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Surgical complications of renal transplantation in patients with diabetes mellitus
Clinical Queries: Nephrology 0102 (2012) 157–158
Contents lists available at ScienceDirect
Clinical Queries: Nephrology j o u r n a l h o m e p a g e : h t t p : / / w w w. e l s e v i e r. c o m / l o c a t e / c q n
Surgical complications of renal transplantation in patients with diabetes mellitus Rakesh Kapoor*, Srivastava Alok†, Aneesh Srivastava**, Sureka Sanjoy Kumar† *Professor and Head, †Senior Resident, **Professor, Department of Urology and Renal Transplant, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow – , UP, India.
A R T I C L E
I N F O
Article history: Received 22 December 2011 Accepted 5 January 2012
Keywords: Diabetes mellitus Diabetic nephropathy Renal transplant Surgical complications
A B S T R A C T
Diabetic nephropathy (DN) is the most common cause of end-stage renal disease (ESRD) entering renal replacement programs (dialysis/transplantation) worldwide. Renal transplantation (RTx) offers the best survival advantage to patients with DN-related ESRD. Theoretically diabetic ESRD patient’s possess higher risk for surgical complications in comparison to non-diabetic ESRD. We reviewed the current literature to analyze the risk for surgical complications after kidney transplantation in patients with diabetes mellitus (DM) vs patients without DM. Between January 1990 to May 2011, 1990 live related renal transplant were performed at our center. Computer Database of these patients were analyzed retrospectively to compare surgical complications between diabetic and non-diabetic patients. Analyzing the existing literature and the results of our center, we found that the surgical complications of renal transplant in a diabetic patient are similar to that of non-diabetic patients. Copyright © 2012, Reed Elsevier India Pvt. Ltd. All rights reserved.
Introduction The estimated number of adults living with diabetes has soared to 366 million, representing 8.3% of the global adult population. This number is projected to increase to 552 million people by 2030, or 9.9% of adults, which equates to approximately three more people with diabetes every 10 seconds. India being the ‘diabetic capital of the world’,1,2 7.1% of the population in the age group 20–79 years suffers from diabetes mellitus (DM). Diabetic nephropathy (DN) is the most common cause of end-stage renal disease (ESRD) entering renal replacement programs (dialysis/transplantation) worldwide.3,4 In India, DM has been reported to be the main cause of chronic kidney disease (CKD) as found in 31.2% of the ESRD patients.5 Renal transplantation (RTx) offers the best survival advantage to patients with DN-related ESRD.5 If possible, a living-related donor (LRD) is preferred to deceased donor (DD) transplantation.6–10 Renal transplantation in DN faces major challenges, such as the high incidence of cardiovascular disease, increased risk of bacterial and fungal infections, and the difficulty of glycemic control. Long-term prognosis following RTx was comparable between diabetic and non-diabetic patients.11 Nevertheless data concerning peri-operative surgical complications in the setting of kidney transplantation with DM are rare in the literature. Here, we are sharing our experience with a review of literature focusing on the surgical complications of RTx in diabetic ESRD.
Review of literature Though, there were plenty of literature evaluating the long-term graft function and outcome of RTx in diabetic ESRD,6,8,11–14 surgical complications in these group of patients were hardly studied. *Corresponding author. E-mail address: [email protected]; [email protected] ISSN: 2211-9477 Copyright © 2012. Reed Elsevier India Pvt. Ltd. All rights reserved. doi: 10.1016/S2211-9477(12)70011-0
Treckmann found that surgical complications were similar in both diabetic and non-diabetic ESRD following RTx.15 In their series, surgical site infections was 15.6 and 8.2%, urinary leak or stenosis was 12.1 and 7.1, and postoperative bleeding was 6.2 and 7.1 in diabetic and non-diabetic group, respectively. All those complications were comparable statistically in both groups. Violeta et al noted a higher incidence of surgical complications in diabetic patients with a significant increase in incidence of vascular complications.16
Surgical complications of renal transplantation in patients with or without diabetes mellitus—review of our database
