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The Reasons Why Renal Transplant Recipients Admit to the Emergency Department
and Their Management in the Emergency Department
ABSTRACT
Introduction: Number of patients with end stage renal disease are increasing worldwide and
so do the patients who had renal transplantation. These patient population are having much
more health problems especially due to immunosuppressive therapies, and also they are
admitted to the Emergency Departments more than normal population. Renal transplant
patients may admit to the emergency department of the hospital for several reasons including
issues either related or not related to renal transplantation. The causes of death for renal
transplant patients were found as infections with 69. 6%, cardiovascular diseases with 12. 7%
and acute rejection 6.9%, respectively. The aim of our study is determining the reasons why
patients admit to the emergency departments of the hospitals after renal transplantation and
highlighting the importance of the approach to renal transplantation patients in the emergency
department.
Methods: In this retrospective case-control study, we analyzed the admission reasons to the
ED, diagnoses and results of 41 patients, who underwent renal transplantation in our hospital
between 2011 and 2014. Some important parameters of the patients such as their age, sex,
vital functions, their medications, concomitant diseases, emergency diagnoses, graft loss,
mortality and whether they were outpatients or in-patients during treatment were recorded.
Results: The most common reason for admission to the emergency room was fever and this
was followed by abdominal pain, nausea and vomiting. The most common problem in patients
admitted to the emergency room was infection 28 (68%). The non-infectious causes were
acute renal failure observed in 4 (9.7 %) patients, acute graft rejection in 3 (7.3%) patients,
acute cholecystitis in 2 (4.8%), wrist fractures in 2 (4.8%) patients, cardiovascular disease in 1
(2.4%) patient and anxiety in 1 (2.4%) patient, respectively.
Thirty (73.1%) of these 41
patients admitted to the emergency department were hospitalized. The average duration of
stay of patients in the emergency department was 2.1 ±0.69 (1.2-3.4) hours, the average
duration of making hospitalization decision was determined as 1.9 ±0.46 (1.1-2.3),
respectively
Conclusion: As a result, the most common complaint of renal transplant patients presented to
the emergency department was fever. The most common diagnosis was infection. Acute renal
failure may be associated with graft rejection. Having a well-equipped emergency department
and well-trained and organized emergency team to provide adequate and effective treatment
to these patients will improve the success of treatment.
Key Words: renal transplantation recipients, emergency department
Introduction
Number of patients with end stage renal disease are increasing worldwide and so do the
patients who had renal transplantation. This patient population are having much more health
problems especially due to immunesupressive therapies, and also they are admitted to the
Emergency Departments (ED’s) more than normal population (1).
Some problems are encountered when renal transplant patients admit to the emergency
department and in the management of these patients in the emergency department (2). The
main causes of these problems are the drugs used by the patients and the lack of sufficient
knowledge and experience of renal transplantation. Good knowledge of effects, side effects
and interactions of the drugs used by the patients and understanding the drug doses and blood
levels play an important role in protecting renal graft (1). There may not be physicians
experienced in renal transplantation in the emergency departments of the hospitals all the
time. Therefore, it seems useful to educate and train emergency physicians about basic issues
of renal transplantation (2).
Renal transplant patients may admit to the emergency department of the hospital for
several reasons including issues either related or not related to renal transplantation. The
separation of causes related to transplantation has a vital importance in protection of graft.
Some causes of transplantation such as acute rejection episodes, infections, cardiovascular
diseases and side effects of immunosuppressive drugs and the problems of renal transplant
surgery should be able to be identified in the emergency department (1-3). The acute rejection
after renal transplantation constitutes the major cause of long-term graft loss (4). The most
important cause of death in renal transplant patients is developing infections during treatment
of acute rejection. Another major cause of death is due to cardiovascular diseases (2, 5).
In a study, the causes of death for renal transplant patients were found as infections with
69.6%, cardiovascular diseases with 12.7% and acute rejection 6.9%, respectively (6).
