Risks and complications during the transplant operation

A kidney transplant is a big operation. Your child’s transplant team will carefully monitor your child and check for signs of complications during and after the operation. They will discuss the possible risks and complications with you in detail, and you will be asked to give written agreement (consent) for the operation to take place.

Generally, a kidney transplant is a safe procedure, and the benefits are likely to outweigh any risks.

Side effects and complications may include:

• infection in the incision site. Your child will be given antibiotics to help prevent this.
• bleeding. Your child may need a blood transfusion if they bleed a lot.
• an incisional hernia. This is when the abdominal wall does not fully heal where the surgeon cuts through it during the transplant. This can cause organs such as the small bowel to push through and will need further treatment.
• damage to the lung cavity, nearby organs or blood vessels. This is rare but can be repaired if it occurs, although it may sometimes require further surgery
• serious complications such as blood clots. These are very rare.
• delayed graft function. Your child’s new kidney may take a few days to start working, especially if it is from a deceased donor. Occasionally, children need dialysis for some time before the kidney is fully functioning.
• primary non function. The new kidney never starts to work after it has been transplanted and may need to be removed. Your child may need to go back to dialysis and will then need another transplant. This is rare.

Risk and complications after the transplant operation

After your child goes home from hospital, they will continue to be monitored by their kidney team. You will have regular hospital visits to check how well the transplanted kidney is doing and to prevent or treat any complications. Your child will need to take medication for the rest of their lives to prevent their body from rejecting the new kidney.

Rejection

When a kidney – or any other body tissue – is transplanted from a donor to a recipient, the recipient’s body recognises it as ‘foreign’ and tries to reject or destroy it. This happens because of the immune system, which protects the body against disease and infection. Parts of the immune system find and destroy foreign things such as germs or other people’s cells, which are the tiny living parts of the body. If your child’s immune system sees their new kidney as foreign, it will try to destroy it. This is called rejection and is the major complication of kidney transplantation.

To reduce the risk of rejection, your child’s transplant team will have tried to find a close match between your child and their kidney donor. Your child will also take medicines called immunosuppressants to stop their immune system from rejecting the transplanted kidney. If children forget or choose not to take these medicines, their bodies are likely to reject the new kidney. Teenagers have the highest rates of kidney transplant loss of all age groups (including adults). This is thought to be due to not taking the medicines as prescribed.

Rejection may be sudden (acute) – there may be one or more episodes, or it may occur over a longer period of time.

Symptoms and signs

Many children do not have symptoms of rejection.

Occasionally children experience:

• fever
• pain or tenderness around transplanted kidney
• blood in their urine (haematuria)
• reduced urine output
• tiredness/feeling unwell.

Tests

Your child will have blood and urine tests after the operation to check how well the new kidney is working. The amount of creatinine in their blood will be measured. Creatinine is a waste product in the blood, which healthy kidneys filter. A high amount of creatinine may be a sign of rejection.

An ultrasound scan and a biopsy of the transplanted kidney, to confirm the problem.

Treatment

Early rejection can generally be successfully treated by changing medicines. Do not change or stop any medication without advice from your child’s doctor.

Rejection that occurs after six months or more since the transplant may be more difficult to treat, particularly if the rejection is due to your child not taking their medicines correctly.

Unfortunately, sometimes kidney transplants stop working because of rejection. If the new kidney does not work – or stops working after a time – your child may need to start dialysis. Your child will then be considered for another transplant.

Infections

All transplant recipients need to take anti-rejection medicines (called immunosuppressants), which make the immune system less active. This means they are at higher risk of getting infections caused by germs such as bacteria and viruses. Some of these are minor but may need treatment with antibiotic or antiviral medicines. Others may be more serious.

Cytomegalovirus (CMV) and Epstein–Barr virus (EBV)

Cytomegalovirus (CMV) and Epstein–Barr virus (EBV) are viruses that cause a glandular fever-like illness in people with healthy immune systems. Symptoms include a fever (temperature above 38°C), sore throat and tiredness. These often get better after a few weeks. The virus does not leave the body but rather stays in a dormant (in-active) state.

In people whose immune system has been suppressed – such as when taking anti-rejection medicines – these viruses can cause more serious illness. Your child will be tested to find out whether they have already been infected with CMV or EBV. If your child has not previously been infected with these viruses, they may be at a higher risk of getting ill if they receive a kidney from a donor who had been exposed to CMV or EBV.

• Cytomegalovirus (CMV): for CMV, your child may be given a low dose of an antiviral medicine to protect them against getting this infection. If your doctor thinks that your child may be ill, they may be tested for CMV infection. If they are infected, your child may be given a higher dose of an antiviral medicine that will kill the virus.
• Epstein-Barr virus (EBV): there is currently no effective antiviral treatment for EBV. Your doctor will test for EBV infection during your child’s routine blood tests after the kidney transplant. If your doctor thinks that your child may be infected with EBV, they may need to reduce the dose or stop some of their anti-rejection medicines. This will help your child’s immune system to fight the infection. Do not change or stop any medication without advice from your child’s doctor.

BKV

The BK virus (BKV) is a very common virus. Nine out of 10 people catch it during childhood in the same way as you catch a cold. The virus is carried in the body for life, but it usually remains inactive and causes no symptoms.

After a kidney transplant, medicines are taken to suppress your child’s immune system and prevent their body from rejecting the new kidney. Because of the suppressed immune system, the BK virus can become active and affect the transplanted kidney. This is known as BK nephropathy. If it is left untreated, BK nephropathy can cause kidney damage or cause your child’s body to reject the new kidney.

Your child will have regular blood and urine tests after a kidney transplant check for the virus.

Treatment involves a change or reduction in the anti-rejection medicines that your child is prescribed. This will help your child’s immune system to fight the infection. Do not change or stop any medication without advice from your child’s doctor.