Methodology Between January 1990 and July 2011, 1990 live donor RTx was performed at our institute. Computer based data of these patients were analyzed for the presence of DM. At our center, the incidence of diabetic ESRD was 31%. Recipients without DM (group 1, n = 1372) were compared with DM (group 2, n = 618) patients regarding the various surgical complications, including vascular, urological, and other miscellaneous surgical complications. In our series 41% of donor nephrectomy was performed laparoscopically. The comparison of the groups was carried out on the basis of the following criteria determined over the first 6 months after transplantation. The occurrence of postoperative complications such as wound infection, urinary fistula, lymphocele—requiring surgical treatment; postoperative bleeding either as acute bleeding requiring emergency reoperation or radiological intervention. Doppler ultrasonography was routinely performed in the second or third day after transplant in order to evaluate vascular flow, as well as the urinary system. Renal arteriography was performed for the diagnosis of arterial stenosis. Significant arterial stenosis was considered when an obstruction >50% on the artery diameter was found. The diagnosis of urinary complications was achieved
158
R. Kapoor et al / Clinical Queries: Nephrology 0102 (2012) 157–158
Table 1 Surgical complications. Complications
Vascular Urological Lymphocele Infection of surgical site Incisional hernia Lymphorrhea Dehiscence of surgical incision Total
have to be evaluated very diligently before being listed for kidney transplantation. Group 1 (n = 1372) (%)
Group 2 (n = 618) (%)
P value
31 (2.3) 25 (1.8) 23 (1.7) 43 (3.1) 12 (0.8) 21 (1.5) 12 (0.9) 167 (12.2)
16 (2.6) 11 (1.7) 12 (1.9) 20 (3.2) 5 (0.8) 10 (1.6) 7 (1.1) 81 (13)
NS NS NS NS NS NS NS
Conclusion The surgical complication of renal transplant in diabetic patients has been inadequately and sporadically cited in the literature. In the light of our own experience and few documented studies, it can be concluded that DM does not increase the risk of surgical complications in patient undergoing renal transplant, provided they are adequately evaluated and optimized peri-operatively.
NS: non-significant.
References by ultrasonography and cystography. Cystography was performed every time there was a suspicion of a urinary fistula.
1. 2.
Results Incidence of overall surgical complications in our series was, 12.5% (n = 248). Complications in group 1 vs group 2 (12.2% vs 13%) were statistically similar. Documented vascular complications in our series were 2.4%. These included renal artery stenosis, renal vein thrombosis, aneurysm formation, significant postoperative bleeding. The overall incidence of vascular complications in groups 1 and 2 was 2.3% and 2.6%, respectively, which was statistically similar. Most common vascular complication in both the groups was significant bleeding. Though, its incidence was slightly higher in group 2, but statistically not significant (Table 1). The overall incidence of urological complications was 1.8% with 1.8% and 1.7% in group 1 and group 2, respectively (Table 1). These included vesico-ureteric anastomotic stricture and urinary fistula. In both groups the overall incidence of urinary leak was higher than the stricture (P > 0.05; non-significant). Among the other surgical complications, surgical site wound infections was the most common complication, followed by lymphocele. They were statistically comparable in both groups. Among all surgical complications, 43% required major surgical intervention under anesthesia. The needs for major surgical correction were similar in both groups (group 1 vs group 2 = 41% vs 44%).
3.
4. 5. 6. 7.
8.
9. 10. 11.
12.
13.
14.
15.
Discussion Diabetes mellitus is described as an additional risk factor for kidney transplantation.17–20 Recently Baskin-Bey et al showed that DM is one of the strongest predictors of the recipient’s long-term survival besides recipient age, history of angina, and time on dialysis.19 In this review of literature and database from our center, we did not find any significant difference in the frequency of surgical complications of RTx with DM and without DM. In the patients with ESRD, the presence of DM is a frequent co-morbidity and is per se not a contraindication for kidney transplantation as a way of treatment. Because of the elevated cardiovascular risk profile of patients with DM, they
16.
17. 18.
19. 20.
