Prophylactic Cholecystectomy Is Not Indicated following Renal Transplantation

doi:10.1016/S0002-9610(98)00009-9

The American Journal of Surgery

Volume 175, Issue 4, April 1998, Pages 317-319

https://doi.org/10.1016/S0002-9610(98)00009-9 Get rights and content

Abstract

Background: The appropriate management of gallstones in patients undergoing renal transplantation is controversial. Screening for gallstones and subsequent prophylactic cholecystectomy has been recommended by some authors for kidney transplant candidates. Our program does not practice routine pretransplant screening for gallstones, and we reviewed our data to determine the outcome of our management approach.

Methods: We reviewed the records of the 1,364 currently followed patients who have undergone kidney transplant at our institution since 1985 in order to evaluate the morbidity and mortality of biliary disease in the post-transplant period. We attempted to contact all patients by telephone or mail survey for the presence of biliary tract disease or operations.

Results: Six hundred and sixty-two patients were fully evaluated. Fifty-two (7.85%) required cholecystectomy for stone disease. Seven patients underwent incidental cholecystectomy during other operations, 2 patients developed acalculus cholecystitis, and 14 patients with asymptomatic cholelithiasis are being followed up. Surgical indications included 38 biliary colic, 9 acute cholcystitis, 3 gallstone pancreatitis, and 2 patients who were asymptomatic. Fifty-two patients underwent 30 laparoscopic cholecystectomies, 20 open cholecystectomies, and 2 conversions. Surgery occurred from 7 days to 9.6 years following transplantation. Overall, the median hospital stay (no postoperative stay) was 4 days (range 1 to 57). Patients undergoing laparoscopy had a median stay of 2 days compared with 7 days for those undergoing an open procedure. Complications were seen in 6 patients (11.5%) with no morbidity and no graft loss. The 1-, 2-, and 5-year graft survival was 98%, 96%, and 85%, respectively, in patients undergoing cholecystectomy.

Conclusions: Transplant patients are not at an increased risk for developing biliary tract disease compared with nontransplant patients. Gallstone disease does not have a negative impact on graft survival. Treatment of gallstones has a low risk and does not represent an increased risk of complications in patients following renal transplantation.

Section snippets

Methods

The database of transplant recipients at our institution was utilized to identify all patients who had undergone a kidney or kidney/pancreas transplant within the last 10 years. Hospital records were examined to identify patients who had undergone cholecystectomy at our institution. All patients who were currently followed up by our transplant team were surveyed by mail. Individuals were questioned concerning biliary tract symptoms and their knowledge of gallstones. We specifically searched for

Results

One thousand three hundred and sixty-four patients with kidney/pancreas or kidney transplants are currently followed up by our office. Complete evaluation was performed on 662 patients, and 518 (78%) patients were identified who had no previous or current history of biliary tract symptoms or identified gallstones. Sixty-nine patients had undergone cholecystectomy prior to transplantation, and 14 patients had known gallstones but remained asymptomatic and were being followed up without

Comments

The true prevalence of gallstones in the transplant population is not known. Our patients did not undergo routine screening. However, Graham et al[1]screened 423 patients either following transplantation or when they were placed on the waiting list; 29 had previous cholecystectomy, and 10% were found to have gallstones, a combined prevalence of 17%. This was somewhat higher than seen in general population studies. A series of 26,895 autopsies demonstrated that 11.6% of the entire population and

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Cited by (42)

