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 Table of Contents  
Year : 2020  |  Volume : 26  |  Issue : 2  |  Page : 144-146

Surgical complications in post-live-donor renal transplantation recipients – Our experience and lessons learnt

Division of Urology, Lourdes Institute of Nephro-Urology, Lourdes Hospital, Kochi, Kerala, India

Date of Submission11-Aug-2020
Date of Decision14-Aug-2020
Date of Acceptance13-Sep-2020
Date of Web Publication07-Nov-2020

Correspondence Address:
Dr. H Krishna Moorthy
Division of Urology, Lourdes Institute of Nephro-Urology, Lourdes Hospital, Kochi, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ksj.ksj_30_20

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Introduction: Renal transplantation has become a common treatment for end-stage renal disease. The surgical techniques for renal transplantation are well established and associated with high success rates. Complications of the procedure are low (15%–17%) when compared to other solid organ transplants such as liver and pancreas. Surgical complications of renal transplantation are mostly related to either surgical site infection or problems in one of the three anastomoses (renal artery, renal vein or ureter). Most of the complications require prompt surgical or radiologic intervention for appropriate management. Materials and Methods: This is a retrospective observational study of surgical complications in patients undergoing live-donor renal transplantation for a period of 10 years before 2020 in the urology department of a tertiary care hospital. The incidence and potential reasons for the complications were analysed and reviewed. Results: Of the 250 cases reviewed, surgical complications were observed in 20 (8%). Among these, ureteric necrosis, arterial thrombosis and significant symptomatic lymphocele were the main surgical complications. Through this study, a causal relationship was established in all these patients with complications and preventive measures have been suggested. Conclusions: Surgical complications of live-donor renal transplantations could be reduced by adopting appropriate precautionary measures. Early identification and treatment of surgical complications are critical for graft survival after kidney transplantation.

Keywords: End-stage renal disease, graft survival, kidney transplantation, surgical complication

How to cite this article:
Kumar R, Pillai BS, Moorthy H K. Surgical complications in post-live-donor renal transplantation recipients – Our experience and lessons learnt. Kerala Surg J 2020;26:144-6

How to cite this URL:
Kumar R, Pillai BS, Moorthy H K. Surgical complications in post-live-donor renal transplantation recipients – Our experience and lessons learnt. Kerala Surg J [serial online] 2020 [cited 2022 Jun 26];26:144-6. Available from: http://www.keralasurgj.com/text.asp?2020/26/2/144/300239

  Introduction Top

Renal transplantation is the treatment of choice for end-stage renal disease (ESRD), despite improvements in peritoneal dialysis and haemodialysis. Survival rates have improved because of better immune suppression, availability of human leucocyte antigen typing for donor–recipient matching and nationwide coordinating network.

Complications of renal transplantation can be classified into two: pathological and surgical. Pathological complication includes rejection while surgical complication includes vascular and urological complication such as lymphocele, urine leak, wound infection and hernia. It is pertinent to assess the surgical complications and identify probable reasons for the same and adopt appropriate remedial measures to reduce them. This study was done to identify the causal relationship in all these patients with surgical complications and suggest probable preventive measures.

  Materials and Methods Top

This retrospective observational study of 250 live-donor kidney transplant surgeries was done during a period of 10 years before 2020 in a single tertiary care urology unit in South India. Demographic variables, medical history, laboratory tests, details of surgical procedure and post-transplant follow-up at 3 months were reviewed. Surgical complications including those involving arterial, venous and ureteric, anastomoses, significant symptomatic lymphocele and wound infections were noted. The surgical techniques were reviewed, and a probable causal relationship was assessed. Based on these findings, suggestions for avoiding/reducing these complications are also proposed.

  Results Top

Of the 250 cases reviewed, 194 (77.5%) were men and 56 (22.5%) were women. The mean recipient age was 38.3 years and mean body mass index (BMI) was 26.24 kg/m2. The cause of ESRD in majority of patients was diabetic nephropathy and other pathologies such as hypertensive nephropathy, glomerular disease or idiopathic in others. All patients were on renal replacement therapy before transplant for a mean time of 13 months. The mean cold ischaemia time was 30 min, mean blood loss in recipients was 500 ml and mean hospital stay was 12 days.

There were 20 (8%) surgical complications stratified by aetiology [Table 1].
Table 1: Surgical complications of live-donor renal transplant recipient patients

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Surgical wound dehiscence was found in 2 (10%) patients. Both patients were diabetic with BMI of 28 and 30 kg/m2, respectively. Five (25%) patients had urine leak. Among these, 4 patients had leak at ureterovesical junction and 1 had ureteric necrosis below the ureteropelvic junction with concurrent BK virus infection. All these patients presented with urinary leak through incision site and urinoma. The timing of presentation was within 1 week of stent removal.