International Diabetes Federation (IDF) Diabetes atlas, 5th edn. http://shop.idf. org/catalog/ Premlatha G, Shanthi Rani CS, Deepa E, et al. Prevalence of diabetic complications in south Indians. Novo Nordisk. Diabetic Update 2000:59–62. Rugg V. International Diabetes Federation and the International Society of Nephrology Diabetes and Kidney Disease: time to Act, 2003. http://www.isn-online. org/isn/society/publications/isn_20119.html. Modi GK, Jha V. The incidence of end-stage renal disease in India: a populationbased study. Kidney Int 2006;70:2131–3 [Epub 2006 Oct 25. PMID: 17063176]. Acharya VN. Diabetic and hypertensive nephropathy in India. J Assoc Physicians India 2011;59:143. Tobin GS, Tanenbaum ND, Brennanat DC, et al. Renal transplantation in diabetic nephropathy, 2009. http://www. uptodate.com/patients/content/topic Wolfe RA, Ashby VB, Milford EL, et al. Comparison of mortality in all patients on dialysis, patients on dialysis awaiting transplantation, and recipients of a first cadaveric transplant. N Engl J Med 1999;341:1725–30. Luan FL, Samaniego M. Transplantation in diabetic kidney failure patients: modalities, outcomes, and clinical management. Semin Dial 2010;23:198–205 [Epub 2010 Mar 30]. Davis CL, Delmonico FL. Living-donor kidney transplantation: a review of the current practices for the live donor. J Am Soc Nephrol 2005;16:2098–110. Glannon W. Underestimating the risk in living kidney donation. J Med Ethics 2008;34:127–8. Kute VB, Vanikar AV, Trivedi HL, et al. Outcome of renal transplantation in patients with diabetic nephropathy—a single-center experience. Int Urol Nephrol 2011;43:535–41. Kute VB, Godara SM, Shah PR, et al. Outcome of deceased donor renal transplantation in diabetic nephropathy: a single-center experience from a developing country. Int Urol Nephrol 2012;44:269–74. Boucek P, Saudek F, Pokorna E, et al. Kidney transplantation in type 2 diabetic patients: a comparison with matched non-diabetic subjects. Nephrol Dial Transplant 2002;17:1678–83. Cosio FG, Hickson LJ, Griffin MD, Stegall MD, Kudva Y. Patient survival and cardiovascular risk after kidney transplantation: the challenge of diabetes. Am J Transplant 2008;8:593–9. Treckmann JW, Goldenberg A, Malamutmann E, et al. Kidney transplantation in patients with diabetes mellitus: surgical complications. Hepatogastroenterology 2011;58:738–9. Rabrenovic V, Kovacevic Z, Jovanovic D, Ignatovic L. Complications in the kidney transplanted patients previously treated by peritoneal dialysis—10-year experience in a single center. BANTAO J 2007;5:94–6. Orsenigo E, Socci C, Carlucci M, et al. Multivariate analysis of factors affecting patient and graft survival after renal transplant. Transplant Proc 2005;37:2461–3. Wolters HH, Brockmann JG, Diller R, Suwelack B, Krieglstein CF, Senninger N. Kidney transplantation using donors with history of diabetes and hypertension. Transplant Proc 2006;38:664–5. Baskin-Bey ES, Kremers W, Nyberg SL. A recipient risk score for deceased donor renal transplantation. Am J Kidney Dis 2007;49:284–93. Witczak BJ, Jenssen T, Endresen K, Røislien J, Hartmann A. Risk factors for mortality in diabetic nephropathy patients accepted for transplantation. Transplantation 2007;84:356–61.
Contents lists available at ScienceDirect
Clinical Queries: Nephrology j o u r n a l h o m e p a g e : h t t p : / / w w w. e l s e v i e r. c o m / l o c a t e / c q n
Surgical complications of renal transplantation in patients with diabetes mellitus Rakesh Kapoor*, Srivastava Alok†, Aneesh Srivastava**, Sureka Sanjoy Kumar† *Professor and Head, †Senior Resident, **Professor, Department of Urology and Renal Transplant, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow – , UP, India.
A R T I C L E
I N F O
Article history: Received 22 December 2011 Accepted 5 January 2012
Keywords: Diabetes mellitus Diabetic nephropathy Renal transplant Surgical complications
A B S T R A C T
Diabetic nephropathy (DN) is the most common cause of end-stage renal disease (ESRD) entering renal replacement programs (dialysis/transplantation) worldwide. Renal transplantation (RTx) offers the best survival advantage to patients with DN-related ESRD. Theoretically diabetic ESRD patient’s possess higher risk for surgical complications in comparison to non-diabetic ESRD. We reviewed the current literature to analyze the risk for surgical complications after kidney transplantation in patients with diabetes mellitus (DM) vs patients without DM. Between January 1990 to May 2011, 1990 live related renal transplant were performed at our center. Computer Database of these patients were analyzed retrospectively to compare surgical complications between diabetic and non-diabetic patients. Analyzing the existing literature and the results of our center, we found that the surgical complications of renal transplant in a diabetic patient are similar to that of non-diabetic patients. Copyright © 2012, Reed Elsevier India Pvt. Ltd. All rights reserved.
