Sudden Development of ATN in Living-Related Donor Kidney Transplant Recipient?

Velma Scantlebury, MD


September 18, 2003


We have observed a number of living-related donor kidney transplant recipients with good graft function who develop a sudden rise in the serum creatinine level between the fifth and seventh posttransplant days. Biopsies have sometimes been reported as acute tubular necrosis (ATN). What could have precipitated ATN at this point of time?

Amitava Mukherjee, MS, MCh

Response from Velma Scantlebury, MD

ATN is often expected when kidneys are used from non-heart-beating donors or when there is a long cold ischemic time. However, this phenomenon, generally not associated with kidneys from live donors, can be seen in as many as 9% of living donor cases. Physiologically, a similar circumstance may be occurring in such cases where condition(s) may cause lower rates of perfusion to the kidney. While overall perfusion may be minimally impaired, microperfusion of the cortical region of the kidney may be more easily affected. Several conditions may precipitate this condition:

  • Intraoperative manipulation of the kidney may induce low cortical perfusion, which may not be manifested immediately after reperfusion, but may be seen a few days later.

  • Laparoscopic removal of kidneys (initial learning phase) can cause lower perfusion states as the kidney is moved back and forth during dissection of the vessels.

  • Any technical element of narrowing, which would decrease flow to the kidney. Osman and colleagues[1] reported that vascular complications of stenosis and thrombosis were often associated with biopsies showing ATN. These complications may not be obvious in the early posttransplant period.

  • Recipient factors include intraoperative fluid management and postoperative hypotension.

  • Drug-related complications. Lawson and Light[2] reported 2 cases of severe ATN associated with the use of the combination of sirolimus and tacrolimus in patients post living donor kidney transplantation.

  • Kidneys from older donors. Our observation is that these kidneys often are more easily affected by many variables compared with kidneys from younger donors.


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