Cholecystectomy-Associated Complications in Kidney Transplant Recipients Compared With the General Population
2021, Transplantation Proceedings
Cholelithiasis is one of the most prevalent diseases in the general population. Among kidney transplant (KT) recipients, atypical clinical presentation may delay the diagnosis and proper treatment. This single-center retrospective cohort study compared cholelithiasis clinical presentation and cholecystectomy-associated complications in 230 KT recipients and in 172 members of the general population. KT recipients had a higher proportion of men, comorbidities, biliary pancreatitis, choledocholithiasis, and acute cholecystitis clinical presentations than the general population. KT recipients presented higher American Society of Anesthesiologists scores and higher rates of emergency surgeries (15.7% vs 9.9%, P = .091), conversion (5.7% vs 1.2%, P = .019), drainage (7.8% vs 2.3%, P = .016), postoperative complications (10% vs 4.7%, P = .047), and longer hospital length of stay (1 vs 1 days, interquartile range, 2 vs 0 days; P < .001). There were 5 deaths, all of which occurred in KT recipients. History of diabetes mellitus, renal function, and surgical conversion were independent risk factors associated with postoperative complications. Male sex and level of renal function were independent risk factors associated with postoperative acute cholecystitis. KT was an independent risk factor associated with postoperative choledocholithiasis (adjusted odds ratio, 5.89; 95% confidence interval, 3.03-15.66) and pancreatitis (adjusted odds ratio, 6.89; 95% confidence interval, 2.99-11.61). In conclusion, KT recipients with cholelithiasis have an increased risk for clinical and surgical complications compared with the general population.
An Analysis of Epidemiology, Etiology, and Outcomes of Acute Pancreatitis in Renal Transplant Recipients
2020, Transplantation Proceedings
Acute pancreatitis after renal transplantation is seldom seen yet a dreadful complication. The causes include traditional causes and immunosuppressive medications and viral infections. Classical symptoms are not always present at onset, causing delay in diagnosis. The available literature on pancreatitis in renal transplants is either as case reports or case series. Large studies with longer follow-up periods and outcome in renal transplant patients with pancreatitis are lacking. We conducted this retrospective study to analyze the incidence, clinical features, and causes of pancreatitis in our institute in post-azathioprine era.
We conducted a single center retrospective study of renal transplant recipients who suffered at least 1 episode of acute pancreatitis during a period from January 2002 to September 2018. We followed International Association of Pancreatology/American Pancreatic Association evidence-based guidelines for confirming diagnosis of acute pancreatitis and included only patients who fulfilled these criteria. Once the diagnosis is confirmed we retrospectively analyzed the etiology, clinical features, management and outcomes of renal transplant recipients with pancreatitis.
Twenty-six patients (men 81%; mean age 38.5 years) were included. Etiology included gallstones (19.3%), structural lesions (11.5%), viral infections (7.8%), and drugs. Clinical presentations, laboratory parameters were like pancreatitis in non-transplant patients. Graft dysfunction was noted in 20 patients (77%) and all showed either partial or complete recovery. Patient survival was high with 88% of the patients surviving the episode.
Pancreatitis after renal transplantation is a rare complication with outcomes better than what has been reported in the past.
Chapter 37 - Cholecystolithiasis and stones in the common bile duct: Which approach and when?
2016, Blumgart's Surgery of the Liver, Biliary Tract and Pancreas: Sixth Edition
Cholecystectomy for Acute Cholecystitis After Renal Transplantation
2016, Transplantation Proceedings
Citation Excerpt :
Furthermore, in follow-up of transplanted patients, we usually do not perform cholecystectomy in asymptomatic patients with gallstone disease. This approach is in accordance with results of multiple studies published on this topic [16,20,21,28,29]. However, 1 patient in our study developed acute calculous cholecystitis during the kidney transplant hospital stay.
The aim of our study was to evaluate the rate of surgical complications, patient outcomes, and impact on graft function in renal transplant recipients in whom cholecystectomy for acute cholecystitis was performed.
We reviewed data on transplant patients from January 1, 2006, to December 31, 2013. The subgroup of patients who required subsequent cholecystectomy for acute cholecystitis was assessed, and their data were further analyzed.
Thirty-one patients who underwent cholecystectomy for acute cholecystitis after renal transplantation were included in the study. Clinical signs such as pain in the right upper quadrant, temperature >38°C, and elevation in bilirubin levels occurred in 20 (64.5%), 8 (25.8%), and 3 (9.7%) patients, respectively. Ultrasound signs of acute cholecystitis were present in 27 patients (87.1%). In terms of laboratory values, white blood cell counts >10 × 10⁹/L occurred in 17 patients (54.8%), and C-reactive protein levels >40 mg/L were reported in 21 patients (67.7%). The conversion rate to open surgery was 32.3% (10 patients). In 13 cases, acalculous cholecystitis was present (41.9%). The average serum creatinine level 1 year after cholecystectomy had no statistically significant differences. One patient required temporary dialysis during the postoperative period (with subsequent graft recovery), and 1 graft was lost.
Acute cholecystitis in kidney transplant recipients is a serious complication, with frequent difficulties related to evaluation and diagnosis. Because clinical signs could be very mild compared with severity of gallbladder affliction, there is little room if any for conservative treatment in these patients. We have not noticed adverse impact of acute cholecystitis on 1-year graft function.
Evaluation of Patients' Chronic Kidney Disease for Kidney Transplantation
2015, Chronic Renal Disease
There are nearly 450,000 chronic dialysis patients in United States, a number which is growing at a rate of approximately 5% annually. The number of patients undergoing a kidney transplant evaluation is growing at a corresponding rate, so an ordered approach to the evaluation is becoming increasingly important. The purposes of the kidney transplant evaluation are to identify suitable candidates who are most likely to benefit from an allograft, to optimize the preoperative health status of such candidates, and to exclude individuals who may be at undue risk of poor patient or graft survival. The transplant evaluation is an important process not only for the individual, but also for society, which must appropriately utilize scarce organ resources. The evaluation entails comprehensive medical, surgical, social, and psychological assessments by a multidisciplinary team of health professionals.
Cholelithiasis in patients on the kidney transplant waiting list
2010, Clinics
To evaluate the prevalence of cholecystopathy in chronic renal patients awaiting kidney transplants.
The prevalence and management of cholelithiasis in renal transplant patients is not well established.
A total of 342 chronic renal failure patients on the waiting list for a kidney transplant were studied. Patients were evaluated for the presence of cholelithiasis and related symptoms, previous cholecystectomies and other abdominal surgeries, time on dialysis, and general data (gender, age, number of pregnancies, and body mass index).
Cholelithiasis was found in 41 out of 342 patients (12%). Twelve of these patients, all symptomatic, had previously undergone cholecystectomies. Five out of 29 patients who had not undergone surgery were symptomatic. Overall, 17 patients (41.5%) were symptomatic. Their mean age was 54 (range 32–74) years old; 61% were female, and their mean body mass index was 25.4. Nineteen (76%) out of 25 women had previously been pregnant, with an average of 3.6 pregnancies per woman.
The frequency of cholelithiasis was similar to that reported in the literature for the general population. However, the high frequency of symptomatic patients points toward an indication of routine pre-transplant cholecystectomy to avoid serious post-transplant complications.

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¹: Supported by a grant from the Samuel J. Roessler Research Foundation of the School of Medicine of the Ohio State University.

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Scientific PapersProphylactic Cholecystectomy Is Not Indicated following Renal Transplantation 1

Abstract

Section snippets

Methods

Results

Comments

Am J Surg

Gastroenterology

Am J Surg

The incidence of gallstones and their correlation with other diseases

Ann Surg

Prevalence of gallstones in a Danish population

Am J Epidemiol

The natural history of diagnosed gallstone disease in symptomatic and asymptomatic patients

Ann Surg

The natural history of silent gallstones

NEJM

Gallbladder and extrahepatic biliary system

Cholecystitis and diabetes mellitus

NEJM

Scientific Papers
Prophylactic Cholecystectomy Is Not Indicated following Renal Transplantation ¹