Transplant Complications

 

Any patient who has undergone major surgery can experience postoperative complications. In the first few weeks following transplantation, the majority of patients experience some kind of complication including:

1. Delayed Graft Function ‘Sleepy Kidney’

The functioning of your kidney transplant might be delayed, causing a need for dialysis until the kidney ‘wakes up’. Delayed function might last from several days to several weeks.

 

2. Wound Problems

Your incision may not be completely healed when you go home. Keep the wound clean and dry. Do not take a bath or swim until your wound is fully healed. If you have staples or sutures, they will be removed by the transplant nurse. Steristrips (paper stitches) will dry and fall off on their own. Examine your incision every day. Notify your doctor or nurse immediately if you notice any redness, swelling, tenderness at the site or liquid draining from the site.

While we want you to be active, there are some things you should not do during the first two to three months after your transplant. Do not do any heavy lifting, pushing or pulling for at least two months. Do not do any exercises that drag or pull the abdominal muscles. We recommend that recipients do not drive for six weeks following transplant, but there is no evidence to suggest that wearing a seat belt can harm your transplanted kidney.

 

3. Dehydration

One of the best ways to keep you and your kidney healthy is to drink plenty of fluids. Fluids will flush medication from your system, make you feel less hungry, and prevent your skin from becoming dry. Normally you should drink more than 2 litres of fluid each day (please check with your doctor regarding your fluid allowance). If you are dehydrated, you may experience some of the following symptoms: thirst, dry skin, dizziness, feeling light-headed, decrease urine output, dark urine, headache, hunger and weight loss.

 

4. Infection

Transplant patients are at a greater risk of infection because of the need for immunosuppression, which weakens their immune system and ability to fight infection. While it is important for you to limit contact, with potentially infectious situations, it is not necessary to become a recluse! There are some relatively simple measures which you can take to reduce the risk of infection, without unduly limiting your lifestyle.

Infections are caused by viruses, bacteria and fungi and come from these sources:

• Environment - For example, contaminated food or cooking utensils, uncooked food or animals.

• People - Colds, flu's and a range of viral illnesses.

• Bacterial Infections Urinary Tract Infections (UTI) -is one of the most common infections seen in kidney transplant recipients. If not properly treated, the infection can spread and harm your new kidney. The symptoms of a UTI are: cloudy urine, blood in the urine, frequent urination, burning upon urination, difficulty urinating, strong smell from the urine, and high temperature. Here are ways to prevent UTI's:

1. Drink plenty of fluids.
2. Urinate frequently.
3. Avoid bubble baths.
4. Wear cotton underwear.

 

Infections May Cause The Following Symptoms:

• High temperature, sometimes accompanied by chills.
• Diarrhoea, nausea and vomiting.
• Loss of appetite
• Fatigue.
• Shortness of breath.
• Difficulty or discomfort when urinating.
• Appearance of a skin rash.
• Unexplained pain.

 

Thing to Do and Avoid to prevent infections

• Get enough rest and eat a healthy well-balanced diet.
• Reduce close contact with anyone who has an active infection or any children who have been recently vaccinated.
• Wash hands with soap and water frequently throughout the day.
• Do not touch open sores. Keep any wounds clean and covered.
• Wear gloves when gardening or during any other dirty jobs.
• Wash fresh fruit and vegetables and also meat, fish and poultry prior to cooking.
• Never share personal items such as razors or toothbrushes.

 

Preventing Bacterial Infections:

• Most bacterial infections can be avoided by following good common sense and good personal hygiene.Wash your hands frequently throughout the day using warm water and soap.
• If you get a cut, wash and treat it immediately. If it gets red or sore contact your GP.
• Cook meats thoroughly and avoid eating raw eggs, raw meat or raw fish.

 

Fungal Infections

The most common fungal infection, seen in kidney transplant recipients, is Candida. Thrush is a common candida infection, which occurs in the mouth. Thrush creates creamy or grey patches on the inside of the tongue or cheeks. Some women may experience vaginal thrush, which has similar symptoms. You will be given anti-fungal medication to prevent or treat this infection.

