related transplants abroad. The follow-up period ranged from 0-228 months. Fifty eight (39.5%) patients continue to be followed with functioning kidneys, 26 (17.7%) patients lost their grafts, 19 (12.9%) patients died, and 44 (29.9%) were lost to follow-up. Six patients converted to HIV-positive after transplantation, of which five had received living non-related transplantation. Four of these patients died. Other significant infectious complications during follow-up period included pneumonia (n = 37; 25%) and tuberculosis (n = 9; 6%). Hypertension was present in 86% and diabetes mellitus in 30% of the patients. Hepatitis developed in 24% of the patients. Eight patients had pregnancy followed by successful delivery (two of them twice). Twenty seven patients had significant post-operative urological complications, including 12 lymphoceles and three urinary leaks. When the influence of different factors such as type and place of transplant, immunosuppression, infections, and occurrence of acute rejections, hypertension, diabetes, hepatitis and urological complications, on outcome were analyzed, only history of acute rejections and chest infections had a significant independent effect.
Keywords: Renal transplantation, Complications, Infection, Rejection.
|How to cite this article:|
Hussein M, Mooij J, Roujouleh H. Complications in Kidney Transplant Recipients: A Single Center Experience. Saudi J Kidney Dis Transpl 1996;7:168-72
|How to cite this URL:|
Hussein M, Mooij J, Roujouleh H. Complications in Kidney Transplant Recipients: A Single Center Experience. Saudi J Kidney Dis Transpl [serial online] 1996 [cited 2020 Oct 23];7:168-72. Available from: https://www.sjkdt.org/text.asp?1996/7/2/168/39521
| Introduction|| |
The renal transplant program at the AlHada Hospital in Taif, Saudi Arabia began in June 1994. Since then, 12 patients have undergone renal transplantation in this hospital. In this report, we describe our experience on the follow-up of patients transplanted here as well as those trans- other centers but being followed-up here.
| Patients and Methods|| |
The total number of patients being followedup in our hospital after kidney transplantation is 147, which includes 56 females (38%) and 91 males (62%). The age of the patients at the time of transplantation ranged from 8 to 74 years, with a mean of 38 + 14 (SD) years. The etiology of endstage renal disease in these patients has been reported previously  . Of the study patients, 58 (39.5%) had received cadaver donor transplants, the large majority (51 patients; 34.5%) of whom were transplanted in the USA. Five patients received cadaveric transplants in our center (since June 1994), and two patients had been transplanted in other centers in the Kingdom. Thirteen patients had received living related transplants, seven of whom were transplanted in our hospital and included two patients who had transplants from spouse donors. Until last year, many patients (76; 51.7%) opted for commercial living nonrelated transplantation abroad. However, in 1995 this number has fallen dramatically (one only).
The follow-up period after transplantation ranged from 0 to 228 months, with a mean of 47 + 44 months. The immunosuppression which the patients received at the time of transplantation or when they arrived in our hospital after transplantation is given in [Table - 1].
In our center, the immunosuppressive protocol consists of triple therapy (prednisone, azathioprine, and cyclosporine) for both live and cadaveric donor transplants. In high-risk patients (patients with second graft, high panel reactive antibodies or patients with primary non-function), antithymocyte globulin (ATG), given for a period of ten days post-transplant, was added prophylactically to this regimen. In 33 patients, the immunosuppressive regimen was changed during the follow-up, in most cases due to significant infections. Other modifications of the immunosuppression included discontinuation of prednisone in one patient with severe steroid-induced side effects, and of cyclosporin in another patient with Kaposi's sarcoma.
Cyclosporin blood levels were measured initially with polyclonal and, from 1992, with monoclonal fluorescence polarization on TDx Analyzer (Abbott Laboratories, Chicago, IL, USA)  . Rejection episodes were diagnosed on clinical grounds in combination with ultrasound, renogram, and if the patient and relatives agreed, percutaneous coreneedle biopsy. The antirejection treatment consisted of pulse doses of 1 gm methyl prednisolone given for three consecutive days. In steroid-resistant cases, ATG was given for a period of 10 days. The different complications encountered in these patients (medical, infectious, and urological) and the causes of death were evaluated.
