immunology allergic disorders
Kidney Transplantation
Complications of Kidney Transplantation
(See also Posttransplantation Complications .) Despite use of immunosuppressants, about 20% of kidney transplant recipients have one or more Rejection episodes within the first year after transplantation. Most episodes are easily treated with a corticosteroid bolus; however, they contribute to long-term insufficiency, graft failure, or both. Signs of rejection vary by type of rejection (see table Rejection Category Manifestations Hyperacute Fever, anuria Accelerated Fever, oliguria, graft swelling and tenderness Acute Fever, increased serum creatinine, hypertension, weight gain, graft swelling and tenderness Appearance of protein, lymphocytes, and renal tubular cells in urine sediment Chronic Proteinuria with or without hypertension, nephrotic syndrome Rejection can be diagnosed by percutaneous needle biopsy if the diagnosis is unclear clinically. Biopsy may also help distinguish antibody-mediated from T-cell–mediated rejection and identify other common causes of graft insufficiency or failure (eg, calcineurin inhibitor toxicity, diabetic or hypertensive nephropathy, polyomavirus type 1 infection). Tests that may improve accuracy of rejection diagnosis include measurement of urinary mRNA-encoding mediators of rejection and gene expression profiling of biopsy samples using DNA microarrays. Intensified Posttransplantation Immunosuppression (eg, with high-dose pulse corticosteroids or antilymphocyte globulin) usually reverses accelerated or acute rejection. If immunosuppressants are ineffective, dose is tapered and hemodialysis is resumed until a subsequent transplant is available. Nephrectomy of the transplanted kidney is necessary if hematuria, graft tenderness, or fever develops after immunosuppressants are stopped. Chronic allograft nephropathy refers to graft insufficiency or failure≥3 months after transplantation. Most cases are attributable to causes such as calcineurin inhibitor toxicity, diabetic or hypertensive nephropathy, or polyomavirus type 1 infection. Some experts believe the term should be reserved to describe graft insufficiency or failure when biopsy shows chronic interstitial fibrosis and tubular atrophy not attributable to any other cause. Compared with the general population, kidney transplant recipients are about 10 to 15 times more likely to develop some form of cancer, probably because the modulated immune system’s response to cancer as well as infections is weakened. Cancer of the lymphatic system (lymphoma) is 30 times more common among kidney transplant recipients than the general population, but lymphoma is still uncommon. Skin cancer becomes common among kidney transplant recipients after many years of immunosuppression. 