Introduction The estimated number of adults living with diabetes has soared to 366 million, representing 8.3% of the global adult population. This number is projected to increase to 552 million people by 2030, or 9.9% of adults, which equates to approximately three more people with diabetes every 10 seconds. India being the ‘diabetic capital of the world’,1,2 7.1% of the population in the age group 20–79 years suffers from diabetes mellitus (DM). Diabetic nephropathy (DN) is the most common cause of end-stage renal disease (ESRD) entering renal replacement programs (dialysis/transplantation) worldwide.3,4 In India, DM has been reported to be the main cause of chronic kidney disease (CKD) as found in 31.2% of the ESRD patients.5 Renal transplantation (RTx) offers the best survival advantage to patients with DN-related ESRD.5 If possible, a living-related donor (LRD) is preferred to deceased donor (DD) transplantation.6–10 Renal transplantation in DN faces major challenges, such as the high incidence of cardiovascular disease, increased risk of bacterial and fungal infections, and the difficulty of glycemic control. Long-term prognosis following RTx was comparable between diabetic and non-diabetic patients.11 Nevertheless data concerning peri-operative surgical complications in the setting of kidney transplantation with DM are rare in the literature. Here, we are sharing our experience with a review of literature focusing on the surgical complications of RTx in diabetic ESRD.
Review of literature Though, there were plenty of literature evaluating the long-term graft function and outcome of RTx in diabetic ESRD,6,8,11–14 surgical complications in these group of patients were hardly studied. *Corresponding author. E-mail address: [email protected]; [email protected] ISSN: 2211-9477 Copyright © 2012. Reed Elsevier India Pvt. Ltd. All rights reserved. doi: 10.1016/S2211-9477(12)70011-0
Treckmann found that surgical complications were similar in both diabetic and non-diabetic ESRD following RTx.15 In their series, surgical site infections was 15.6 and 8.2%, urinary leak or stenosis was 12.1 and 7.1, and postoperative bleeding was 6.2 and 7.1 in diabetic and non-diabetic group, respectively. All those complications were comparable statistically in both groups. Violeta et al noted a higher incidence of surgical complications in diabetic patients with a significant increase in incidence of vascular complications.16
Surgical complications of renal transplantation in patients with or without diabetes mellitus—review of our database
Methodology Between January 1990 and July 2011, 1990 live donor RTx was performed at our institute. Computer based data of these patients were analyzed for the presence of DM. At our center, the incidence of diabetic ESRD was 31%. Recipients without DM (group 1, n = 1372) were compared with DM (group 2, n = 618) patients regarding the various surgical complications, including vascular, urological, and other miscellaneous surgical complications. In our series 41% of donor nephrectomy was performed laparoscopically. The comparison of the groups was carried out on the basis of the following criteria determined over the first 6 months after transplantation. The occurrence of postoperative complications such as wound infection, urinary fistula, lymphocele—requiring surgical treatment; postoperative bleeding either as acute bleeding requiring emergency reoperation or radiological intervention. Doppler ultrasonography was routinely performed in the second or third day after transplant in order to evaluate vascular flow, as well as the urinary system. Renal arteriography was performed for the diagnosis of arterial stenosis. Significant arterial stenosis was considered when an obstruction >50% on the artery diameter was found. The diagnosis of urinary complications was achieved
158
R. Kapoor et al / Clinical Queries: Nephrology 0102 (2012) 157–158
Table 1 Surgical complications. Complications
Vascular Urological Lymphocele Infection of surgical site Incisional hernia Lymphorrhea Dehiscence of surgical incision Total
have to be evaluated very diligently before being listed for kidney transplantation. Group 1 (n = 1372) (%)
Group 2 (n = 618) (%)
P value
31 (2.3) 25 (1.8) 23 (1.7) 43 (3.1) 12 (0.8) 21 (1.5) 12 (0.9) 167 (12.2)
16 (2.6) 11 (1.7) 12 (1.9) 20 (3.2) 5 (0.8) 10 (1.6) 7 (1.1) 81 (13)
NS NS NS NS NS NS NS
Conclusion The surgical complication of renal transplant in diabetic patients has been inadequately and sporadically cited in the literature. In the light of our own experience and few documented studies, it can be concluded that DM does not increase the risk of surgical complications in patient undergoing renal transplant, provided they are adequately evaluated and optimized peri-operatively.
NS: non-significant.
References by ultrasonography and cystography. Cystography was performed every time there was a suspicion of a urinary fistula.
1. 2.
Results Incidence of overall surgical complications in our series was, 12.5% (n = 248). Complications in group 1 vs group 2 (12.2% vs 13%) were statistically similar. Documented vascular complications in our series were 2.4%. These included renal artery stenosis, renal vein thrombosis, aneurysm formation, significant postoperative bleeding. The overall incidence of vascular complications in groups 1 and 2 was 2.3% and 2.6%, respectively, which was statistically similar. Most common vascular complication in both the groups was significant bleeding. Though, its incidence was slightly higher in group 2, but statistically not significant (Table 1). The overall incidence of urological complications was 1.8% with 1.8% and 1.7% in group 1 and group 2, respectively (Table 1). These included vesico-ureteric anastomotic stricture and urinary fistula. In both groups the overall incidence of urinary leak was higher than the stricture (P > 0.05; non-significant). Among the other surgical complications, surgical site wound infections was the most common complication, followed by lymphocele. They were statistically comparable in both groups. Among all surgical complications, 43% required major surgical intervention under anesthesia. The needs for major surgical correction were similar in both groups (group 1 vs group 2 = 41% vs 44%).
