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Table of Contents
ORIGINAL ARTICLE
Year : 2019  |  Volume : 21  |  Issue : 3  |  Page : 156-160

Living- versus deceased-donor renal transplant recipients: A comparison on pulmonary complications


1 Department of Pulmonary Diseases, Ankara Ataturk Training and Research Hospital, Ankara, Turkey
2 Department of Pulmonary Diseases, Faculty of Medicine, Yildirim Beyazit University, Ankara, Turkey
3 Department of General Surgery, Faculty of Medicine, Gaziosmanpasa Hospital, Istanbul, Turkey
4 Department of General Surgery, Faculty of Medicine, Yildirim Beyazit University, Ankara, Turkey
5 Department of Nephrology, Ankara Ataturk Training and Research Hospital, Ankara, Turkey
6 Department of Family Medicine, Faculty of Medicine, Yildirim Beyazit University, Ankara, Turkey

Date of Submission18-Oct-2018
Date of Decision19-Nov-2018
Date of Acceptance15-Apr-2019
Date of Web Publication30-Dec-2019

Correspondence Address:
Dr. Ebru Sengul Parlak
Department of Pulmonary Diseases, Ankara Ataturk Training and Research Hospital, Ankara
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ejop.ejop_56_18

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  Abstract 


BACKGROUND: In renal transplant recipients, evaluation of pulmonary complications and investigation of reduction interventions are important due to the potentially fatal results of pulmonary complications after transplant surgery. However, data are lacking about pulmonary complications in renal transplant recipients with living- or deceased-renal donors. Therefore, we aimed to assess the pulmonary complications in living- versus deceased-donor renal transplant recipients.
METHODS: We retrospectively searched the medical records of patients who underwent renal transplantation in our tertiary referral center between 2013 and 2018. Sociodemographic characteristics, pulmonary complications, and major comorbidities were compared according to the donor type (living or deceased).
RESULTS: Fifty-two of 100 transplantations from living donors and 48 of 100 transplantations from deceased donors were formed the patient groups. There were no statistically significant differences in terms of sociodemographic and clinical characteristics between the groups except with regard to pneumonia complication. The pneumonia rates were 11/48 (22.9%) and 3/52 (5.8%), P = 0.020, for the deceased- and living-donor renal transplant recipients, respectively. Deceased-donor transplant recipients had a 4.8-fold risk of developing pneumonia (odds ratio, 4.8; 95% confidence interval, 1.2–18.6; P = 0.021).
CONCLUSION: Deceased-donor renal transplant recipients are more vulnerable to pulmonary complications than are living-donor ones and should thus be monitored closely.

Keywords: Deceased donor, living donor, pneumonia, pulmonary complication, renal transplantation


How to cite this article:
Parlak ES, Karalezli A, Tokac M, Dumlu EG, Altinoglu A, Cevik FT, Kilic M, Hasanoglu HC. Living- versus deceased-donor renal transplant recipients: A comparison on pulmonary complications. Eurasian J Pulmonol 2019;21:156-60

How to cite this URL:
Parlak ES, Karalezli A, Tokac M, Dumlu EG, Altinoglu A, Cevik FT, Kilic M, Hasanoglu HC. Living- versus deceased-donor renal transplant recipients: A comparison on pulmonary complications. Eurasian J Pulmonol [serial online] 2019 [cited 2020 Jan 21];21:156-60. Available from: http://www.eurasianjpulmonol.com/text.asp?2019/21/3/156/274392




  Introduction Top


Renal transplantation is the most commonly performed solid organ transplantation (SOT) worldwide.[1] Meanwhile, pulmonary complications are important in the prognosis of renal transplant recipients,[2] and respiratory tract infections are the most frequently observed complications and an important cause of mortality and morbidity.[1],[2]

Immunosuppression therapy is the most likely cause of pulmonary complications. However, investigation data regarding the differences of pulmonary complications according to the donor type (living or deceased) are lacking. To the best of our knowledge, no study has examined the pulmonary complications in renal transplant recipients according to donor type. Therefore, we aimed to assess the postoperative pulmonary complications in living- versus deceased-donor renal transplant recipients who underwent surgery at our center.