The effect of different factors including type of transplant (cadaveric, living-related, living non-related), age and sex, immunosuppression, place of transplant, urological complications, the occurrence of acute rejection episodes, occurrence of infections, chest infections, diabetes, hypertension and hepatitis on the outcome was analyzed by-a logistic regression analysis (SPSS/PC Advanced Statistics 5.0)  . Patients lost to follow-up were not included in this analysis. Comparison between groups of patients was made by ANOVA. Survival rate was calculated by life-table analysis (SPSS/PC Advanced Statistics version 5.0)  . Values are given as mean ± standard deviation (SD).
| Results|| |
Of the 147 study patients, 58 (39.5%) continue to be followed-up in our hospital up to end of 1995 with functioning kidneys, 26 (17.7%) lost their transplants and are back on maintenance dialysis, and 19 patients (12.9%) died. Forty-four patients (29.9%) were lost to follow-up. The different medical, infectious and urological complications observed in these patients are listed in [Table - 2],[Table - 3],[Table - 4] respectively. Eight female patients had at least one pregnancy each followed by successful delivery, and in two cases there were two pregnancies each. When the influence on the outcome, of different factors such as type of transplant (cadaveric, living-related, living-non related), age, immunosuppression, sex, place of transplant, urological complications, the occurrence of acute rejection episodes, occurrence of infections, chest infections, diabetes, hypertension and hepatitis, was analyzed, only acute rejections (p < 0.001) and chest infections (p < 0.01) had a significant effect on outcome (logistic regression).
Of the patients with functioning kidneys, the mean serum creatinine level was 132 ± 60 µmol/1 (range 38-407 µmol/1). There was no significant difference in the serum creatinine level between the patients on triple and double therapy, and between the patients with cadaveric, living-related and living non-related grafts (ANOVA).
Of the 26 patients who lost their transplants, four presented with primary nonfunction after transplantation, one each due to hyperacute rejection, infected anastomosis with sepsis and bleeding, thrombosis of the anastomosis, and cortical necrosis. The other patients lost their kidneys due to chronic rejection. The cumulative graft survival of all patients and of the two subgroups (cadaveric and living non-related) is given in [Figure - 1]. Nineteen patients expired. The causes of death are listed in [Table - 5].
| Discussion|| |
During the follow-up period, several serious complications were encountered, of which a large number was seen in patients who underwent living non-related kidney transplantation. These included six patients who contracted HIV-virus infection. Four of these patients died following serious complications of AIDS.
As reported previously  , there was a high prevalence of significant complications following non-related kidney transplantation in the HIV-negative patients too. One reason for the increased frequency of infections might be the high level of immunosuppression these patients were receiving at arrival to our hospital , . Technical factors may also be involved, as several patients presented with urinary tract infection and lymphocele, and one patient had an infected arterial vascular anastomosis. As indicated by Salahudeen, et al  , the local nursing care might also be a reason. There was a high incidence of hypertension (86%) after transplantation, the cause of which is likely to be multi-factorial  .
We saw an increased frequency of hepatitis, occurring in 24% (n = 35) of our patients [Table - 2]. Non-A, non-B hepatitis (of which hepatitis C virus (HCV) positive hepatitis is the most common) is believed to be the most prominent cause of post-transplantation liver disease  . Transmission of hepatitis C by a positive kidney donor has been reported  . There is a high prevalence of positive HCV-antibodies among dialysis patients reported from Middle-East centers with figures up to 45.5% , , making it possible that post-transplantation hepatitis is caused by pre-existent infection. However, we have no figures about the prevalence of hepatitis C in our study patients.
