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Colonic perforations after renal transplantation.

BACKGROUND
Perforation of the colon is a rare but serious complication in renal transplantation; allograft recipients constitute a patient population uniquely at risk with end-stage renal failure, maintenance therapy with dialysis before transplantation, and then chronic immunosuppression thereafter.


STUDY DESIGN
In 1,401 consecutive transplants performed between 1951 and 1995 at the Brigham and Women's Hospital, 30 recipients (2.1 percent) experienced 34 episodes of colonic perforations, 13 of which (38 percent) were fatal. The medical records and clinic charts of each person were analyzed for variables between those who survived and those who died of the colon perforation.


RESULTS
Significant differences in patient demography and clinical and laboratory findings including age, mean corticosteroid dose, and nutritional status were noted between the two groups. Early diagnosis and intervention improved the prognosis; 22 percent of those operated on within 24 hours died; 47 percent died after delayed intervention. Excision of the lesion with end-to-end anastomosis was effective in most right colon perforations, and removal of the lesion and formation of an end-colostomy and Hartmann pouch was preferred in rectosigmoid perforations. The incidence and outcome of posttransplant colonic perforations were associated with the intensity of immunosuppression, with 28 percent of perforations occurring within the first month after engraftment and 47 percent within the first 3 months; the mean daily dose of corticosteroids was three times higher in those who died compared with those who survived. The levels of serum albumin were significantly lower among nonsurvivors.


CONCLUSIONS
Colon perforation is a catastrophic event in immunosuppressed renal transplant recipients. Prompt diagnosis and treatment are critical; because of the masking effects of corticosteroids on symptoms and signs, a high index of suspicion and urgent investigation are indicated. Prompt surgical intervention and attention to the nutritional status are essential for survival.