  Materials and Methods Top


This retrospective study was conducted in the Department of Chest Diseases and approved by the Local Ethics Committee (Approval No. 26379996/82). We retrospectively reviewed the medical records of patients who underwent renal transplantation at our center between 2013 and 2018 in terms of postoperative pulmonary complications. The recipients' demographic characteristics, renal disease etiology, preoperative posteroanterior lung radiography findings, concomitant medications, tuberculin skin test (TST) results, smoking status, and baseline pulmonary function test results were recorded from their medical files. Pulmonary complications of the patients and the diagnostic methods were noted. The renal transplant recipients were grouped on the basis of whether transplantation was performed from living or deceased donors. The groups were then compared in terms of age, gender, and type of pulmonary and extrapulmonary complications.

Statistical analysis

IBM SPSS Statistics for Windows, version 20.0 (IBM, Armonk, NY, USA) was used for the statistical analyses. The normal distribution of the data was assessed with the Kolmogorov–Smirnov test, and descriptive statistics were defined as mean, standard deviation, number, and percentage values. Variables were compared according to the mean and standard deviation for continuous data. The Chi-square test was used to find differences between the categorical variables, and Student's t-test was used to determine differences between group means for the continuous variables. P < 0.05 indicated statistical significance.


  Results Top


The medical files of 168 patients who had undergone renal transplantation were retrospectively reviewed. One hundred patients did not have missing data in their medical files and were thus included in the analyses. Of the recipients, 64% were men and 36% were women. The mean ages were 44.8 ± 11.3, 44.2 ± 11.3, and 45.9 ± 11.4 years for all patients, for men, and for women, respectively. Fifty-two and 48 of the 100 transplantations were performed from living and deceased donors, respectively. The patients were administered different combinations of tacrolimus, mycophenolic acid (MPA), cyclosporine, antithymocyte globulin, and methylprednisolone as immunosuppressive therapy.

Hypertension (37%) and diabetes mellitus (15%) were the most common concomitant chronic diseases in our study population [Table 1]. Hypertension (27%), diabetes mellitus (15%), and polycystic kidney disease (12%) were the major causes of renal failure among the renal transplant recipients. The other etiological causes of renal failure are depicted in [Table 2].
Table 1: Preoperative demographic characteristics of the patients with renal transplant recipients

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Table 2: Etiology of the renal disease

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A comparison of the renal transplant recipients according to donor type (deceased versus living) revealed that the average ages of the deceased- and living-donor renal transplant recipients were 46.7 ± 7.8 and 43.1 ± 13.7 years, respectively. The difference between average ages was not statistically significant. Similarly, there were no statistical differences in sociodemographic characteristics, including gender, concomitant chronic diseases, diabetes mellitus, cardiovascular diseases, and chronic lung diseases between the deceased- and living-donor renal transplant recipients [Table 3]. By contrast, the difference in pulmonary complications was statistically significant; the results were 13/48 (27.1%) and 4/52 (7.7), P = 0.015, in the deceased- and living-donor renal transplant recipients, respectively. Appearance times of postoperative pulmonary complications in the renal transplant recipients are shown in [Figure 1]. Pneumonia and pulmonary thromboembolism were categorized as pulmonary complications, whereas urinary tract infections, acute gastroenteritis, soft-tissue infections, malignant colon carcinoma, and acute respiratory distress syndrome were categorized as extrapulmonary complications. A statistically significant difference was found solely with regard to pneumonia; the pneumonia rates were 11/48 (22.9%) and 3/52 (5.8%), P = 0.020, in the deceased- and living-donor renal transplant recipients, respectively [Table 4].
Table 3: The comparison of the sociodemographic characteristics of living- versus cadaveric-donor renal transplant recipients

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Figure 1: Time of postoperative pulmonary complications in renal transplant recipients

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Table 4: The comparison of the postoperative pulmonary and extrapulmonary complications in living- versus cadaveric-donor renal transplant recipients

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Pulmonary complication and pneumonia were significantly associated with deceased-donor transplantation (odds ratio [OR], 4.4; 95% confidence interval [CI], 1.3–14.8; P = 0.015 for pulmonary complication, and OR, 4.8; 95% CI, 1.2–18.6; P = 0.021 for pneumonia).


