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Surgical complications post renal transplantation

 

Surgical Complications Post Renal Transplantation

 

 Operative Procedure

• Usually extraperitoneal placement in right iliac fossa.

• Intraperitoneal placement usually made with simultaneous kidney./ pancreas operation.

• Anastamosis of transplant artery to external iliac artery(end to side)

• Anastamosis of transplant vein to external iliac vein (end to side)

• Anastamosis of utransplant ureter to bladder +/- stent placement

 

Haemorrhage

• Usually from unligated vessels in graft hilum or severed retroperitoneal vessels of recipient.

• Look for:

- Hypotension / low CVP

- Blood in drain

- Falling Hb

- Tenderness over graft

• Investigations

- US scan or CT scan

- Sometimes fresh bleeding difficult to visualize on US scan

- Repeat clotting / stop heparin / Aspirin.

• Outcome

- Usually bleeding settles spontaneously with conservative management

- Reexploration performed if persisting transfusion requirements or

haemodynamic instability

- Often no bleeding source identified with reexploration and haematoma evacuated.

 

Renal Artery Thrombosis

• Rare...less than 1%

• Occurs early post transplantation

• Usually due to technical problem such as intimal tear

• May be due to hypotension or hypercoaguable state.

• Look for:

- Sudden onset anuria

- Tender kidney

- Raised LDH

- Absent flow on colour Doppler

• Urgent reexploration and thrombectomy indicated

• However tolerance to warm ischaemia is poor and most grafts are lost

 

Renal Vein Thrombosis

• Rare

• Usually due to either

- Kinking / angulation or vein

- External compression by lymphocoele

- Extension of DVT within recipient vasculature

- Hypercoaguable state

• Look for:

- Haematuria followed by anuria

- Tender / swollen graft

- Diagnosis made on colour Doppler

• Reexploration and thrombectomy indicated

• Graft salvage rarely achieved and only if diagnosis made early

 

Recipient vasculature complications

• Patients with peripheral vasculature are at increased risk of iliac artery thrombosis

post transplantation

• Usually due to trauma from vascular clamp

• Occurs early post transplantation (hours)

• Look for evidence of ischaemic limb. Check femoral pulses post transplantation

• Immediate surgical exploration with balloon thrombectomy

 

Urine leak

• Occurs within the first few days

• May manifest with removal of bladder catheter

• Usually occurs from anastamotic site

• May be due to ureteric ischaemia

• Look out for

- Onset abdominal pain

- Decreased urine output (caution in patients with good native output!)

- Drainage of urine from wound

- Urinoma on ultrasound

- Send fluid for creatinine level

• Early (days post op ) and large leaks managed by reanastomosis

• Some leaks can be managed conservatively by placement of drain in urinoma and stenting

or ureter (peformed percutaneously)

 

Obstruction

• May present early or late

• Causes of early obstruction (first few weeks):

- Ureteric oedema

- Blood clots

- External compression from haematoma or lymphocoele

- Kinking

• Causes of late obstruction

- Fibrosis from chronic ureteric ischaemia

- Nephrolithiasis

- Bladder outlet obstruction

• Urine output may be decreased, normal or increased

• Diagnosis made by Ultrasound and comparison with previous scans

• Note mild hydronephrosis may be seen in normal transplants

• Ensure bladder empty at time of US scan

• Percutaneous nehrostogram most specific test

• Management may consist of

- Ureteric reimplantation if stricture very distal

- Ureteropylostomy (anastomosis of transplant pelvis with native collecting system) if stricture proximal

- Long term stent placement should be last resort (risk of recurrent infections)

- Long term nephrostomy is very last resort

 

Lymphocoeles

• Fluid collections of lymph arising from cut lymphatics of recipient

• Usually lymphatics surrounding iliac artery

• Incidence 0.5-15%

• Increased with use of sirolimus

• Commonly at lower pole of transplant

• Most do not cause problems

• May cause

- Partial urinary obstruction

- Compression of renal transplant vein

- Compression of iliac veins / DVT

• Problematic lymphocoeles can be:

- Single percutaneous drainage under US guidance

- Recurrence treated with placement of percutaneous drain

- Continued drainage managed by creation of a window into the peritoneal cavity

 

Transplant artery stenosis

• Incidence 1-10%

• Late complication

• Most are at anastomotic site

• Caused by progression of recipient atherosclerotic disease

• Look for

- Hypertension

- Graft dysfunction

- Worsening graft dysfunction with control of blood pressure

- No proteinuria

- Salt and water retention

Investigations

- Doppler US scan

- MRA / CT renal angiogram

Management

- Ballon angioplasty +/- stent insertion

- Surgical Reanastomosis: but this is difficult due to extensive fibrosis around older

kidney transplants

 

 

For pdf click below.

Surgical Complications


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