|Year : 2002 | Volume
| Issue : 1 | Page : 68-72
Graft nephrectomy: The SGPGI experience
Nand Kishore Arvind, Aneesh Srivastava, Anant Kumar, Subodh K Das
Department of Urology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
Department of Urology, SGPGIMS, Lucknow - 226 014
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Graft nephrectomy is often considered a hazardous procedure with high morbidity and occasional mortality, and this may pose a technical challenge. The aim of this study was to evaluate the indications, etiology and complications following graft nephrectomy.
Materials and Methods: From 1988 to 2001, among total of 1,019 live related renal transplants carried at our center, 46 underwent graft nephrectomy. Patients were divided into 2 groups depending on timing of graft removal. The early group included 27 patients (within 2 months of transplantation) while in late group (graft removal after 2 months of transplantation) there were 19 patients. The 2 groups were compared in terms of indication, etiology and complications.
Results: In early group the indications for graft removal were acute rejection, thrombosis/infarction and hyperacute rejection, while in late group the indications were pain, hematuria, fever, hypertension and infection along with chronic failure. Overall, the external iliac artery injury occurred in I and 4 patients in early and late group respectively. Major blood loss occurred in I and 6 patients in early and late graft removal respectively. There were 2 deaths in early group due to ftdminant pneumonitis that progressed to sepsis and disseminated intravascular coagulation. There were 9 major wound infections all in early group except in 2 patients of late group. Respiratory infections occurred in 14 patients in early group and 1 in late group. In early group patients had CNS complications in form of seizures, clinical depression and delusional psychosis in 12 patients.
Conclusions: Our experience highlights the risk involved in graft nephrectomies. Severe acute rejection and thrombosis lead to early graft nephrectomies. Pain, hematuria, infection and hypertension in setting of chronic rejection are predominant causes for the delayed graft ne phrectomies. Early graft nephrectomy, though technically easy, is associated with systemic complications; late graft nephrectomy is technically more demanding with relatively increased risk of vascular and visceral injuries.
Keywords: Graft Nephrectomy, Renal Transplant
|How to cite this article:|
Arvind NK, Srivastava A, Kumar A, Das SK. Graft nephrectomy: The SGPGI experience. Indian J Urol 2002;19:68-72
| Introduction|| |
Graft survival is not indefinite, and a proportion of the failures may need removal. The percentage of transplants ending in nephrectomies varies from 0.5% to 43.5% depending on the policy of the institution involved. , Most centers follow a policy of removing all early failures and any late failures as needed. 10% to 60% of the late cases will eventually require nephrectomy. ,, Graft nephrectomy has often been considered a potentially hazardous procedure with significant morbidity and mortality rates. ,,,, Herein, we present our experiences with graft nephrec tomy and suggest measures to lower the morbidity and mortality.
| Materials and Methods|| |
From November 1988 to March 2002, of 1,019 renal transplants performed at our center, 46 underwent graft nephrectomy. Demographically there were 29 male and 17 female patients. Mean age at nephrectomy was 33 yrs (range 24 to 57). Operative records of 3 patients were incomplete, so only 43 patients were analyzed for various factors, such as the indication for surgery, morbidity and mortality rates. The cause of renal failure in 46 patients is shown in [Table - 1]. Patients were divided into 2 groups depending upon the time of graft removal after renal transplantation. (Early group - graft removal within 2 months and Late group - graft removal after 2 months of renal transplantation.) Acute rejection was treated with methylprednisolone 500 mg per day for 3 to 5 days and steroid resistant cases were treated with antithymocytic globulin or the monoclonal antibody OKT3.
All patients received a prophylactic intravenous antibiotic, which was continued for 48 hours postoperatively. In early group the extracapsular technique of nephrectomy was used while in late group the approach was subcapsular.
| Results|| |
There were 27 patients in the early group and 19 patients in late group. The indications for 46 graft nephrectomies are shown in [Table - 2]. Acute rejection was present in 76% of patients with thrombosis or infarction who underwent graft nephrectomy. The 2 patients with renal artery stenosis underwent graft nephrectomy after failed balloon angioplasty. These patients also had significant rejection.