  Discussion Top


We conducted this study to assess the complications, particularly pulmonary complications, in renal transplant patients. We compared existing pulmonary complications in living- and deceased-donor renal transplant recipients as well. Only pneumonia (pulmonary and extrapulmonary complications) was seen to be in a greater rate among the deceased-donor renal transplant recipients (11%) than among the living-donor renal transplant recipients (3%).

Due to the increasing frequency of renal transplantation procedures all over the world and the postoperative use of immunosuppressive therapies, patients and health-care professionals encounter several complications of infectious. Respiratory tract infections, pulmonary thromboembolism, and pulmonary complications that may develop secondary to medications are among the most commonly reported clinical conditions. Pulmonary complications are the most important cause of mortality and morbidity.[2]

Immunosuppressive treatment protocols for SOT increase the susceptibility of recipients to several infections. Among these, lower respiratory tract infections are the most common.[1] In this patient group, the incidence of pneumonia ranges between 8% and 18%.[3] Sarnak and Jaber demonstrated that pulmonary infections increased the mortality rate twofold in their studied renal transplant recipients compared with that for their overall population.[4] Prolonged hospitalization, tracheal damage resulting from endotracheal tubes, and impaired clearance of respiratory secretions contribute to the occurrence of pneumonia. Although infections commonly exhibit onset within the 1st year after transplantation, life-threatening viral and fungal infections mostly occur within the first 2 months after the procedure. The incidence of infections is higher during the first 3–6 months than after 6 months,[5] and immunosuppressive therapies administered during the postoperative period substantially contribute to the development of respiratory tract infections and drug-related pulmonary complications. Meanwhile, tacrolimus and cyclosporine are the two most commonly used calcineurin inhibitors. Their major side effects are endothelial damage and interstitial fibrosis-related nephrotoxicity.[6] Other side effects include infection, malignancy, hypertension, hyperglycemia, neurotoxicity, and hyperlipidemia.[6],[7] Furthermore, MPA may cause abdominal pain, diarrhea, nausea, bone marrow suppression, and (particularly at high doses) Cytomegalovirus infection. The side effects of the antibodies include allergic reactions, serum sickness, seizures, thrombocytopenia, arthralgia, and an increased risk of infection.[6] In the present study, the incidence of pneumonia was 14% in accordance with the literature in all patients. Deceased-donor transplantation presented a 4.8-fold risk of developing pneumonia (OR, 4.8; 95% CI, 1.2–18.6; P = 0.021). Extrapulmonary complications were more common (45%), but fatal infections resulted only from acute respiratory distress syndrome (ARDS) secondary to pneumonia.

Tuberculosis (TB) is the tenth leading cause of death worldwide [8] and the most significant opportunistic infection in transplant recipients. While the rate of TB varies between 1.2% and 6.4% in developing countries, it may reach 15% in transplant recipients from endemic regions. In such areas, the TB incidence is 8.5-fold higher among SOT recipients than among the overall population.[9] In Turkey, the incidence of TB is 18/10,000.[10] Immunosuppressive therapy increases the risk of TB development by 100 times.[1] In the present study, none of the patients had a history of TB. A review of the medical files showed that 69% of the patients with TST results ≥5 mm were administered prophylactic INH therapy. Such therapy is recommended for renal transplant recipients with TST ≥5 mm (with a booster effect or in the first test).[11],[12],[13],[14] In countries with a high prevalence of TB, prophylactic INH therapy is recommended for recipients whose donors have positive TST results.[15] Hence, at our clinic, renal transplant recipients with TST results exceeding 5 mm also undergo prophylactic INH therapy. None of our patients developed TB. In a large patient series, TB developed 1 year after transplantation.[16] Sayiner et al. demonstrated that TB in Turkey was diagnosed at a mean of 6 months after transplantation (range: 3–111 months).[17]

