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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2021  |  Volume : 32  |  Issue : 6  |  Page : 1700-1706
Assessing the Inhospital Complications in Patients Postrenal Transplantation, in a Tertiary Care Center, Riyadh, Saudi Arabia

1 Department of Surgery, Division of Transplant, King Abdulaziz Medical City, Riyadh, Saudi Arabia
2 General Surgery Resident, General Surgery Residency Program, King Abdulaziz Medical City, Riyadh, Saudi Arabia

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Date of Web Publication27-Jul-2022


Complications of chronic kidney disease (CKD) can range from localized to systemic manifestations that can worsen patients’ outcomes. CKD results in irreversible deterioration in renal function, which ultimately progresses to end-stage renal failure and necessitates the need for renal transplantation. Our study aimed to identify patients’ complications postrenal transplant during hospitalization and assess the main factors affecting these patients’ outcomes and survival rates. This study is a single-centered, retrospective cohort chart review conducted from January 2016 to March 2019. The collected data parameters included patients’ characteristics (e.g., gender, age, body mass index), as well as surgical-related details and postoperative complications. Microsoft Excel and IBM SPSS Statistics version 22.0 were used for data entry and analysis. The descriptive statistics were presented as frequency and percentage for the categorical variables (e.g., gender and smoking status), while the mean ± standard deviation was used for numerical variables. A total of 80 posttransplant patients who fulfilled the inclusion criteria were recruited. Urogenital complications were the most commonly seen during the postoperative period, especially developing urinary tract infections by 16%. During our study, the rate of complications was considered minimal and not significant in assessing posttransplant patients.

How to cite this article:
Altamimi A, Alsadun SA, Albassri TK, Almutairi SN, Altamimi YA. Assessing the Inhospital Complications in Patients Postrenal Transplantation, in a Tertiary Care Center, Riyadh, Saudi Arabia. Saudi J Kidney Dis Transpl 2021;32:1700-6

How to cite this URL:
Altamimi A, Alsadun SA, Albassri TK, Almutairi SN, Altamimi YA. Assessing the Inhospital Complications in Patients Postrenal Transplantation, in a Tertiary Care Center, Riyadh, Saudi Arabia. Saudi J Kidney Dis Transpl [serial online] 2021 [cited 2022 Sep 25];32:1700-6. Available from: https://www.sjkdt.org/text.asp?2021/32/6/1700/352431

   Introduction Top

Globally, the incidence of chronic kidney disease (CKD) has significantly increased and various meta-analyses have highlighted its high prevalence.[1] Complicated CKD can further lead to an increased risk of end-stage renal failure (ESRF), which will necessitate those patients to require renal replacement therapy to survive.[1] CKD is estimated to occur in 20%–40% of Asian patients attending primary care clinics, thus placing a significant burden on health-care systems to control the risk factors to reduce progression to ESRF.[2],[3],[4] Locally, the prevalence of CKD in Saudi Arabia during the year 2008 alone was reported to be around 6%, and currently, this number has been increasing noticeably.[5],[6] Complications of CKD can range from localized to systemic manifestations, thusworsening patients’ outcome.[2] Renal transplantation is currently the best available treatment and is considered the treatment of choice for ESRF.[7],[8],[9] It improves the quality of life of recipients andahs lower financial costs as well as its correlation with higher survival rates in comparison to other management modalities.[7],[10] Organs can be retrieved from living-relative donors (LRKT), nonrelative living donors (LNKT), orlastly, from cadavers.[11] By the end of the year 2013, a total of 5820 living donors and 2563 deceased donors renal transplantations have been performed in Saudi Arabia.[11] The postoperative status of patients postrenal transplant varies from successful recovery with no to minimize adverse effects, to patients with serious life-threatening complications.[12] Complications of renal transplantation can be classified as either pathological or surgical, as well as immediate to delayed responses.[12],[13] Pathological complications vary from immediate organ rejection, infection, to cardiovascular events, while surgical complications involve vascular, urological complications, and wound infection.[12],[14] Other patients might face the struggle of developing posttransplant diabetes mellitus (DM), which significantly increases the risk of graft loss and mortality.[15],[16],[17] Despite all advances, graft-endangering complications are primarily of vascular etiology.[12] Vascular complications account for 3%–15% of all cases.[12] These include thrombosis or stenosis of the renal artery or vein.[12],[18] Many factors can affect patients’ risk of infections, such as immunosuppression, exposure to infectious diseases, and quality of postoperative care.[12]