Despite the various infectious and urological complications encountered in our patient group, we could still achieve an acceptable outcome at 5 years of 72% and at 10 years of 48% in the whole patients group. When comparing the cadaveric transplant group with the patients who had living non-related transplants, there was a consistent trend toward better survival in the cadaveric group [Figure - 1]. The living related transplant patients were not separately evaluated as their number was relatively small. The patients lost to followup were included in the survival analysis, as they were comparable to the remaining group. Most of them had stable renal function at the time of the last visit and were subsequently referred to their original centers.
We took the opportunity to evaluate the influence of different factors such as type of transplant (cadaveric, living-related, livingnon related), age, immunosuppression, sex, place of transplant, urological complications, the occurrence of acute rejection episodes, occurrence of infections, chest infections, diabetes, hypertension, and hepatitis on the outcome. For this analysis the patients lost to follow-up were not included. In this multi-factorial analysis only the history of acute rejections and chest infections had a significant effect on the outcome. This confirms other reports highlighting the importance of acute rejection episodes in the pathogenesis of chronic rejection , . The occurrence of chest infections is possibly related to the higher level of immunosuppression due to the anti-rejection treatment. There was no difference in outcome between patients on "triple" and "double" therapy.
In summary, we would like to underline that despite serious complications encountered, especially in the early phases after transplantation  , it was possible to achieve an acceptable outcome. This was made possible by a considerable amount of medical care given to these patients during the follow-up period.
| References|| |
|1.||Hussein MM, Mooij J, Roujouleh H, El Sayed H. Observations in a Saudi-Arabian dialysis population over a 13-year period. Nephrol Dial Transplant 1994;9:1072-76. |
|2.||Shaw L. Advances in cyclosporine pharmacology, measurement, and therapeutic monitoring. Clin Chem 1989;35:1299-308. |
|3.||Nouris MJ. Logistic Regression, in SPSS/PC + Advanced Statistics Version 5.0. SPSS Inc., Chicago, U.S.A. 1992;288-301. |
|4.||Nouris MJ. Survival Analysis, in SPSS/PC + Advanced Statistics Version 5.0. SPSS Inc., Chicago, U.S.A. 1992;263-76. |
|5.||Hussein MM, Mooij J, Roujouleh H, El Sayed H. Commercial living non-related renal transplantation observations on early complications. Transplant Proc, in press. |
|6.||Al-Khader AA, Abomelha MS, Saltissi D, Chang R, Jawdat M, Etaibi K. Our experience in live non-related renal transplantation performed in Bombay and followed up in Saudi Arabia. Proceedings of the Xlth International Congress of the Transplantation Society, Helsinki, 1986;S11:4. |
|7.||Salahudeen AK, Woods HF, Pingle A, et al. High mortality among recipients of bought livingunrelated donor kidneys. Lancet 1990;336:725-8. |
|8.||Laskow DA, Curtis JJ. Post-transplant hypertension. Am J Hypertens 1990;3(9):721-5. |
|9.||Gomez E, Aguado S, Gago E, et al. A study of renal transplants obtained from antiHCV positive donors. Transplant Proc 1991;23:2654-5. |
|10.||Alfurayh O, Sobh M, Buali A, et al. Hepatitis C virus infection in chronic haemodialysis patients, a clinicopathologic study. Nephrol Dial Transplant 1992;7:327-32. |
|11.||Al-Nasser MN, Al-Mugeiren MA, Assuhaimi SA, Obineche E, Onwabalili J, Ramia S. Seropositivity to hepatitis C virus in Saudi haemodialysis patients. Vox Sang 1992;62:94-7. |
|12.||Almond PS, Matas A, Gillingham K, et al. Risk factors for chronic rejection in renal allograft recipients. Transplantation 1993;55:752-7. |
|13.||Burke JF Jr, Pirsch JD, Ramos EL, et al. Long-term efficacy and safety of cyclosporine in renal transplant recipients. N Engl J Med 1994;331:358-63. |
Department of Nephrology and Hemodialysis, Al Hada Armed Forces Hospital, P.O. Box 1347, Taif
[Figure - 1]
[Table - 1], [Table - 2], [Table - 3], [Table - 4], [Table - 5]