Pneumocystis carinii - Pneumocystis carinii is a germ that is similar to a fungus, and it is normally found in the lungs of people whose immune systems are suppressed. It may cause a type of pneumonia. Early in the illness, you might have mild, dry cough and a fever. If you think that you have a cold or flu-like illness that does not get better, contact your transplant team right away. You will be prescribed Septrin (Co-trimoxazole) to prevent this infection.

 

Viral Infections

Although there are many viruses that can cause infection in transplanted patients, the ones that most often cause problems belong to the herpes group. You may be taking oral anti-viral medications such as Valtrex to prevent these.

CMV (Cytomegalovirus) - CMV is a member of the herpes family and is present in more than half of all adults, before they reach middle age. For most people CMV causes only mild symptoms including a lowfever and tiredness. Although these symptoms disappear, the virus remains in the body forever.When the immune system is suppressed, following a kidney transplant, the CMV could be reactivated and can cause a range of serious infections such as pneumonia, eye infections or gastrointestinal disease.

Varicella Zoster - Varicella virus is the cause of chickenpox in children. As with CMV, the virus continues to live on in the body. If someone has previously had chicken pox, the virus will/can reactivate in the form of shingles. If you never had chicken pox and come into contact with shingles then you may develop chicken pox which is the primary form of Varicella. If you never had chicken pox and come into contact with chicken pox then you will get chicken pox. For the last five years patients have been tested for Varicella prior to going on the transplant pool and before going on the pool will be vaccinated if test is negative. If on the transplant pool before this and patient has never had chicken pox then you will need to be very careful to avoid infection. Measles, Mumps and Rubella are all highly contagious viral diseases that can be severe, if caught by anyone taking immunosuppressants. The vaccines against these diseases, as well as the oral polio vaccine, are made from live viruses and can cause an immunosuppressed person to catch the disease. Avoid these vaccines and anyone who has recently received them.

Herpes Simplex Type 1 and Type 2 - Herpes Simplex Type 1 causes painful cold sores on the lips or mouth or it can appear as an eye infection. It is known that exposure to strong sunlight and stress can contribute to these attacks. Herpes Simplex Type 2 causes sores in the genital area and is usually transmitted through sexual intercourse. Even after the mouth sores heal, it is still possible to infect others for up to seven days afterwards. Genital herpes is contagious for up to twelve days and although using a condom is a safe practice, it does not protect you or your partner from spreading herpes. It is best to abstain during this period.

5. Rejection

Rejection is the natural process of your body trying to protect itself, from anything that is foreign. Kidney transplant rejection means that your immune system is 'confused' and attacks your kidney, thinking it is attacking a group of bacteria, infecting your body. Rejection may sound quite dramatic but, in fact, it is very common and, fortunately, in most cases, when rejection is discovered and treated early, it can be controlled.

There are things you can do to reduce your risk of rejection:

• Take your medication as directed;
• Learn the early warning signs of rejection, and
• Attend all scheduled clinic and doctor visits.

 

Types of Rejection

There are three types of rejection:

• Hyper acute rejection — happens very suddenly, usually during the transplant surgery or the first few hours after. This form of rejection is, thankfully, rare due to careful tissue type matching, but is very difficult to treat.
• Acute rejection — is the most common kind and develops over a short period of time, a few days or weeks. The risk is highest during the first 2 to 3 months, but can also happen a year or more after transplant.
• Chronic rejection — is a process that occurs slowly and over a long period of time. It may begin immediately after the transplant, but the visible signs of chronic rejection are rarely seen within the first year. It is not known why it occurs, but the risk of chronic rejection is reduced when patients continue to take all their medications exactly as prescribed.

 

Warning Signs of Rejection

Sometimes, when rejection starts, you may feel fine, with no symptoms. More often, there will be signs to alert you to possible rejection. If these occur, you should immediately contact your transplant team. Quick action can make the difference between keeping and losing your transplant.