In our study, 5 (25%) had renal arterial thrombosis, among which 3 patients had allograft with multiple renal arteries. All renal arterial thrombosis occurred at a mean period of 24 days. All the patients presented with silent drop in urine output. Two (10%) patients had renal vein thrombosis, of which 1 patient had renal vein thrombosis with underlying deep vein thrombosis (DVT) due to prior amputation of the right lower limb.

In our study, 6 (30%) patients developed symptomatic lymphocele. All of them presented within a mean time period of 6 weeks. Five patients were managed with computed tomography (CT)-guided aspiration alone and one patient underwent laparoscopic deroofing of lymphocele.

  Discussion Top

The overall rate of surgical complications (8%) seen in our studies was similar to the results reported from other centres (10%–25%).[1],[2] Urologic and vascular complications may occur in renal transplant recipients, and they have a substantial impact on morbidity and mortality. Urologic complications occur in 4%–8% of patients and vascular complications occur in approximately 1%–2%.[3] In our study, the incidence of urological complications was 2% and vascular complication was 2.4%.

Surgical site infection is a common complication in renal transplant recipient patients. In our study, 2 (10%) patients suffered wound dehiscence and were treated by regular dressing and intravenous antibiotics as per culture sensitivity report. Both patients had high BMI. Other reasons for surgical site infection include uncontrolled diabetes mellitus and cross infection. It is advisable to reduce BMI before transplant whenever feasible and have strict control of diabetes.

Approximately two-thirds of the early ureteric complications (urine leak or obstruction) were detected within the 1st week of stent removal and treated appropriately. Currently, ureteric complication rates reported are 4%–8% with very low patient mortality.[4],[5] In our patients, the ureteric complication rate was 2%.

On reviewing the surgical techniques, we observed that the reasons of ureteric leak in our series included too tight antireflux anastomosis, especially in patients with thick-walled bladder and BK virus infection in one patient. Other reasons of ureteric necrosis could be overzealous dissection and surgical handling of the graft ureter. Post-operative haematoma due to anticoagulation therapy and pressure exerted by haematoma may also compromise blood supply of graft ureter. Based on our experience, we suggest avoiding a tight detrusorrhaphy, especially in a thick-walled bladder. A refluxing anastomosis could be adopted in these situations. Meticulous haemostasis to preserve graft ureteric blood supply and keeping ureter short and well vascularised also helps to prevent this complication. Retaining DJ stent for a longer period of time [6],[7] and drainage of post-operative haematoma could also reduce ureteric necrosis.

Vascular complications occur with an incidence rate of 1%–23%.[8] In our study, the incidence of this complication was only 2.8%. Renal arterial thrombosis was seen in 5 out of 7 patients (2%). On review of literature, reasons identified for the causation of these complications include elderly donors, recipients with diabetic nephropathy and multiple allograft renal arteries.[9],[10] Other reasons for renal arterial thrombosis could be per- or post-operative haemodynamic instability, recipients with history of thrombotic disorders, long duration on haemodialysis before transplant and technical errors at the time of arterial anastomosis (turbulent flow from kidney malposition or arterial twisting, kinking or compression). Based on our experience, we suggest that a thrombophilic evaluation should be done in every potential transplant candidate to identify those at an increased risk of thrombosis. It has been suggested that long-term maintenance with warfarin or low dose of heparin should be considered, targeting INR values at 2.5.[11] In patients at low clinical risk, aspirin (75–150 mg/day) with or without short period of unfractionated heparin (5000 U twice a day for 5 days) appeared to significantly reduce the risk of renal allograft thrombosis.[12],[13]

Renal vein thrombosis is a rare complication after renal transplantation with multifactorial aetiologies. In our study, only two patients had renal vein thrombosis, including one patient who had concurrent DVT due to prior amputation of ipsilateral lower limb. Based on our experience, we suggest that transplant should be avoided to the side where prior history of limb trauma, DVT or amputation is present. Early recognition of renal vein thrombosis is crucial, for which Doppler ultrasound and magnetic resonance venography could be of great help. Literature mentions treatment with streptokinase [14] or urokinase [15] as useful treatment tools, particularly in case of acute or partial vein thrombosis.[16] Percutaneous mechanical thrombectomy and localised catheter-directed thrombolysis may also allow the return of kidney function in some patients.[17]

The development of symptomatic significant Lymphocele is a frequent postoperative complication after kidney transplantation with a prevalence of 0.5%–20%. In our study, six patients developed significant lymphocoele with a mean period of 6 weeks. Five patients were managed with CT-guided aspiration alone and one underwent laparoscopic deroofing. We identified inadequate ligation of lymphatic channels across iliac vessels and the use of heparin postoperatively as the potential causes. We suggest meticulous ligation of lymphatics, longitudinal dissection of lymphatics and judicious use of heparin postoperatively as corrective measures.