Venous thromboembolism (VTE) is another important health problem that may be encountered by renal transplant recipients. Its incidence varies between 0.6% and 25%. VTE can be associated with the surgical procedure, impaired hemostatic balance, impaired fibrinolysis, and/or ongoing hypercoagulation.[18],[19] In the current study, the incidence of VTE was 3%, and all cases were noted within the first 6 months after transplantation. One of these cases involved massive pulmonary thromboembolism, which led to a life-threatening right ventricular dysfunction. The risk of recurrent thrombosis was also higher in this patient group. Poli et al. showed that the risk of recurrent VTE was tenfold higher after the first episode in renal transplant recipients.[19] In this patient group, pulmonary embolism is a significant, life-threatening health concern after pulmonary infections.

We found an association between deceased-donor transplantation and pulmonary complications. It is known that living donors offer longer graft survival [20],[21] and have better outcomes than do deceased donors.[22],[23] Guimarães et al. found that living donors have shorter hospitalization times and lower postoperative infection rates.[23] The fact that rates of pulmonary complications in deceased-donor transplantation are higher than those in living-donor transplantation may be due to donor waiting period, prolonged exposure to chronic renal failure effects, and extended periods of dialysis.

In this study, we found that extrapulmonary complications were more common than pulmonary complications in the renal transplant recipients, but the patients responded well to the medical therapy. Meanwhile, despite being less frequent, pulmonary complications could increase mortality and threaten life.

The present study had certain limitations because of the lack of adequate data on the induction therapy and doses of the patients before surgery. Induction therapy regimens before the transplantation surgery may contribute to postoperative complications.


  Conclusion Top


The findings of this work showed that the deceased-donor renal transplant patients had a greater risk of developing pneumonia than did the living-donor renal transplant patients. Potential pulmonary complications in the renal transplant recipients may cause significant health problems that affect survival, quality of life, and therapeutic success. Most of the pulmonary complications developed within the first 6 months after transplantation under intense immunosuppressive regimens. Renal transplant recipients should, therefore, be investigated carefully through such means as systematic assessments and pulmonary examinations. Patients receiving transplants from deceased donors are more susceptible to pulmonary complications and should thus be closely monitored.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kupeli E, Ulubay G, Colak T, Ozdemirel TS, Ozyurek BA, Akcay S, et al. Pulmonary complications in renal recipients after transplantation. Transplant Proc 2011;43:551-3.  Back to cited text no. 1
    
2.
Pencheva V, Petrova D, Genoz D, Georgiev O. Pulmonary complications as a cause of death after renal transplantation. Open J Intern Med 2014;4:41-6.  Back to cited text no. 2
    
3.
Eyüboğlu FÖ, Küpeli E, Bozbaş SS, Ozen ZE, Akkurt ES, Aydoğan C, et al. Evaluation of pulmonary infections in solid organ transplant patients: 12 years of experience. Transplant Proc 2013;45:3458-61.  Back to cited text no. 3
    
4.
Sarnak MJ, Jaber BL. Pulmonary infectious mortality among patients with end-stage renal disease. Chest 2001;120:1883-7.  Back to cited text no. 4
    
5.
Miller WT Jr. Pulmonary infections in patients who have received solid organ transplants. Semin Roentgenol 2000;35:152-70.  Back to cited text no. 5
    
6.
Katabathina V, Menias CO, Pickhardt P, Lubner M, Prasad SR. Complications of immunosuppressive therapy in solid organ transplantation. Radiol Clin North Am 2016;54:303-19.  Back to cited text no. 6
    
7.
Li CJ, Li L. Tacrolimus in preventing transplant rejection in Chinese patients – optimizing use. Drug Des Devel Ther 2015;9:473-85.  Back to cited text no. 7
    