It should be noted that gastrointestinal emergency situations may occur depending on
high dose immunosuppressive and steroids used by post-transplant patients. Sometimes,
emergency surgeries may be required for reasons such as gastrointestinal perforation (1, 7).
The reasons of admittance of renal transplant patients to the emergency department
should be quickly analyzed and the treatment should be performed after determining the most
appropriate approach. Reduction in morbidity and mortality can be achieved by preventing the
graft loss with timely diagnosis, fast management and treatment (1-3).
The aim of our study is determining the reasons why patients admit to the emergency
departments of the hospitals after renal transplantation and highlighting the importance of the
approach to renal transplantation patients in the emergency department.
Methods
In this retrospective case-control study, we analyzed the admission reasons to the ED,
diagnoses and results of 41 patients, who underwent renal transplantation in our hospital
between 2011 and 2014.
Some important parameters of the patients such as their age, sex,
vital functions, their medication, concomitant diseases, emergency diagnoses, graft loss,
mortality and whether they were outpatients or in-patients during treatment were recorded.
Triple immunosupression protocol was applied to renal transplantation recipients. Anti-thymocyte
globulin (ATG) (1.5 mg/kg) induction therapy was started and continued for 5 to 7 days on all cadaver
graft recipients. Tacrolimus (TAC) or cyclosporine, mycophenolate mofetil (MMF) and prednisolone
was admistered to maintain immunosuppression. Tripple immunosupression protocol and basiliximab
was started on living donor recipients. They also received MMF and prednisolone with TAC or
cyclosporine. The immunosupressive agent of m-TOR inhibitory group was not used to any patient.
The data obtained via analysis of the patient files were analyzed using SPSS 13.0 for
windows statistical software. In this study as a basic statistical analytical method, descriptive
statistics, mean, standard deviation, and frequency tables were used. Continuous variables
were presented as mean±standard deviation; categorical variables were presented as
frequency and percentage.
In this study, patient registries were examined retrospectively only. In this study, the
private information and images of the patients were not used. For these reasons, it was not
necessary ethics committee permission for this study.
Results
During the study period, 160 renal transplants were performed in our center. A total of
41 renal transplant patients admitted to our emergency department for various reasons were
included in the study. 25 (60.9%) of these patients were men, while the remaining 16 (39.1%)
were women, respectively. 21 (51.2%) of the renal transplantations were applied from
cadavers and the remaining 20 (48.8%) were applied from living donors.
The most common reason for admission to the emergency room was fewer and this was
followed by abdominal pain, nausea and vomiting (Table 1).
The most common problem in patients admitted to the emergency room was infection.
The most common infection was acute gastroenteritis seen in 11 (26.8%) patients, followed
by 9 (21.9 %) patients with gastroenteritis, 4 (9.7%) patients with upper respiratory tract
infection, 2 (4.8%) patients with urinary tract infection and 1 (2.4%) patient with pneumonia,
respectively (Table 2).
The non-infectious causes were acute renal failure observed in 4 (9.7 %) patients, acute
graft rejection in 3 (7.3%) patients, acute cholecystitis in 2 (4.8%), patients, cardiovascular
disease in 1 (2.4%) patient and anxiety in 1 (2.4%) patient, respectively (Table 2). Two
patients admitted with wrist fractures (4.8%), one was apparent on x ray, but the other was
only visible by CT.
Eleven of 41 patients admitted to the emergency room twice, while 8 patients admitted
for the third time. The period of these admittances to the emergency department after
transplantation were summarized in Table 3.
Thirty (73.1%) of these 41 patients admitted to the emergency department were
hospitalized. The remaining 11 patients were treated in the emergency department. The most
common cause of hospitalization in patients treated was acute gastroenteritis. Other causes
were related to upper respiratory tract infections, urinary tract infections, pneumonia, acute
renal failure and acute cholecystitis. No graft loss and mortality was seen in patients admitted
to the emergency room.
