Key Clinical Questions
When is renal, pancreas, or liver imaging indicated after transplant?
What are the common postoperative complications that arise after liver, kidney, and pancreas transplant?
Organ transplantation is a complex but effective treatment for end-stage organ failure. Since the advent of more potent immunosuppressive medications, the demand for transplantation has far exceeded the supply. Every year in the United States more than 25,000 people undergo organ transplantation, while at the same time more than 100,000 people remain on the waiting list. The combination of complex surgery, immunosuppression, and very ill and debilitated patients make postoperative management very challenging.
Complications related to transplantation are most often divided into early (typically technical in nature) and late (typically related to immunosuppression or other medications). All of the complications associated with less complicated general surgical procedures can also be seen after transplantation. This chapter will focus on the complications that are particular to transplantation and that are most likely to be encountered by Hospitalists.
COMPLICATIONS OF KIDNEY TRANSPLANT
POSTOPERATIVE OLIGURIA/GRAFT DYSFUNCTION
The causes of early graft dysfunction range from the benign to the truly emergent and include, but are not limited to, thrombus in the Foley catheter, acute tubular necrosis, thrombosis of the renal artery or vein, ureteric leak or stenosis, and rejection. Prompt diagnosis and appropriate management are necessary to salvage the graft (Figure 66-1).
Low or absent urine output may be attributable to the renal parenchyma (ATN), the renal vasculature, ureteral issues, or Foley catheter obstruction/malfunction. ATN is the most likely cause for poor/delayed graft function and complicates approximately 20% to 30% of kidney transplants. It is more common in the setting of long cold ischemic times, older donors, and highly sensitized recipients. It typically improves spontaneously over the first few weeks posttransplant. Although ATN is the most likely etiology of poor initial function, it is a diagnosis of exclusion, and a rapid and systematic evaluation must occur to rule out the other more worrisome possibilities:
The Foley catheter should be irrigated to ensure that clot or tissue has not affected its patency.
The adequacy of resuscitation should be evaluated by reviewing the vital signs, central pressures, and fluid balances; intravascular depletion should be treated with a bolus of an appropriate crystalloid fluid.
The patency of the renal artery and vein should be evaluated using duplex Doppler ultrasonography. Urgent surgical exploration is indicated when vascular compromise is demonstrated by imaging or when clinical suspicion is high. Renal scintigraphy can be used as a confirmatory test after ultrasound.
Acute cellular rejection is unlikely early after transplant but must be a part of the differential if the clinical scenario is appropriate (ie, high panel reactive antibodies or PRA, ...