Outcomes of renal transplantation in patients with major lower limb amputation.

INTRODUCTION: The impact of severe peripheral vascular disease on graft survival in patients undergoing renal transplantation is poorly defined. The aim of our study is to establish outcomes in renal transplant recipients who have severe peripheral vascular disease necessitating major lower limb amputation. METHODS: Data for patients undergoing renal transplantation from January 2001-December 2010 was extracted from a regional transplantation database. Patients undergoing lower limb amputation pre- and post-transplantation were identified and outcome measures including delayed graft function, biopsy-proven acute rejection, serum creatinine level at 1 year, and graft loss and recipient survival at 1 year and long-term were compared with patients who did not undergo amputation. Student t and Pearson's chi-squared tests were used to compare patients with and without amputation and Kaplan-Meier curves were used for survival analysis. A P value < .05 is considered statistically significant. RESULTS: A total of 762 patients underwent renal transplantation. Four (0.5%) patients had an amputation before transplantation and 16 (2.1%) underwent amputation after transplantation. Serum creatinine levels at 1 year were significantly higher in patients who had amputation after transplantation (308.5 ± 60.8 µmol/l vs 177.6 ± 6.4 µmol/l; P = .03). During longer follow-up (mean: 2053.1 ± 58.3 days), patients who underwent amputation after transplantation had a higher rate of graft loss (P < .01) and higher death rate (P < .01). CONCLUSION: The requirement for amputation after renal transplantation is associated with poor long-term graft and patient survival and higher serum creatinine levels at 1 year. Patients at increased risk of severe peripheral vascular disease should be identified and measures taken to reduce the long-term risk.

A single center experience of abdominal wall graft rejection after combined intestinal and abdominal wall transplantation.

We report our outcomes following combined intestinal and abdominal wall transplantation, focusing on the presentation and treatment of acute rejection of the abdominal wall vascularized composite allograft (VCA). Retrospective analysis of all patients with combined intestinal/VCA transplantation was undertaken. Graft abnormalities were documented photographically and biopsies taken, with histological classification of rejection according to Banff 2007 guidelines. We have performed five combined intestinal and abdominal wall transplants to date. Two patients developed erythematous, maculopapular to papular eruptions confined to the VCA, histologically confirmed as grade II/III rejection, yet with normal bowel on endoscopy. Both patients' rashes resolved within 72 h of increasing immunosuppressive treatment. One patient later developed a recurrence of the rash, confirmed as skin rejection, but did not immediately seek medical attention. Treatment was therefore delayed, and mild intestinal rejection developed. We describe the rash associated with VCA rejection, and propose that while the skin of an abdominal wall VCA may reject independently of the intestinal allograft, delay in treatment of rejection episodes may result in rejection of the intestinal graft.