We did not encounter complications such as ureteric obstruction, significant haematomas, renal artery/segmental artery stenosis and arteriovenous fistula/aneurysm, probably because of high case volumes and surgeon expertise. Other factors for low rate of surgical complications were routine use of DJ stent for 6 weeks, urethral catheter for 10 days, use of appropriate antibiotics till patient is urine cultural negative, early mobilisation of the patient and judicious use of heparin.

  Conclusions Top

Renal transplantation is currently the preferred treatment of ESRD. Improvement in surgical techniques and potent immunosuppressive drugs has resulted in remarkable improvement in survival of patients and renal grafts. Nevertheless, substantial complications occur in both the immediate postoperative period and later. Surgical complications can be minimised with standardisation of surgical techniques. Early identification and treatment of these complications are crucial in improving the results of live-donor renal transplantation.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Dinckan A, Tekin A, Turkyilmaz S, Kocak H, Gurkan A, Erdogan O, et al. Early and late urological complications corrected surgically following renal transplantation. Transpl Int 2007;20:702-7.  Back to cited text no. 1
Kamali K, Zargar MA, Zargar H. Early common surgical complications in 1500 kidney transplantations. Transplant Proc 2003;35:2655-6.  Back to cited text no. 2
Koçak 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;72:252-6.  Back to cited text no. 3
Egli A, Helmersen DS, Taub K, Hirsch HH, Johnson A. Renal failure five years after lung transplantation due to polyomavirus BK-associated nephropathy. Am J Transplant 2010;10:2324-30.  Back to cited text no. 4
Catalona WJ, Kadmon D, Crane DB. Effect of mini-dose heparin on lymphocele formation following extraperitoneal pelvic lymphadenectomy. J Urol 1980;123:890-2.  Back to cited text no. 5
Wilson CH, Rix DA, Manas DM. Routine intraoperative ureteric stenting for kidney transplant recipients. Cochrane Database Syst Rev 2013;17:CD004925.  Back to cited text no. 6
Dominguez J, Clase CM, Mahalati K, MacDonald AS, McAlister VC, Belitsky P, et al. Is routine ureteric stenting needed in kidney transplantation? A randomized trial. Transplantation 2000;70:597-601.  Back to cited text no. 7
Fervenza FC, Lafayette RA, Alfrey EJ, Petersen J. Renal artery stenosis in kidney transplants. Am J Kidney Dis 1998;31:142-8.  Back to cited text no. 8
Luna E, Cubero JJ, Hernández Gallego R, Barroso S, Caravaca F, García MC, et al. Evolution of suboptimal renal transplantations: Experience of a single Spanish center. Transplant Proc 2006;38:2394-5.  Back to cited text no. 9
Baden L, Katz J. Infectious disease issues in the well transplant patient. Graft 2001;4:276-89.  Back to cited text no. 10
Friedman GS, Meier-Kriesche HU, Kaplan B, Mathis AS, Bonomini L, Shah N, et al. Hypercoagulable states in renal transplant candidates: Impact of anticoagulation upon incidence of renal allograft thrombosis. Transplantation 2001;72:1073-8.  Back to cited text no. 11
Robertson AJ, Nargund V, Gray DW, Morris PJ. Low dose aspirin as prophylaxis against renal-vein thrombosis in renal-transplant recipients. Nephrol Dial Transplant 2000;15:1865-8.  Back to cited text no. 12
Stechman MJ, Charlwood N, Gray DW, Handa A. Administration of 75 mg of aspirin daily for 28 days is sufficient prophylaxis against renal transplant vein thrombosis. Phlebology 2007;22:83-5.  Back to cited text no. 13
Kaveggia LP, Perrella RR, Grant EG, Tessler FN, Rosenthal JT, Wilkinson A, et al. Duplex Doppler sonography in renal allografts: The significance of reversed flow in diastole. AJR Am J Roentgenol 1990;155:295-8.  Back to cited text no. 14
Chiu AS, Landsberg DN. Successful treatment of acute transplant renal vein thrombosis with selective streptokinase infusion. Transplant Proc 1991;23:2297-300.  Back to cited text no. 15
Bedani PL, Galeotti R, Mugnani G, Risichella IS, Rizzioli E, Verzola A, et al. Successful local arterial urokinase infusion to reverse late postoperative venous thrombosis of a renal graft. Nephrol Dial Transplant 1999;14:2225-7.  Back to cited text no. 16
Ortega Herrera R, Medina Benítez A, Hernández Abad MJ. Renal vein partial thrombosis in 3 recipients of kidney transplantation. Arch Esp Urol 2000;53:45-8.  Back to cited text no. 17


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