The average duration of stay of patients in the emergency department was 2.1 ±0.69 (1.23.4) hours, the average duration of making hospitalization decision was determined as 1.9
±0.46 (1.1-2.3), respectively. In our study, the most frequent consultation was requested from
nephrology (29) followed by infectious diseases (13), transplant surgeon (6), orthopedics (2)
and cardiology (1), respectively.
Discussion
Transplants are applied in an increasing number every year. Parallel to the increase in the
number of patients, the number of transplant patients admitted to the emergency department
also increased (3). Emergency departments are the units receive transplant patients in the first
place. Therefore, the emergency services are very important for transplant patients. It is very
important to correctly assess these patients, manage their issues and use algorithms
effectively(2). The causes should be analyzed quickly and probable diagnoses should be
identified. Treatment should be applied immediately right after diagnosis phase.
In this patient group, problems that may develop due to immunosuppression should be
kept in mind. One of the most significant side effects of immunosuppressive use is making the
patient more susceptible to infections with opportunistic organisms (8). 28 of the patients
admitted to the emergency department were diagnosed with infection. All of these patients
were hospitalized in the clinic. In some other studies conducted in this field, infection was
determined to be the most common diagnosis made in the emergency departments (2,3).
The most common infection after renal transplantation is reported to be urinary tract
infections (3,9, 10). In another study, mucocutaneous infections were determined to be the
most common infection seen after renal transplantation (11). In a study conducted with renal
transplant patients admitted to the emergency department, the most common one was
determined as upper respiratory tract infections (2). According to a study conducted with 78
renal transplant patients, 10 of these patients admitted to the emergency department with a
diagnosis of gastroenteritis (2). In another study, gastroenteritis was developed in 19 patients
(3). Gastroenteritis were the most frequent infections encountered in our study, and this may
be due to eating habits of patients or change in water quality of the district that they live. The
high rate of gastroenteritis in our study may be due to this reason. All of these patients were
treated in the clinic. Neither sepsis nor graft loss was developed in any of these patients.
Although the most common infection was acute gastroenteritis in our study, urinary system
infections are the most important source of sepsis in renal transplant patients (12). In our
study, the urinary system infection was developed in 4 patients. All of these patients were
treated in the clinic. Neither sepsis nor graft loss was developed in any of these patients.
Renal transplant patients may admit to the emergency department with pulmonary
problems. The most common pulmonary problem is pneumonia (1). In our study, pneumonia
was observed in 2 patients. One patient was diagnosed with pneumococcal pneumonia and the
other one with atypical bacterial pneumonia. Both patients were treated in the clinic. Upper
respiratory tract infections are common infections in renal transplant patients receiving
immunosuppressive therapy. These infections may become more complicated. In our study,
uncomplicated upper respiratory tract infections were seen in 7 patients. These patients were
treated at the clinic.
Acute renal failure is the most important reason why renal transplant patients admit to
the emergency department. Acute renal failure may develop due to pre-renal and post-renal
causes. Acute cyclosporine or tacrolimus nephrotoxicity and acute rejection may be
responsible for acute renal failure (1). Development of renal failure due to acute graft
rejection is a major risk factor in renal transplant patients (13). In a study, acute renal failure
due to rejection was developed in 14 patients admitted to the emergency department and
mortality was developed in 3 of these patients (3). In our study, 4 patients were diagnosed
with acute renal failure in the emergency department. Then, 2 of these patients were
diagnosed with acute graft rejection and treated for acute rejection episodes. Acute rejection
episodes were reduced in these two patients and their blood urea creatinine values were found
within normal limits. In the other two patients, dose adjustment was made by considering
immunosuppressive drug toxicity. No graft loss and mortality was seen. Neither mortality nor
graft loss was developed in these patients.
