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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2009  |  Volume : 20  |  Issue : 5  |  Page : 867-871
Post-transplant urological and vascular complications

1 Department of Nephrology, Tabriz University of Medical Sciences, Tabriz, Iran
2 Department of Radiology,Young Researchers Club and Drug Applied Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
3 Department of Radiology, Tabriz University of Medical Sciences, Tabriz, Iran
4 Drug Applied Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
5 Renal Transplantation Unit in Imam Khomeini Hospital, Tabriz University of Medical Sciences, Tabriz, Iran

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Date of Web Publication2-Sep-2009


To determine the prevalence of urological and vascular complications in renal trans­plant recipients (RTx) at Tabriz Renal Transplant Center, we studied 55 recipients of renal allo­grafts (25 male and 29 female patients with a mean age of 38.3 ± 13.4 years) from October 2005 to November 2006. The surgical complications in our study included hematomas: 20.4%, renal artery stenosis: 20.4%, calculi: 7.4%, hydronephrosis or ureteral stricture: 5.6%, urinary leakage: 5.6%, lymphoceles: 1.9%, and renal vein thrombosis: 1.9%. We conclude that the most common urologic complications in our center were ureteric strictures and urine leaks, and the most common vascular complication was renal artery stenosis.

How to cite this article:
Safa J, Nezami N, Tarzamni MK, Zarforooshan S, Rahimi-ardabili B, Bohlouli A. Post-transplant urological and vascular complications. Saudi J Kidney Dis Transpl 2009;20:867-71

How to cite this URL:
Safa J, Nezami N, Tarzamni MK, Zarforooshan S, Rahimi-ardabili B, Bohlouli A. Post-transplant urological and vascular complications. Saudi J Kidney Dis Transpl [serial online] 2009 [cited 2022 Aug 18];20:867-71. Available from: https://www.sjkdt.org/text.asp?2009/20/5/867/55382

   Introduction Top

Renal transplantation (RTx) is the treatment of choice for patients with end stage renal di­sease, [1],[2] and continues to be the most commonly per-formed solid organ transplant (more than 10,000 operations/yearly) in the USA. [3] Urologic and vascular complications that accompany the transplant procedure may have a significant mor­bidity and mortality; they occur in approximately 4%-8% and 1%-2% of patients, respectively. [4] Many of these problems can be avoided by correcting abnormalities that are detected in the pre-transplantation period. To minimize morbi­dity and mortality, all complications must be diagnosed quickly and treated appropriately.

The aim of this study was to determine the prevalence of urological and vascular compli­cations, and their correlation with demographic, laboratory and ultrasonographic findings.

   Materials and Methods Top

We studied 55 transplant recipients' data trans­planted at Imam Khomeini Hospital of Tabriz University of Medical Sciences from October 2005 to November 2006. The complications were grouped as urologic and vascular. The urologic complications included urine leakage, distal ure­teric necrosis, and urinary obstruction, while the vascular complications included renal artery thrombosis and stenosis, renal vein thrombosis, hematomas and lymphoceles. We excluded the patients who were retransplanted, died, or did consent for the study. All the patients under­went Doppler ultrasonography one month prior to the study to detect any vascular or urologic complications in the allografts. All the sonogra­phies were performed with Hitachi model EUB 525 ultrasound machine using linear and convex probes 3.5 & 7.5 MHz by a single ultrasonogra­pher. Doppler ultrasonography indices such as resistive index (RI), pulsatility index (PI), peak systolic velocity (PSV), and percent of lumen stenosis were measured.

Demographic data, clinical evaluations inclu­ding body weight (BW) and blood pressure (BP), and laboratory studies including hemoglobin (Hb), serum creatinine (Cr), blood urea nitrogen (BUN), uric acid (UA), triglyceride (TG), cho­lesterol (Chol), high density lipoprotein (HDL), calcium (Ca), phosphorus (P), and cyclosporine levels (CsA) were measured on the day of the ultrasonographic evaluation. Pre-transplant panel reactive antibody level was measured for each patient.

   Statistical Analysis Top

Statistical analyses were performed using the SPSS 11.0 for windows software package (SPSS, Chicago, USA). The results are presented as mean values ± standard deviation. Statistical signifi­cance between compared groups was estimated using independent sample "t" test, X 2 test and Pearson correlation. The results were considered significant when the P value was <0.05.