Although you may experience symptoms of rejection, it is also possible to have no symptoms at all. That is why it is so important that you have all of the tests indicated by your transplant team. Blood tests are the best way to monitor kidney function and catch early warning signs of rejection. A rise in the patient's creatinine level may often be the first sign of rejection.

Some warning signs of rejection can include:

• Flu-like symptoms, such as chills, headache, fatigue, dizziness or vomiting.
• High temperature – over 38ºC (You should have a thermometer at home, as an increase in temperature is an important sign of possible rejection or infection).
• Any signs of fluid retention, such as rapid weight gain or swelling of the ankles.
• Pain or redness over the transplant site.
• Reduction in the amount of urine you are producing.

 

Treating Rejection

When rejection is suspected, it is usually confirmed by a kidney biopsy, as this is the most precise test to diagnose rejection. The earlier rejection is detected, the better the chance of reversing it. Most commonly a mild to moderate episode of rejection is treated successfully, with a 3 to 5 day course of Methylprednisolone (steroid). Where a rejection episode is very severe, more potent forms of immunosuppression, such as ATG, are sometimes used. Some forms of rejection (antibody mediated), however, need to be treated with a course of plasmapheresis.

 

 

 

6. Diabetes

Glucose is a simple sugar and is the main source of energy in the body's cells. A condition called diabetes mellitus occurs if glucose accumulates, because your body is not using it properly and/or not enough insulin is produced. Some of your prescribed anti-rejection medicines may cause diabetes. The onset of diabetes post-transplant is usually mild and early signs can include: tiredness, thirst, weight loss, excessive production of urine, blurred vision and confusion.

If you have any of these symptoms you should inform your transplant team. You will be monitored, in clinic, for this condition by regular blood and/or urine tests. Post-transplant diabetes is often resolved, by reducing some of your anti-rejection medicines or converting you to different ones, though you may need a specific oral diabetic medicine or insulin injections. Should you develop diabetes, your transplant team will give you specific advice. Careful diet, weight loss and exercise are all helpful in controlling this condition. If you were diabetic, prior to your transplant, you may have problems with blood sugar control following your surgery. This will be discussed with you on an individual basis.

 

7. High blood pressure

High blood pressure (Hypertension) is a very common complication following kidney transplantation, particularly during the early months. This is why your blood pressure will be checked more frequently, during this period. It is vital to control high blood pressure; if left untreated, you will be at an increased risk of heart disease or of having a stroke.

Often high blood pressure does not produce symptoms. Some patients complain of headaches or blurred vision. It can be associated with several problems, which include fluid overload, rejection and narrowing of the renal transplant artery (renal artery stenosis). It can also be a sideeffect of some of your medicines. There are many different ways of treating high blood pressure:

• If your doctor thinks you are fluid overloaded, you will be given a diuretic (water pill) which will drive your kidney to increase your urine output and thus help lower your blood pressure.
• Blood pressure medicines - There are many different types of blood pressure medicine including vasodilators, beta-blockers and calcium channel blockers; your doctor will choose the most appropriate one for you. Many patients will need a combination of more than one blood pressure medicine.
• If your doctor suspects you have a rejection episode, or renal artery stenosis, the appropriate diagnostic tests will be performed and treatment initiated.
• If your high blood pressure is caused by a side effect of your antirejection therapy, you may be switched to a different type of medication.

Heart Disease
Hypertension and raised cholesterol levels can occur as a result of some of the immunosuppressive drugs. This leads to an increased chance of heart disease. At each clinic visit your blood pressure and cholesterol level will be measured. Your doctor may prescribe medication to control your blood pressure or decrease your cholesterol level. However, regular exercise and keeping to a low-fat, low salt diet with plenty of vegetables, as advised by your dietician, are ways by which you can help control your blood pressure and cholesterol levels.