In all renal transplant patients admitted to the emergency department with acute renal
failure, rejection is the first clinical case that should come to mind. Acute renal failure should
be diagnosed by emergency physician. Patients with acute renal failure should be hospitalized
and nephrologist should be informed quickly. In graft rejections that are not managed very
well, the rate of morbidity and mortality increases (3, 5).
In our study, 2 patients were admitted to the emergency room because of a broken wrist.
In both patients, partial carpal fracture was detected due to the challenging trauma. Plaster
splint was applied to both patients and they were followed without hospitalization. In a
previous retrospective study including 1572 renal transplant recipients, O’Shaughnessy et al.
reported various fractures due to independent multifactorial causes, and emphasized that these
patients must be protected against trauma and fractures (14). According to our findings renal
transplant patients are more sensitive in term of especially wrist fractures. Traumatic wrist
fractures are a clinical entity that may be encountered after renal transplantation. Therefore,
these patients must be carefully evaluated, and CT examination must be performed in order
reveal small fractures that are not apparent on x ray, just as in our case.
One of the most important mortality causes of renal transplant patients other than acute
rejection and infections, was related to cardiovascular diseases (2). One of the most important
reasons of this is high prevalence (15%) of atherosclerotic vascular diseases (15).
Cardiovascular risk in patients with renal transplantation has increased 5 times compared to
the normal population (1). In our study, one patient presented with chest pain and palpitations.
Supraventricular tachycardia was detected in the patient. The patient was treated in the
coronary intensive care unit.
The other complaints of the patients admitted to the emergency departments are
hypertension, tacrolimus and headache associated with the use of cyclosporine, insomnia,
neurologic complications such as tremor, haematologic disorders such as anemia, leukopenia,
thrombocytopenia, electrolyte disorders such as hyperkalemia and hypomagnesemia, muscle
joint problems caused by immunosuppressive and corticosteroid side effects and de novo
diabetes supported by tacrolimus, cyclosporine and corticosteroids (1). However, in our study,
no patient admitted to the emergency department with these reasons. Diabetes, hypertension
and hematologic problems were observed in the routine follow ups of the patients.
In this study, we found being that such as 1-36 months in a wide range time period of
admission to the ED after renal transplantation (Table 1). Current literature does not have
enough information on this subject. After transplantation the admission period to the ED’s of
the patients may be due to several factors.
Hospitalization rates among these patients were 73.1%. Our hospitalization rates were
high according to previous studies in the literature (2, 11). The reason for the high rate of
hospitalization was that the clinicians preferred patients to be hospitalized for treatment.
There is not enough data about the average waiting time in the emergency department of renal
transplant patients. Considering all patients included in our study, the average waiting time in
the emergency department was determined as 2.1 ± 0.69 (1.2-3.4) hours. The average time to
make hospitalization decision was 1.9 ±0.46 (1.1-2.3) hours. Since most of patients that are
decided to be hospitalized are diagnosed with infection and acute renal failure, this time
should be short.
All centers performing renal transplantation should raise awareness of their emergency
teams about renal transplantation. They should be trained about emergency situations that can
be faced by post-transplant patients. Management of patients must be made with a standard
procedure. All centers should have a well-equipped emergency department and well-trained
and organized emergency team in order to provide adequate and effective treatment to these
patients (2). In our center, fast decision and treatment procedures are provided to renal
transplant patients with our experienced and well-organized team. No graft loss or mortality
was seen in any of our renal plant patients presenting to the emergency department.
Conclusion
As a result, the most common complaint of renal transplant patients presented to the
emergency department was fever. The most common diagnosis was infection. Acute renal
failure may be associated with graft rejection. Having a well-equipped emergency department
and well-trained and organized emergency team to provide adequate and effective treatment
to these patients will improve the success of treatment.
Acknowledgments
The authors would like to thank Prof. Dr. M. Fatih Yuzbasıoglu for assisting with preparation
of the manuscript.
