Kidney transplantation stands as a definitive treatment for end-stage renal disease (ESRD), offering patients a significant improvement in quality of life and survival compared to dialysis. In spite of the improvements in surgical methods and after-care, early complicated surgical events still occur and are capable of influencing the total success rate and further prognosis of the transplant [1]. These complications that may range from vascular thrombosis, urinary leak, wound infection, hematoma can cause graft dysfunction, higher morbidity and or graft loss. KT is considered the preferred option for patients with ESRD since most patients experience better survival and improved quality of life as compared to other RRT. Although the overall survival of the patient and the graft has enhanced over the years, the issues of morbidity and mortality due to postoperative complications are still a major challenge in clinical practices [2].

Early postoperative SC can be defined by Clavien Grades, which differentiate them by the severity of the complication. Major groups of SC related to KT include vascular complications, urological problems, peri-graft fluid collections and general surgical complications. The worst form of SC particularly, the vascular complications rises to the most serious and urgent of the lots, which includes renal artery stenosis, renal artery thrombosis, pulmonary embolism, deep vein thrombosis, and peri-graft haemorrhage [3]. According to the reported symptoms, vascular complications are said to occur with a frequency ranging from 2% to 4%. 5% to 13. 5%, and they are also related to lower outcomes of 5-year patient and graft survivals. Potential urological complications after KT include changes in patient graft function, graft survival and morbidity profile [4]. According to the literature, urologic complications are reported to occur in a variation of 3 to 7 percent. 4% to 11. 2%. Some of the complications relating to the urinary system include; urinary leak, ureteral stricture, DJ stent encrustation or misplacement, urolithiasis, obstruction of the bladder outlet, and bladder rupture [5]. The most important adverse outcome is urinary leak which taking place due to improper anastomosis or because of the injury of the ureter [6]. Obstruction can involve clots in the urine adding to its bulk and hurting the free flow of urine in cases where the ureters are already kinked or compressed due to other factors, swelling, or scarring from prior surgeries and operations, (Surgical instrumentation can also cause it) DJ stent Encrustation happens due to the accumulation of minerals in urine naturally occur when the levels of calcium, oxalate, or phosphorus are high Bladder in-jury is iatrogenic complication though the rate of bladder injury in patients undergoing renal transplantation is low [7]. Factors that related to the immune system must be closely monitored mainly because of the efforts to minimize immunosuppression as well as the general complications that may arise from the transplantation surgery. Both of these complications if left undiagnosed or untreated can be catastrophic to the graft function and patient result [8]. These results stress the importance of careful monitoring of surgical complications during the early period of transplantation and the development of effective programs for preventing complications in recipient and donors in the course of reduced mobility and rehabilitation after transplantation [9,10].

Objectives

The main objective of the study is to find the impact of early surgical complications on kidney transplant outcomes.

This prospective observational study was conducted at Jinnah hospital, Lahore during June 2023 to January 2024. 85 kidney transplant recipients were followed in this study. For each of the 85 kidney transplant recipients, comprehensive demographic information was recorded, including age, gender, underlying cause of kidney disease, and comorbidities. Detailed transplant-related information was also gathered, such as the type of donor (living or deceased), the specific immunosuppressive regimen administered, and surgical details. Early surgical complications occurring within the first 30 days post-transplant were systematically categorized into three primary types: vascular, urological, and wound-related complications. Vascular complications included issues such as thrombosis, arterial or venous stenosis, and significant bleeding. Urological complications encompassed urinary leaks, ureteral obstructions, and fistulas, while wound-related complications comprised wound infections, dehiscence, and hematomas. The primary outcome measures focused on the incidence of these complications, their impact on graft function, length of hospital stay, readmissions, and overall patient morbidity and mortality.

All collected data were carefully documented and subsequently analyzed using descriptive and inferential statistical methods by using SPSS v29.