   Results Top

Our study included 54 patients; 25 were males and 29 were females who were transplanted from 46 male and 8 female donors. The means of the age of recipients was 38.3 ± 13.4 years, age of donors 28.0 ± 4.95 years, body weight of recipients 56.9 ± 14.3 Kg, duration of dialysis 14.3 ± 11.4 years, post transplantation duration 4.07 ± 2.59 Months, systolic blood pressure 129 ± 18.7 mmHg, diastolic blood pressure 78.5 ± 13.0 mmHg, and mean blood pressure 95.4 ± 14.4 mmHg.

[Table 1] shows the ultrasonographic findings of the study patients including RI, PI, PSV of renal and iliac artery, kidney size and cortex diameter.

Twenty (37%) recipients developed vascular complications; renal artery stenosis (11 patients, 20.4%) and hematoma compressing the renal artery and vein (11 patients, 20.4%) were the most common, followed by renal vein throm­bosis (1 patient, 1.9%) and renal artery and iliac vein obstruction due to pressure from a lym­phocele (1 patient, 1.9%).

Ten (18.5%) recipients developed urologic complications; 3 (5.6%) cases of urine leakage, 3 (5.6%) hydronephrosis or ureteral stricture, 2 (3.7%) vesicoureteral reflux, and 4 (7.4%) renal calculi in the late postoperative period.

There was no difference in age and BP, or la­boratory investigations of patients with and with­out urologic complications. In addition, there was no significant difference in the sonographic indices between the patients with and without urologic complications and without.

We performed arterial anastomosis of the allo-grafts in 39 patients from the internal iliac ar­teries and in 15 patients from the external iliac arteries. The prevalence of stenosis in the exter­nal artery anastomoses was more than that of the internal anastomoses (6/15 vs. 5/39) and the difference was statistically significant (P= 0.025).

Although there was no difference in systolic blood pressure of patients with and without vas­cular complications, the diastolic and mean blood pressure of were higher in the patients with than those without the vascular complications (83.3 ± 10.2 vs. 75.6 ± 13.8; P= 0.034, 100 ± 11.0 vs. 92.0 ± 15.5; P= 0.015, respectively).

   Discussion Top

Urological complications remain a major source of morbidity and occasional mortality in renal transplantation, despite a reduction in their inci­dence of at least half over the last 30 years. [5] Most urological complications are a result of tech­nical errors at retrieval or reimplantation, or failure of tissue healing influenced by ischemia, inflammation, infection, immunosuppressive and anti-proliferative agents, and the nutritional status of the recipient. The cause of these complica­tions is of course multifactorial, and comparison of internationally published series shows wide variation among centers with different practices.

Our results show an 18.5% incidence of uro­logical complications and 37% vascular compli­cations. The urologic complications included ure­teral stricture, urine leakage, vesicoureteral re­flux and renal calculi, and the vascular compli­cations included renal artery stenosis, renal vein thrombosis, lymphoceles, and hematomas. Many patients develop gross hematuria after renal trans­plantation. This may be due to the ureteroneo­cystostomy or to irritation from stents or Foley's catheters; most resolved spontaneously without intervention.

As expected, the most common complication was that of ureteric obstruction (5.6%), which occurred due to a distal ureteric stricture. This problem was initially managed conservatively with an indwelling stent and balloon dilation. If conservative treatment failed, open surgery was required, namely, either a repeated ureteroneo­cystostomy or ureteroureterostomy using the native ureter. Similar prevalence reported by Whang et al that Lich technique is associated with 4% ureteral obstruction. Butterworth [6] and Thrasher [7] have reported similar results.

The second most common complication was urine leaks (5.6%). Somewhat surprisingly, more than half of the leaks occurred distant to the ureterovesical anastomosis. The etiology of this is unclear. The urine leaks were generally trea­ted successfully using a conservative approach with a stents and Foley's catheters. Patients who did not respond to the conservative manage­ment and required surgical interventions almost always displayed ureteric necrosis, which found more in our study than other reports. [8],[9]

Two patients developed symptomatic vesico­ureteral reflux (3.7%). While the true incidence of vesicoureteral reflux is unknown, since voi­ding cystourotherogram (VCUG) tests are not routinely performed on transplant patients; only recipients with recurrent pyelonephritis were evaluated by this method.