Significant perirenal hematoma was found around the grafts in 7 patients, which was due to graft, rupture, biopsy and anastomotic bleeding. 
Of 27 nephrectomies performed within 2 months of transplantation, major intraoperative blood loss (i.e., greater than 1000 ml) occurred in 1 patient due to injury to external iliac artery. In late nephrectomies, moderate to major blood loss occurred in 6 out of 16 patients due to injury to either external iliac vein or external iliac artery. Overall, external iliac artery injury occurred in I patient in early and in 4 patients in the late group, while external vein injury occurred in 4 and 7 patients in early and late group respectively. All cases of vascular injury were successfully repaired. The mean operative time and technical difficulty of the procedure increased in tandem with length of implantation of the graft. Of the kidneys requiring nephrectomy, 78% were anastomosed to the internal iliac. This factor had no bearing on need for nephrectomy or operative morbidity.
Postoperative complications, major or minor, occurred in 24 of the 46 nephrectomies (51%) [Table - 3]. In early group 2 patients died due to fulminant pneumonitis that progressed to sepsis and disseminated intravascular coagulation. These patients also had resistant acute rejection or sepsis beforehand.
There were 9 major wound infections. 7 patients were in early and 2 in late group nephrectomies. Persistent oozing from the fossa resulted in re-exploration in 2 cases.
Respiratory infections occurred in 14 patients in the early group and 1 in late group. All recovered except 1 who progressed to fulminant septicemia. Debilitating cytomegalovirus infection affected 3 patients (early group). I died and I had cardiomyopathy and hematemesis, and 1 had delayed recovery. CNS complications in early group included grand mal seizures,  clinical depression  and delusional psychosis.  However, all conditions resolved within 6 months.
1 patient died because of unrelated causes within months after nephrectomy. Of the remaining 42 patients, 11 underwent another live related renal transplantation. The mean interval to transplantation was 34 months (range 7 to 67 months). The rest of the patients are on peritoneal or hemodialysis, awaiting transplantation.
| Discussion|| |
The morbidity and mortality rates of transplant nephrectomy are closely related to the indications for nephrectomy which are used in different units. ,,,,, Our policy is to remove failed transplants when they interfere with health. Most of the failures in this series were due to rejection. In early group the indication for graft nephrectomy in order of decreasing frequency were resistant acute rejection, vascular complications and hyper-acute rejection. Hypertension, hematuria, pain, infection and heavy proteinuria were the indication in the late group. Indications of graft nephrectomy vary from series to series; in early series, all failures were removed while in late group, late symptomatic graft failures were removed. ,
The extracapsular approach to graft nephrectomy is used for early failures. In late graft nephrectomies, the subcapsular approach is advocated. ,, Vosen et al reported a lower complication rate with the subcapsular method, however; the 2 groups were not comparable. Sinha et al found that the subcapsular method was associated with greater bleeding at operation. , In this study, no particular advantage could be attributed to either technique because the surgical approach was chosen based on intraoperative findings in each patient. Vascular injury has been reported intraoperatively in late graft nephrectomies because of dense adhesions, the incidence being 2 to 14%. ,,,, We had vascular injury in 11 patients with late graft nephrectomies and 5 in the early graft nephrectomies. In the late group, most of these injuries were due to violation of renal capsule, while in the early group all injuries occurred because of inadvertent application of vascular clamps on external iliac vessel. It is thus advisable to achieve proper orientation of graft vessels before application of clamps to avoid injuries to surrounding vessels in early graft nephrectomies. There is no choice of surgical approach in early nephrectomies. The approach has to be extracapsular, while in late nephrectomies because of dense perigraft adhesions and poor surgical plane subcapsular approach to hilar vessels is the safest.
