CHAPTER 89: Kidney Transplantation Complications

OVERVIEW

• Complications are important to consider after kidney transplantation in children due to their potential impact on graft survival and overall mortality

• Complications can be divided into infectious and noninfectious complications

INFECTIOUS COMPLICATIONS

General Considerations

• Children are at higher risk of infection after transplantation given immunosuppressed status

• It is important to consider that immunosuppression may alter the fever response to infections by cytokine suppression

• Risk of infection is greatest in the first 6 months after transplantation, along with instances in which immunosuppression is increased (episodes of rejection)

• Infection has surpassed rejection as the leading cause of hospitalization after pediatric kidney transplantation

• Infection is the most common cause of mortality after transplantation, accounting for 24–56% of deaths

Types of Infections

Bacterial Infections

• Can be life-threatening in the setting of immunosuppression

• Most common are urinary tract infections (UTIs), followed by pneumonia, postoperative infections, and septicemia

• Escherichia coli is the single most identified bacterial organism, particularly in those with foreign hardware (ureteral stent, etc.) or bladder abnormalities

Viral Infections

• Surveillance for viral infections is of the utmost importance to intervene early and prevent morbidity and mortality

• Most important include cytomegalovirus (CMV), Epstein Barr virus (EBV), and human polyomavirus 1 (BK virus)

Fungal, Protozoal, and Parasitic infections

• Opportunistic infections

• Cryptosporidium, aspergillosis, and histoplasmosis infections are increased in children after kidney transplant

Urinary Tract Infections (UTIs)

• Most common bacterial infection after pediatric kidney transplantation (15–58% of transplant recipients)

• UTIs can lead to kidney scarring and interstitial injury, which may play a role in the development of chronic interstitial fibrosis/tubular atrophy

• Early infections (within 6 months of transplantation) are associated with an increased risk of graft loss (hazard ratio [HR] 5.47)

• Acute kidney injury (AKI) may develop in the setting of UTI in pediatric kidney transplant recipients, and acute graft rejection may also be triggered by infection

• Infection may develop in native and/or transplanted kidneys

• Risk factors include underlying urogenital abnormalities (obstructive uropathy, hydronephrosis, vesicoureteral reflux [VUR], neurogenic bladder, functional bladder abnormalities, etc.), stent placement during transplantation, female sex

• Antibiotic prophylaxis is often utilized after transplantation (Bactrim) for the prevention of Pneumocystis jiroveci (PCP), which can be expanded to also protect against UTI particularly in those with stents placed

• Frequent voiding, appropriate prevention of constipation, and/or prescribed intermittent catheterization (however, catheterization also can be a risk factor for infection) are important in the prevention of urinary stasis and bladder pressure buildup resulting in VUR, particularly in those with neurogenic and functional bladder abnormalities

Cytomegalovirus (CMV)

• CMV is the most frequent opportunistic pathogen and most important infectious agent in pediatric kidney transplant recipients

• Incidence of CMV viremia after kidney transplantation is ...