In our study of 85 kidney transplant recipients, patients with early surgical complications (n=22) had a mean age of 58.01 ± 9.5 years, slightly higher than those without complications (54.23 ± 10.5 years). The mean donor age for patients with complications was 52 ± 7.8 years, compared to 49 ± 9.2 years for patients without complications. There was a higher prevalence of hypertension among patients with complications (82%) versus those without (68%), while rates of diabetes mellitus were 32% ± 10% and 27% ± 9%, respectively. The demographic distribution by sex (64% male in complications vs. 62% in non-complications).

Table 1: Baseline Characteristics of Study Participants

Patients in the complication group (n=22) experienced significantly higher rates of delayed graft function compared to those without complications (45.5% vs. 12.5%, p=0.002). The median length of hospital stay was notably longer for patients with complications (15 days, IQR 10-18) compared to those without (7 days, IQR 5-10), with a significant difference observed (p=0.001). Although not statistically significant, one-year graft survival was slightly lower in the complication group (80%) compared to the non-complication group (88%, p=0.153). Additionally, patients with early surgical complications had a higher incidence of acute rejection episodes within the first-year post-transplant (31.8% vs. 12.5%, p=0.041).

Table 2: Early Surgical Complications and Clinical Outcomes

In our study of 22 kidney transplant recipients with early surgical complications, vascular issues were the most common, affecting 54.5% of patients, with arterial thrombosis noted in 22.7% and venous stenosis in 31.8%. Urological complications were also prevalent, observed in 31.8% of cases, including ureteral obstruction in 18.2% and urine leaks in 13.6%. Wound-related complications, primarily infections, affected 13.6% of patients.

Table 3: Types of Early Surgical Complications

In our study, patients with early surgical complications had significantly higher odds of experiencing delayed graft function, with an adjusted odds ratio of 3.82 (95% CI 1.67-8.74, p<0.001). Similarly, the odds of developing acute rejection episodes within the first-year post-transplant were also elevated, with an adjusted odds ratio of 2.91 (95% CI 1.12-7.54, p=0.027).

Table 4: Logistic Regression Analysis of Factors Associated with Clinical Outcomes

Our study provides valuable insights into the significant impact of early surgical complications on kidney transplant outcomes. The findings showed that early complications were significantly correlated with fairly poor clinical outcomes such as DGF and more frequent AR. The fact that arterial thrombosis and venous stenosis are common immediately after several weeks or months after transplantation requires extra care when treating patients with vascular anastomoses [11]. Some of these complications even threaten graft perfusion and at the same time call for emergency measures to restore graft function. The other urological diagnoses identified in this cohort include uroteral obstruction and urine leaks [12]. These complications if not managed can culminate into urinary tract complications, infections, and may even affect the graft function [13]. Wound related complications although less common underline the need to adhere to proper surgical site care in order to prevent the occurrence of infections and enhance wound healing in the post-transplant period. The results of our studies based on the logistic regression models comparing the early surgical complications group with others also indicated that the patients in the former group were at a greater risk of developing delayed graft function and acute rejection episodes [14]. These conclusions stress the importance of performing highly precise surgeries, as well as the necessity of close monitoring of the patients in the early period after the surgery in order to avoid such complications [15]. Nevertheless, our study found that one-year graft survival was not statistically different in patients who had complications than in patients who did not, therefore, indicating that though complications affect the early postoperative period, they could not necessarily lead to impaired graft survival in the long run [16]. However, it is crucial to continue the extenuation of every attempt aimed to decrease early complications rate as well as their timely treatment to enhance the general results of transplantation and patient’s quality of life [17]. Finally, our study has shortcomings; it is conducted at a single institution, which restricts the generalization of its findings in a broader transplant population, and has a small sample size, which is always a disadvantage. It is, therefore, necessary to conduct similar studies in other multi-center settings involving larger populations to confirm our results and examine other factors contributing to the outcomes of transplantation.

It is concluded that early surgical complications significantly affect the outcomes of kidney transplant recipients, leading to increased graft dysfunction, longer hospital stays, and higher readmission rates. Vigilant perioperative care, early detection, and prompt management of these complications are essential to improving patient prognosis and overall transplant success. Enhanced surgical techniques and postoperative protocols can mitigate these risks, ensuring better outcomes for transplant recipients.

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