Wound infection occurred in 20% of our patients. In literature, wound sepsis rates ranging from 3% to 24% have been reported. ,, In general, lower infection rates have been reported from institutions where a policy of removing a high proportion of failed transplants existed compared to series from institutions with selective nephrectomy. ,,, In our study, all patients with wound infections had acute rejection. Pre-existing wound infection is also an important factor in postnephrectomy sepsis. ,, Only 2 of our patients had wound infections before nephrectomy. Use of prophylactic antibiotics and vacuum drainage after nephrectomy may decrease the incidence of infection.
Major postoperative haemorrhage is the second most common complication of graft nephrectomy, occurring in 2 to 15% of the reported series and it is associated with a high mortality rate. ,,, The majority of cases occur in patients with wound infections that causes inflammation and necrosis of the exposed vessels. 2 of our patients in early group had generalized oozing from graft bed on exploration and both were managed conservatively.
Cytomegalovirus infection was associated with 1 death and 1 major illness in this series. Sinha et al have also reported 1 death from cytomegalovirus. 
Transplantation is the hope for end stage renal disease patients, and to have this expectation realized and then dashed by allograft failure leading to nephrectomy is a major emotional trauma. 8 patients had major psychiatric illness after early graft nephrectomy. Patients with emotional distress need psychological support during the period of failure. This feature of graft nephrectomy is usually forgotten in surgical studies. ,,,,,,
Incidence of major postoperative complications is 57%, 39% and 18% in the nephrectomies performed for acute rejection, infarction and chronic rejection respectively. Minor complications occurred with equal frequency (approximately 25%), in each of these groups. The proportions of patients with postoperative morbidity have been lower in some studies when nephrectomy was performed at an earlier stage. , However, in the early group, there is an increased incidence of complications related to generalized immunosupression, as seen in our study. Although one-third of our patients had respiratory, cardiac or other medical illnesses before transplantation, only 3 suffered any exacerbations during the postoperative period. Similarly, medical disorders have not been a major problem in other series. ,,,,
2 patients who died both underwent nephrectomy because of resistant acute rejection. In both cases progression of the overwhelming sepsis and disseminated intravascular coagulation could not be contained by nephrectomy and withdrawal of immunosupression. In 1976 Sinha and Castro reported 7 deaths: 5 from haemorrhage and 2 from systemic infections.  More recently, overwhelming sepsis secondary to immunosupression has become the major cause of death after transplant nephrectomy. ,,, Treatment of acute rejection has become more intensive during recent years with induction of OKT3 and antithymocytic globulin, and most of the patients now receive triple and quadruple therapy. These patients are prone to opportunistic infections associated with significant morbidity and mortality.
Overall mortality in this series was 4.6%. Mortality rates in other studies have ranged from 1.2%  to 38%.  This large variation is mainly due to the policy followed for the indication for nephrectomy. Chiverton et al removed all failed kidneys and had mortality rate of 1.2%.  Sharma et al only removed early failures and symptomatic late failures, and had mortality of 38%.  Following this policy, Sharma et al removed only 0.5% of all transplants as opposed to 35% in the series of Chiverton et al. , O'Sullivan et al calculated the mortality rate by comparing the percentages of all transplant patients who die following graft nephrectomy and in their review of reported series on graft nephrectomy, the mortality rates varied from 0.16% to 7.5%. 
| Conclusions|| |
Our experience highlights the risks involved in graft nephrectomies. Severe acute resistant rejection and thrombosis were responsible for early graft nephrectomies. Pain, hematuria and infection during chronic rejection are predominant causes for the delayed graft nephrectomies. Early graft nephrectomy, though technically easy, is associated with systemic complications; late graft nephrectomy is more demanding with more chances of vascular injuries. Graft nephrectomy is thus a technical challenge, which requires a great deal of caution before undertaking it. Operative details must be read before surgery for proper anatomical orientation. Intraoperatively, it is important to meticulously identify the hilar vessels in early graft nephrectomies. In late graft nephrectomies, a subcapsular approach with dissection close to hilum is required. Apart from technical hazards, sepsis and associated morbidity are the main factors responsible for complications.
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[Table - 1], [Table - 2], [Table - 3]