In this study, we aim to identify the complications of patients’ postrenal transplant and assess the main factors affecting these patients’ outcomes and survival rates at King Abdulaziz Medical City (KAMC), a tertiary care center in Riyadh, Saudi Arabia.

   Patients and Methods Top

This study is a single-centered chart review study conducted at KAMC in Riyadh, Kingdom of Saudi Arabia. KAMC started operating in May 1983, and since then, it has been distinguished as one of the most important health-care centers in the area. This study is a retrospective cohort study in which charts of all postrenal transplant patients got reviewed and assessed further for any inhospital complications during the period between January 2016 and March 2019. Patients’ information is collected manually by the co-investigators after getting approval from the Institutional Research Board from King Abdullah International Medical Research Center. The data parameters collected included patients’ characteristics such as age, gender, body mass index (BMI) upon admission, smoking status before transplant, their medical history as well as any relevant family medical history. Also, the type of dialysis, and the status of hepatitis C virus (HCV), cytomegalovirus (CmV) immunoglobulin (Ig) G and IgM. Data about the donors’ types were also collected, as well as the need for any antibiotics given prophy-lactically. As for the transplant procedure itself, the immunosuppression induction agents used, any blood loss or need for blood or fluid transfusion, specifics about the operations like warm ischemia time (anastomosis time), mean cold ischemic time, ureteral implantation technique, also postoperative data such as the duration of admission, the central venous catheters (CVCs) used and duration, and the duration of placing indwelling catheters used, followed by the evaluation of the transplanted graft itself, by assessing its function immediately posttransplant and at last followup. Postoperative complications and laboratory parameters were collected lastly. This study included all patients aging ≥18 years old, both genders, all nationalities, who had this transplant as their primary kidney transplantation, whether transplantation of a kidney from living related, living unrelated or dead donor, and finally with completed medical electronic files. All patients who are pediatrics <18 years old, with secondary/tertiary kidney transplantation, or patients with missing data were excluded from the study. Non-probability consecutive sampling approach. Microsoft Excel and IBM SPSS Statistics version 22.0(IBM Corp., Armonk, NY, USA) were used for data entry and analysis. Numerical data such as age were presented by mean ± standard deviation (SD). Categorical data were presented as frequencies and percentages. The study design is cost-effective and safe for its patients. It did not interfere with the patients’ treatment plans. No extra investigations were carried out other than those that were already performed as part of the standard medical care provided to the patient. To ensure confidentiality, access to the data was restricted to the study group. No direct contact with patients was needed. Patient privacy and confidentiality were assured throughout the study, and no identifiers were collected.

