Evaluation and diagnosis of the patient with renal allograft dysfunction
- Pradeep V Kadambi, MD, MBA
Pradeep V Kadambi, MD, MBA
- Professor of Medicine
- The University of Arizona
- Daniel C Brennan, MD, FACP
Daniel C Brennan, MD, FACP
- Editor-in-Chief — Nephrology
- Section Editor — Renal Transplantation
- Professor of Medicine
- Medical Director and Co-Director of the Comprehensive Transplant Center, Department of Internal Medicine, Division of Nephrology
- Johns Hopkins Medical School
- W James Chon, MD, FACP
W James Chon, MD, FACP
- Associate Professor
- Division of Nephrology & Hypertension, Department of Medicine
- University of Arkansas for Medical Sciences (UAMS)
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 . Prompt recognition and evaluation of allograft dysfunction is vital, as it is usually reversible. Persistent dysfunction without timely intervention may lead to irreversible loss of allograft function and, eventually, allograft failure.
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.
This topic will provide an overview of the evaluation and diagnosis of renal allograft dysfunction among patients who have undergone kidney transplantation. The classification, diagnosis, and treatment of acute renal allograft rejection, chronic renal allograft nephropathy, and BK virus-induced (polyomavirus-induced) nephropathy are discussed in more detail elsewhere. (See "Clinical manifestations and diagnosis of acute renal allograft rejection" and "Acute renal allograft rejection: Treatment" and "C4d staining in renal allografts and treatment of antibody-mediated rejection" and "Chronic renal allograft nephropathy" and "Clinical manifestations and diagnosis of BK virus-induced (polyomavirus-induced) nephropathy in kidney transplantation" and "Prevention and management of BK virus-induced (polyomavirus-induced) nephropathy in kidney transplantation".)
There is no consensus definition for allograft dysfunction following kidney transplant. We define acute renal allograft dysfunction as one or more of the following:
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- APPROACH TO THE DIAGNOSIS OF RENAL ALLOGRAFT DYSFUNCTION
- Patients with allograft dysfunction immediately (<1 week) posttransplant
- Patients with allograft dysfunction >1 week posttransplant
- - Patients presenting with an elevated serum creatinine
- - Patients presenting with proteinuria
- DIFFERENTIAL DIAGNOSIS OF ACUTE ALLOGRAFT DYSFUNCTION
- Immediate (<1 week) posttransplantation
- - Postischemic acute tubular necrosis
- - Hyperacute antibody-mediated rejection
- - Volume depletion
- - Surgical complications
- Vascular thrombosis
- Fluid collections
- - Urinary leak (urinoma)
- - Perinephric hematoma
- - Lymphocele
- Multiple renal arteries
- - Atheroemboli
- - Calcium oxalate
- Early (1 week to 3 months) and late (>3 months) posttransplantation
- - Acute rejection
- - Calcineurin inhibitor nephrotoxicity
- - Thrombotic microangiopathy
- - Recurrent primary disease
- - Transplant renal artery stenosis
- - Urinary obstruction
- - Viral infections
- - De novo renal disease
- - Chronic allograft nephropathy
- - Less common causes
- SUMMARY AND RECOMMENDATIONS