 

8. Cancer

Transplant patients are at increased risk for certain types of cancers, especially lymphoma, skin and cervical cancer. Fortunately Lymphoma is very rare. Skin cancer, however, is very common, but if detected early, is very easily treated. Several factors influence the types of cancers seen in transplant patients. These include:
i) viral infections acquired either before, or after, transplant.
ii) Use of immunosuppressive therapy to prevent rejection of the kidney.

 

Skin Care
Taking good care of your skin is vital for kidney transplant recipients because, once you receive a transplant and begin taking immunosuppression, you are more at risk for developing skin cancer. This risk also increases with time. Immunosuppressesive drugs prevent rejection of your kidney, by reducing the immune system’s natural capacity to repair or destroy sun damaged cells. These cells can develop into cancer.

Some patients will be at higher risk due to other factors such as: fair skin that burns easily, light coloured eyes, blonde/red hair, numerous freckles, outdoor working environment, previous skin cancer, or prolonged sun exposure in the past.

There are different types of Skin Cancers:

 

Actinic Keratosis
These lesions pre dispose to skin cancer. They are usually pink or red spots with a jagged surface. They most frequently appear on sun exposed sites such as hands, face or neck. Early treatment may prevent progression to skin cancer.

 

 

 

 

 

Basal Cell Carcinoma (BCC)
Most BCC present as a lesion, that never heals completely, and may bleed occasionally. This may look like a scaly red flat mark or a lesion with a white rim surrounding a central dip. If left untreated it may become ulcerated.

 

 

 

 

 

Squamous Cell Carcinoma (SCC)
This is the most common type of skin cancer in transplant recipients. Again, it usually appears on sun exposed sites. It may appear as a scaly area of skin with a red inflamed base. Both BCC & SCC are usually painless.

 

 

 

 

 

Melanoma
This is the most serious form of skin cancer but also the rarest. It is best described as an irregular black or brown spot. It may appear as a new lesion or occur on an existing mole.

 

 

IF YOU NOTICE ANY OF THE ABOVE LESIONS OR ANY CHANGES IN A PRE-EXISTING MOLE SUCH AS: INCREASE IN SIZE, BLEEDING OR CHANGE IN APPEARANCE, YOU SHOULD CONSULT YOUR DOCTOR.

 

Treatment of Skin Cancer

SURGERY:  An injection is given to numb the skin and the lesion is cut away. 

CRYOTHERAPY:  The lesion is frozen with liquid nitrogen

TOPICAL CREAM:  Medicated cream is applied to the lesion. 

PHOTODYNAMIC THERAPY:  A cream is applied to the lesion followed by a special light that destroys the lesion. In some cases radiotherapy can also be used where x-rays are directed, at the lesion, to destroy it.

 

                      Photodynamic Therapy                                 Cryotherapy

In serious advanced cases of skin cancer your doctor may recommend that you stop taking your immunosuppressant. If your doctor suspects a lesion may be cancerous, a small portion of your skin may be excised and further examined. This is called a skin biopsy and is performed under local anaesthetic.

 

Protecting Your Skin

Exposure to the sun or its ultraviolet rays is the main cause of skin cancer in transplant patients. Exposure to the sun does not just mean sunbathing, by just being outside you are exposed to the sun. This includes walking, gardening, outdoor work etc. You should take simple precautions to protect
yourself:

• Cover Up — wear a wide sun hat and long sleeves.
• Stay in the shade during peak times of sun intensity (11am-3pm).
• Never, ever, use sun beds.
• Wear a high intensity sun cream, Sun Protection Factor (SPF) 30 or higher with a 3 or 4-star rating. Ensure the sun cream protects against UVB and UVA rays.
• If planning to travel to Australia, purchase sun cream when you get there, that is designed specifically to protect against UVC rays.

 

Cervical Cancer

The Cervix is the neck of the womb and is prone to develop cancer. This form of cancer is very treatablebut it needs to be detected early. For this reason all sexually active female transplant recipients should have a smear test annually. Your GP or practice nurse can arrange this but you need to remind them. The Department of Health and Children is currently providing vaccination to young girls who have not been exposed to the human papilloma virus which can cause cervical cancer.