According to previous reports, a renal artery stenosis is found in 1 to 23% of all renal allo­ graft recipients [10],[11],[12],[13],[14],[15],[16] including Iran. [17] In our study the prevalence of transplant renal artery steno­sis was 20.4%.

Renal artery thrombosis is an uncommon event with an incidence of less than 1%, [18] but we did not encounter any case in our study. However, the prevalence of renal vein thrombosis, which ranges from 0.3% to 4.2%, [19],[20],[21] was found in 1.9% of the patients in our study. Risk factors for development of renal vein thrombosis in­clude intimal dissection, kinking, or torsion of vessels, and patients related risk factors include hypotension, multiple renal arteries, unidentified intimal graft, and hypercoagulable state. [18],[22],[23] Furthermore to these etiologies, compression by hematomas or lymphoceles, anastomotic steno­sis and extension of underlying deep venous thrombosis might lead to this complication. [18] Lymphocele was found in one (1.9%) patient in our study, which is comparable to 0.6% repor­ted elsewhere. [24]

The study of Ardalan [25] previously reported linear correlation between RI and PI, and our results showed a similar correlation. However, Ardalan found a statistically significant correla­tion between RI or PI indices and serum Cr level during the first month after renal trans­plantation [25] , but we did not find such a corre­lation in our study.

The urologic complications can be minimized by several approaches including routine use of a ureteric stent, shortening the ureter length with the Lich technique, and increased surgical expe­rience or skill. Emiroglu et al [26] stated that their low rate of urological complications was the re­sult of the team having "worked as a unit for 25 years." In our program, one urologist has per­formed almost all transplants as well as treats all complications for the past 10 years, leading to a consistent approach with respect to uro­logic complications. It is therefore advisable to limit the transplant team to a few dedicated surgeons and urologists who work together to achieve optimal results.

We conclude that the rates of the vascular complications and the urological complications in our renal transplant patients were comparable to what was previously reported elsewhere. How­ever, the complications can be minimized fur­ther by compiled surgical experience.