   Results Top

A total of 80 posttransplant patients who fulfilled the inclusion criteria were recruited. The characteristics of the study population are shown in [Table 1]. The average age is 44 (SD ± 16) years. The range from 60 up to 70 years comprised 22.5% of the total sample size. Patients’ genders were equal, 40 of them were female (50%) and 40 were male (50%). As for their smoking status, the majority of patients were nonsmokers (85%), while eight were smokers (5%) and four were smokers in withdrawal (10%). As for the BMI upon admission, four patients were malnourished (5%), 28 were healthy (35%), 22 were overweight (27%), and 26 were obese (33%). The majority of patients had a no-related positive family history of ESRF or transplant before by 64 patients (80%), while 16 of them had (20%). For patients’ pretransplant comorbidities or original kidney disease, 42 of them had idiopathic kidney disease (42%), 63 patients had hypertension as seen in 63 of them (33%), while 29 had DM (16%). For the dialysis type, 63 patients had hemodialysis (79%), 16 had peritoneal dialysis (20%), and one patient had pre-emptive dialysis (1%). Pretransplant viral values were also recorded, as 72 patients had negative HCV values (90%), while eight had positive (10%). Furthermore, for CMV IgG, 12 patients had negative values (15%) and 68 had positive results (85%). Finally, for CMV IgM, 15 patients had negative values (19%), while 65 had positive values (81%). The types of donor included were divided into three categories: 51 were from LRKT (64%), LNKT (14%), or 18 received from deceased/cadaveric donor (23%). For the transplant procedure, the immunosuppression induction agents were diverse in usage. Basiliximab (Simulect) was most commonly used in 46 patients (58%), followed by methylprednisolone in 45 (57%), thyroglobulin (ATG) in 32 patients (40%), mycophenolate (Cellcept) MMF in six patients (8%), and finally tacrolimus (FK) in five patients (6%). Regarding the ureteral implantation technique, the most common technique used was Lich-Gregoire (79%), while the rest was done by single-stitch Lich (21%). Calculating the warm ischemia time (anastomosis time) as well as the mean cold ischemic time was also recorded. Blood and blood products received were given in only eight patients, three of them received one packed unit red blood cells (PRBCs), two patients received two PRBC, and also two received four units. Initial graft function was reported to be immediate (90%) for most of our patients, followed by slow graft function, which was seen in five patients, delayed graft function in two patients, and finally, nonfunctioning graft seen in only 1%. Only one patient had a graft loss that could be attributed to a surgical complication related to a ureteral injury with ferula placement and posterior urinoma formation. CVCs were placed in 73 patients (91%). The average time of using CVC was 5.9 ± 1.77 days. As for the indwelling catheter usage and time, the average was 5.7 ± 1.69 days. [Table 2] summarizes the surgical data and postoperative complications occurring during hospitalization. For the inhospital stay, the average of period of hospitalization was 11.6 ± 6.06 days, and for the three-month follow-up periods, 96% of patients reported to have functioning graft while declining in function or failure was seen in three patients at the last follow-up. Preoperative, postoperative, and three-month follow-up laboratory data were reviewed and summarized in [Table 3].
Table 1. Demographic and clinical characteristics of renal transplant recipients.

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Table 2. Surgical data and postoperative complications occurring during hospitalization.
UTI: Urinary tract infection, PRBCs: Packed red blood cells.

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Table 3. Preoperative, postoperative, and follow-up laboratory test results of all patients.

