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Differential diagnosis of renal allograft dysfunction

Pradeep V Kadambi, MD, MBA
Daniel C Brennan, MD, FACP
Section Editor
Barbara Murphy, MB, BAO, BCh, FRCPI
Deputy Editor
Albert Q Lam, MD


The most common complication of renal transplantation is allograft dysfunction, which in some cases leads to graft loss. Although there is a wide intercenter variability, data from the United States indicate that overall one-year unadjusted survival of a renal allograft is approximately 89 percent for a deceased-donor kidney and approximately 95 percent for a living-donor kidney [1].

A number of risk factors have been identified for lower one-year deceased-donor renal allograft survival. These include prior sensitization with >50 percent panel reactivity, the presence of delayed graft function (DGF; defined as the requirement for dialysis during the first week after transplantation), the number and severity of rejection episodes, second or third transplant, donor age <5 or >60 years, greater degrees of human leukocyte antigen (HLA) mismatching, and allograft dysfunction at discharge (plasma creatinine concentration >2 mg/dL [176 micromol/L]).

The causes of renal allograft dysfunction vary with the time (usually classified as immediate, early, and late period) after transplantation. The best approach is to consider prerenal, postrenal, and intrinsic renal causes of dysfunction during each time period. This topic review will serve as an overview in those areas; the major issues are discussed in detail elsewhere.


Overview — Renal failure persisting after transplantation necessitating dialysis within the first week is called delayed graft function (DGF). The incidence is markedly higher among extended-criteria (ECD) donors and non-heart-beating donor kidneys compared with standard-donor kidneys (ie, Kidney Donor Profile Index [KDPI] of <85 percent) [2]. This most likely reflects inherent donor disease, with a predisposition to atherosclerosis and acute tubular necrosis (ATN). Since the new kidney allocation system adopted in December 2014, ECD kidneys are now classified as KDPI >85 percent. Formal evaluation of these kidneys has not been determined, and there may be significant changes since the presence of hepatitis C virus (HCV) in the donor is a significant contributor to the KDPI score and may not have as great an impact historically, as there are now effective treatments for most HCV infections.

The definition of DGF varies in different studies but generally refers to oliguria or the requirement for dialysis in the first week posttransplantation. Less than 5 percent of kidneys with DGF never function (primary nonfunction).


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Literature review current through: Mar 2017. | This topic last updated: Jan 22, 2016.
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