   References Top

1.Suthanthiran M, Strom T. Renal Transplantation. N Engl J Med 1994;331(6):365-76.  Back to cited text no. 1    
2.Akbar SA, Jafri SZ, Amendola MA. Complica­tions of renal transplantation. RadioGraphics 2005;25(5):1335-56.  Back to cited text no. 2    
3.Terasaki PI, Cecka JM, Gjertson DW, Takemoto S. High survival rates of kidney transplants from spousal and living unrelated donors. N Engl J Med 1995;333(6):333-6.  Back to cited text no. 3    
4.Kocak T, Nane I, Ander H, Ziylan O, Oktar T, Ozsoy C. Urological and surgical complications in 362 consecutive living related donor kidney transplantations. Urol Int 2004;72(3):252-6.  Back to cited text no. 4    
5.Praz V, Leisinger HJ, Pascual M, Jichlinski P. Urological Complications in Renal Transplan­tation from Cadaveric Donor Grafts: A Retros­pective Analysis of 20 Years. Urol Int 2005; 75(2):144-9.  Back to cited text no. 5    
6.Butterworth PC, Horsburgh T, Veitch PS, Bell PR, Nicholson ML. Urological complications in renal transplantation: impact of a change of technique. Br J Urol 1997;79(4):499-502.  Back to cited text no. 6    
7.Thrasher JB, Temple DR, Spees EK. Extra­vesical versus Leadbetter Politano ureteroneo­cystostomy: a comparison of urological compli­cations in 320 renal transplants. J Urol 1990; 144(5):1105-9.  Back to cited text no. 7    
8.Nicol DL, P'Ng K, Hardie DR, Wall DR, Hardie IR. Routine use of indwelling ureteral stents in renal transplantation. J Urol 1993;150(5 Pt 1): 1375-9.  Back to cited text no. 8    
9.Lin LC, Bewick M, Koffman CG. Primary use of a double J silicone ureteric stent in renal transplantation. Br J Urol 1993;72(5 Pt 2):697­701.  Back to cited text no. 9    
10.Karakayah H, Basaran O, Moray G, Emiroglu R, Haberal M. Major postoperative complica­tions of renal transplantation: results from a single center in Turkey. Transplant Proc 2003; 35(7):2657-9.  Back to cited text no. 10    
11.Fervenza FC, Lafayette RA, Alfrey EJ, Petersen J. Renal artery stenosis in kidney transplants. Am J Kidney Dis 1998;31(1):142-8.  Back to cited text no. 11    
12.Vaiculescu A, Hollenbeck M, Plum J, et al. Iliac artery stenosis proximal to a kidney transplant. Clinical findings, duplex sonographic criteria, treatment, and outcome. Transplantation 2003; 76(2):332-9.  Back to cited text no. 12    
13.Roberts JP, Ascher NL, Fryd DS, et al. Trans­plant renal artery stenosis. Transplantation 1989; 48(4):580-3.  Back to cited text no. 13    
14.Smith RB, Cosimi AB, Lordon R, Thompson AL, Ehrlich RM. Diagnosis and management of arterial stenosis causing hypertension after suc­cessful renal transplantation. J Urol 1976;115 (6):639-42.  Back to cited text no. 14    
15.Sankari BR, Geisinger M, Zelch M, Brouhard B, Cunningham R, Novick AC. Post-transplant renal artery stenosis: Impact of therapy on long­term kidney function and blood pressure con­trol. J Urol 1996;155(6):1860-4.  Back to cited text no. 15    
16.Sozen H, Dalgic A, Karakayali H, et al. Renal Transplantation in Children. Transplantation Proc 2006;38(2):426-9.  Back to cited text no. 16    
17.Khosroshahi HT, Tarzamni MK, Oskuii RA. Doppler ultrasonography before and 6 to 12 months after kidney transplantation. Transplant Proc 2005;37(7):2976-81.  Back to cited text no. 17    
18.Louridas G, Botha JR, Meyers AM, Myburgh JA. Vascular complications of renal transplantation. The Johannesburg experience. Clin Transpl 1987;1:240-5.  Back to cited text no. 18    
19.Debleke D, Sacks GA, Sandler M. Diagnosis of allograft renal vein thrombosis. Clin Nucl Med 1989;14(6):415-20.  Back to cited text no. 19    
20.Duckett T, Bretan P Jr, Cochran ST, Rajfer J, Rosenthal JT. Noninvasive radiological diagnosis of renal vein thrombosis in renal transplan­tation. J Urol 1991;146(2):403-6.  Back to cited text no. 20    
21.Merion RM, Calne RY. Allograft renal vein thrombosis. Transplant Proc 1985;17(2):1746-50.  Back to cited text no. 21    
22.Osman Y, Shokeir A, Ali-el-Dein B, et al. Vascular complications after liver donor renal transplantation study of risk factors and effects on graft and patient survival. J Urol 2003;169 (3):859-62.  Back to cited text no. 22    
23.Humar A, Johnson EM, Gillingham KJ, et al.Venous thromboembolic complications after kidney and kidney pancreas Transplantation: a multivariate analysis. Transplantation 1998;65 (2):229-34.  Back to cited text no. 23    
24.Lapointe SP, Charbit M, Jan D, et al. Urological complications after renal transplantation using ureteroureteral anastomosis in children. J Urol 2001;166(3):1046-8.  Back to cited text no. 24    
25.Ardalan MR, Tarzamni MK, Mortaazavi M, Bahloli A. Relation between resistive index and serum creatinine level in first month after renal transplantation. Transplant Proc 2003(7);35: 2628-9.  Back to cited text no. 25    
26.Emiroglu R, Karakayall H, Sevmis S, Akkoc H, Bilgin N, Haberal M. Urologic complications in 1275 consecutive renal transplantations. Transplant Proc 2001;33(1-2):2016.  Back to cited text no. 26    

Correspondence Address:
Nariman Nezami
Clinical Pharmacy Laboratory, Drug Applied Research Center, Tabriz University of Medical Science, Pashmineh, Daneshgah Street Tabriz, East Azerbaijan
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Source of Support: None, Conflict of Interest: None

PMID: 19736494

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