8.
Sester M, van Leth F, Bruchfeld J, Bumbacea D, Cirillo DM, Dilektasli AG, et al. Risk assessment of tuberculosis in immunocompromised patients. A TBNET study. Am J Respir Crit Care Med 2014;190:1168-76.  Back to cited text no. 8
    
9.
Cavusoglu C, Cicek-Saydam C, Karasu Z, Karaca Y, Ozkahya M, Toz H, et al. Mycobacterium tuberculosis infection and laboratory diagnosis in solid-organ transplant recipients. Clin Transplant 2002;16:257-61.  Back to cited text no. 9
    
10.
World Health Organization. Available from: http://apps.who.int/gho/data. [Last accessed on 2018 Jun 06].  Back to cited text no. 10
    
11.
Fischer SA, Lu K; AST Infectious Diseases Community of Practice. Screening of donor and recipient in solid organ transplantation. Am J Transplant 2013;13 Suppl 4:9-21.  Back to cited text no. 11
    
12.
Fishman JA; AST Infectious Diseases Community of Practice. Introduction: Infection in solid organ transplant recipients. Am J Transplant 2009;9 Suppl 4:S3-6.  Back to cited text no. 12
    
13.
Mejie Y, Piersimoni C, Torre-Cisneros J, Dilektasli AG, Aguado JM. Behalf of the ESCMİD study group of infection in compromised hosts (ESGICH). Clin Microbiol Infect 2014;20:89-101.  Back to cited text no. 13
    
14.
Bumbacea D, Arend SM, Eyuboglu F, Fishman JA, Goletti D, Ison MG, et al. The risk of tuberculosis in transplant candidates and recipients: A TBNET consensus statement. Eur Respir J 2012;40:990-1013.  Back to cited text no. 14
    
15.
Mycobacterium tuberculosis. Am J Transplant 2004;4:37-41. Doi; https://doi.org/10.1111/j.1600-6135.2004.00724.x  Back to cited text no. 15
    
16.
Singh N, Paterson DL. Mycobacterium tuberculosis infection in solid-organ transplant recipients: Impact and implications for management. Clin Infect Dis 1998;27:1266-77.  Back to cited text no. 16
    
17.
Sayiner A, Ece T, Duman S, Yildiz A, Ozkahya M, Kiliçaslan Z, et al. Tuberculosis in renal transplant recipients. Transplantation 1999;68:1268-71.  Back to cited text no. 17
    
18.
Poli D, Zanazzi M, Antonucci E, Bertoni E, Salvadori M, Abbate R, et al. Renal transplant recipients are at high risk for both symptomatic and asymptomatic deep vein thrombosis. J Thromb Haemost 2006;4:988-92.  Back to cited text no. 18
    
19.
Poli D, Zanazzi M, Antonucci E, Marcucci R, Rosati A, Bertoni E, et al. High rate of recurrence in renal transplant recipients after a first episode of venous thromboembolism. Transplantation 2005;80:789-93.  Back to cited text no. 19
    
20.
Opelz G, Wujciak T, Döhler B, Scherer S, Mytilineos J. HLA compatibility and organ transplant survival. Collaborative transplant study. Rev Immunogenet 1999;1:334-42.  Back to cited text no. 20
    
21.
Cecka JM. The UNOS scientific renal transplant registry-2000. Clin Transpl 2000:1-8.  Back to cited text no. 21
    
22.
Guirado L, Vela E, Clèries M, Díaz JM, Facundo C, García-Maset R. Why renal transplant from living donors gives better results than cadaver renal transplant? Nefrologia 2008;28:159-67.  Back to cited text no. 22
    
23.
Guimarães J, Araújo AM, Santos F, Nunes CS, Casal M. Living-donor and deceased-donor renal transplantation: Differences in early outcome – A single-center experience. Transplant Proc 2015;47:958-62.  Back to cited text no. 23
    


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