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   Discussion Top

Renal transplant is the ultimate treatment for patients with ESRF. All of our patients involved had their first kidney transplant. As for gender, it was equally distributed between females and males. Most of the patients were middle aged with concurrent comorbidities, which might affect the surgical procedures and the subsequent outcome or further developing complications. For laboratory results, they included the expected increase in postoperative and three-month follow-up glomerular filtration rate as well as seen in albumin. While for other results, a noticeable decrease in blood urea nitrogen and creatinine over the following three months was reported. Tacrolimus blood levels remained relatively stable with a linear increase during the follow-up, which was all concurrent with the literature. These findings were similar to the one seen in the article by Reyna-Sepúlveda et al.[12] Surgical or postoperative complications in kidney transplantation are usually minimally noted in the majority of patients, with the main complications were developing collections (hematoma, seroma, lymphocele, or another fluid collections). In more depth, hematoma formation is a frequent minor complication that occurs postoperatively, mainly attributed to a small leakage of the vascular anastomosis or minor bleeding from the renal surface of the surrounding tissues. When hematomas grow and produce clinical signs or symptoms by pressure, it may lead to graft dysfunction and thrombotic complications; however, all patients in our study had minor hematomas that resolved spontaneously in the follow-up assessment. Ultrasound (US) or computed tomography might be required for the diagnosis of fluid collections if necessary. In comparison, lymphoceles occur during the dissection process by opening the lymphatics. In most patients, these fluid collections are asymptomatic and are found in the US examination done and mainly resolve spontaneously without any further intervention. For lymphocele, it was seen in two patients in our study. Cardiac and vascular complications were not significant. Thrombosis was seen in <5% of patients, noted over the two weeks postoperative period. However, no single cause of renal artery stenosis was reported in our study. Renal or urogenital complications are the most common complications postoperatively, presenting with an incidence ranging from 2% to 16%. These complications are a major cause of morbidity and increased hospitalization costs. Urinary tract infection (UTI) was the most common complication noted during the inhospital stay by 16%. Postoperatively, patients are placed on an indwelling/Foley catheter to assess their urogenital functions. Our institution has its protocol regarding the usage of Foley catheters in posttransplant patients. The protocol is defined by placing a Foley catheter after the induction of general anesthesia on the day of the transplantation procedure. It must be placed on by a physician or surgeon scrubbed, gowned, and gloved on under full sterilization technique, and then, it gets removed mostly in day 5 postoperatively if patients’ conditions improved and the catheter is no longer needed. UTI was mainly seen in patients having catheters who were required to be placed on for longer than five days. Other complications were mainly highlighted by developing cellular rejection which was seen in <10% of patients. As for graft loss, it was only seen in one case in our study. The need for blood or blood products’ transfusion was also minimal, whether preoperatively, postoperatively, or during the inpatient period. Only eight patients received blood products. Not a single case of developing malignancy was reported nor death in our study.

Regarding the limitations that we faced in our study, it is a single-centered study, so it is preferable to include more centers and assess their transplant and follow-up protocols, which can lead to enhancing and have a better understanding of dealing with such patients and thus better management and treatments plans. Another limitation is that it is a retrospective chart review; hence, some data were missing from the charts and that led us to exclude some patients.

   Conclusion Top

The main complications that the patients face during admission after renal transplantation were mainly urogenital, mostly patients developing UTI and thus further insinuating the need to have longer admission stay. In general, these complications can be attributed to a multifactorial process that includes patients’ comorbidities and pretransplant status, surgical techniques and postoperative manage-ment, longer hospitalization rate and duration of follow-up. Early identification and treatment of surgical complications are critical for patients and graft survival. In general, complications’ rate was considered to be minimal and not significant in assessing posttransplant patients.

Conflict of interest: None declared.

   References Top

Ulasi II, Ijoma C, Onodugo O, et al. Posttransplant care of kidney transplant recipients and their donors in Nigeria. Exp Clin Transplant 2019;17 Suppl 1:50-6.  Back to cited text no. 1
Lim CC, Chee ML, Cheng CY, et al. Simplified end stage renal failure risk prediction model for the low-risk general population with chronic kidney disease. PLoS One 2019;14:e0212590.  Back to cited text no. 2
Schoolwerth AC, Engelgau MM, Hostetter TH, et al. Chronic kidney disease: A public health problem that needs a public health action plan. Prev Chronic Dis 2006;3:A57.  Back to cited text no. 3
James MT, Hemmelgarn BR, Tonelli M. Early recognition and prevention of chronic kidney disease. Lancet 2010;375:1296-309.  Back to cited text no. 4
Alsuwaida AO, Farag YM, Al Sayyari AA, et al. Epidemiology of chronic kidney disease in the Kingdom of Saudi Arabia (SEEK-Saudi investigators) - A pilot study. Saudi J Kidney Dis Transpl 2010;21:1066-72.  Back to cited text no. 5
[PUBMED]  [Full text]  
Alhussain BM, Alqubaisi AK, Omair A, O’hali WA, Abdullah KO, Altamimi AR. Quality of life in living kidney donors: A single-center experience at the king abdulaziz medical city. Saudi J Kidney Dis Transpl 2019;30:1210-4.  Back to cited text no. 6
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Correspondence Address:
Abdulrahman Altamimi
Department of Surgery, Division of Transplant, King Abdulaziz Medical City, Riyadh, Saudi Arabia.
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1319-2442.352431

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