Conflict of interest:
None
Funding support
None
Authors’ contributions
All authors passed four criteria for authorship contribution based on recommendations of the
International Committee of Medical Journal Editors.
References
1. Venkat KK, Venkat A. Care of the renal transplant recipient in the emergency
department. Ann Emerg Med. 2004;44 (4):330-41.
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postoperative renal transplant recipients who present to the emergency unit:
experience at one center. Transplant Proc. 2004;36 (1):184-6.
3. Kartal M, Goksu E, Eray O, Gungor F. Factors affecting to hospital admisson for
renal transplant patients in the emergency department. Turk J Emerg Med
2009;9(4):159-62.
4. Tanabe K, Takahashi K, Toma H: Causes of long term graft failure in renal
transplantatioin: World J Urol 1996;14(4):230.
5. Gorlen T, Abdelnoor M, Enger E, et al: Long term morbidity and mortality after
kidney transplantation: Scand J Urol Neprol 1992;26(4):397.
6. Reis MA, Costa RS, Ferraz AS: Causes of death in renal transplantation recipients: a
study of 102 autopsies from 1968 to 1991. J Royal Soc Med 1995; 88(1):24.
7. Abou-Saif A, Lewis JH. Gastrointestinal and hepatic disorders in end-stage renal
disease and renal transplant recipients. Ther Adv Renal Replace. 2000;7(3):220-230.
8. Fishman JA, Rubin RH. Infection in organ-transplant recipients. N Engl J Med.
1998;338(24):1741-51.
9. Becker S, Witzke O, Rübben H, Kribben A. Urinary tract infections after kidney
transplantation: Essen algorithm for calculated antibiotic treatment. Urologe A.
2011;50(1):53-6.
10. Trzeciak S, Sharer R, Piper D, et al. Infections and severe-sepsis in solid organ
transplant patients admitted from a university-based ED. Am J Emerg Med.
2004;22(7):530-3.
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2000;32(7):1974-5.
12. Schmaldienst S, Dittrich E, Hörl WH. Urinary tract infections after renal
transplantation. Curr Opin Urol. 2002;12(2):125-30.
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Table 1- Physical symptoms in renal transplant recipients who were admitted to emergency
room
Symptoms
Fever
Abdominal pain
Nausea and vomiting
Diarrhea
Hedache
Dyspnea
Hematuria and dysuria
Low back pain
Extremite pain
Palpitation
Hypertension
Number of patients
15
11
9
6
4
3
3
2
2
1
1
Table 2 - The distribution of diagnoses in the emergency room who were admitted to
emergency room
Infectious
Number of patients
Acute Gastroenteritis
%
11
26.8
Upper respiratory tract infection
9
21.9
Urinary tract infection
4
9.7
Pneumonia
2
4.8
Herpes infection
1
2.4
Soft tissue infection
1
2.4
Non Infectious
Number of patients
Acute Renal Failure
4
%
9.7
Acute graft rejection
3
7.3
Acute cholecystitis
2
4.8
Wirst fractures
2
4.8
Cardiovascular disease
1
2.4
Anxiety
1
2.4
Total
41
100
Table 3. Characteristics of the renal transplant patients admitted to the ED†
(n=41)
Characteristics
Values
Gender
Age
25M/16F
40.63±10.95
Cadaveric donor and Living donor ratio
21/20
___________________________________________________________________________
Period of admission to the ED after renal Tx‡ (month±SD and ranges)
For 1st admission
11.04± 8.2 (1-36)
For 2nd admission
12.50± 11.0 (5-34)
For 3rd admission
21.50± 8.6 (5-31)
___________________________________________________________________________
Distribution of renal Tx patients according to their frequency of admission
to the ED after Tx (number of patients and percent)
1st time admission
22 (53.6%)
2nd time admission
11 (26.8%)
3rd time admission
8 (19.5%)
ED†: the Emergency Department , Tx‡:Transplantation