3.
4. 5. 6. 7.
8.
9. 10. 11.
12.
13.
14.
15.
Discussion Diabetes mellitus is described as an additional risk factor for kidney transplantation.17–20 Recently Baskin-Bey et al showed that DM is one of the strongest predictors of the recipient’s long-term survival besides recipient age, history of angina, and time on dialysis.19 In this review of literature and database from our center, we did not find any significant difference in the frequency of surgical complications of RTx with DM and without DM. In the patients with ESRD, the presence of DM is a frequent co-morbidity and is per se not a contraindication for kidney transplantation as a way of treatment. Because of the elevated cardiovascular risk profile of patients with DM, they
16.
17. 18.
19. 20.
International Diabetes Federation (IDF) Diabetes atlas, 5th edn. http://shop.idf. org/catalog/ Premlatha G, Shanthi Rani CS, Deepa E, et al. Prevalence of diabetic complications in south Indians. Novo Nordisk. Diabetic Update 2000:59–62. Rugg V. International Diabetes Federation and the International Society of Nephrology Diabetes and Kidney Disease: time to Act, 2003. http://www.isn-online. org/isn/society/publications/isn_20119.html. Modi GK, Jha V. The incidence of end-stage renal disease in India: a populationbased study. Kidney Int 2006;70:2131–3 [Epub 2006 Oct 25. PMID: 17063176]. Acharya VN. Diabetic and hypertensive nephropathy in India. J Assoc Physicians India 2011;59:143. Tobin GS, Tanenbaum ND, Brennanat DC, et al. Renal transplantation in diabetic nephropathy, 2009. http://www. uptodate.com/patients/content/topic Wolfe RA, Ashby VB, Milford EL, et al. Comparison of mortality in all patients on dialysis, patients on dialysis awaiting transplantation, and recipients of a first cadaveric transplant. N Engl J Med 1999;341:1725–30. Luan FL, Samaniego M. Transplantation in diabetic kidney failure patients: modalities, outcomes, and clinical management. Semin Dial 2010;23:198–205 [Epub 2010 Mar 30]. Davis CL, Delmonico FL. Living-donor kidney transplantation: a review of the current practices for the live donor. J Am Soc Nephrol 2005;16:2098–110. Glannon W. Underestimating the risk in living kidney donation. J Med Ethics 2008;34:127–8. Kute VB, Vanikar AV, Trivedi HL, et al. Outcome of renal transplantation in patients with diabetic nephropathy—a single-center experience. Int Urol Nephrol 2011;43:535–41. Kute VB, Godara SM, Shah PR, et al. Outcome of deceased donor renal transplantation in diabetic nephropathy: a single-center experience from a developing country. Int Urol Nephrol 2012;44:269–74. Boucek P, Saudek F, Pokorna E, et al. Kidney transplantation in type 2 diabetic patients: a comparison with matched non-diabetic subjects. Nephrol Dial Transplant 2002;17:1678–83. Cosio FG, Hickson LJ, Griffin MD, Stegall MD, Kudva Y. Patient survival and cardiovascular risk after kidney transplantation: the challenge of diabetes. Am J Transplant 2008;8:593–9. Treckmann JW, Goldenberg A, Malamutmann E, et al. Kidney transplantation in patients with diabetes mellitus: surgical complications. Hepatogastroenterology 2011;58:738–9. Rabrenovic V, Kovacevic Z, Jovanovic D, Ignatovic L. Complications in the kidney transplanted patients previously treated by peritoneal dialysis—10-year experience in a single center. BANTAO J 2007;5:94–6. Orsenigo E, Socci C, Carlucci M, et al. Multivariate analysis of factors affecting patient and graft survival after renal transplant. Transplant Proc 2005;37:2461–3. Wolters HH, Brockmann JG, Diller R, Suwelack B, Krieglstein CF, Senninger N. Kidney transplantation using donors with history of diabetes and hypertension. Transplant Proc 2006;38:664–5. Baskin-Bey ES, Kremers W, Nyberg SL. A recipient risk score for deceased donor renal transplantation. Am J Kidney Dis 2007;49:284–93. Witczak BJ, Jenssen T, Endresen K, Røislien J, Hartmann A. Risk factors for mortality in diabetic nephropathy patients accepted for transplantation. Transplantation 2007;84:356–61.