| Abstract|| |
Patients from the North-West area of Saudi Arabia had to travel to Riyadh or Jeddah for renal transplantation and post-transplant follow-up. The administration of the North-West Armed Forces Hospitals Program provided medical expertise and financial support to set up a renal transplant program in this area. Suitable staff members including nephrologists, transplant surgeons, staff nurses social workers and laboratory personnel were recruited. A strong link was established with the Saudi Canter for Organ Transplantation in Riyadh. At the end of two years since establishment, 25 renal transplants (11 cadaver donor and 14 living donor) have been performed. During follow-up, nine patients developed serious infection including pneumonia, wound infection and tuberculosis; all were managed successfully. Three grafts were lost necessitating graft nephrectomy and there were four deaths. The two-year graft survival is 83.3% and patient survival, 84%. These results are highly satisfactory taking into consideration the fact that our transplant program is new.
Keywords: Renal transplantation, Saudi Arabia.
|How to cite this article:|
Mansy H, Al-Shareef Z, Shlash S, Filobbos P, Al-Dusari S, Ghasib S. Initiating a New Renal Transplant Program: Problems and Results. Saudi J Kidney Dis Transpl 1996;7:145-8
|How to cite this URL:|
Mansy H, Al-Shareef Z, Shlash S, Filobbos P, Al-Dusari S, Ghasib S. Initiating a New Renal Transplant Program: Problems and Results. Saudi J Kidney Dis Transpl [serial online] 1996 [cited 2020 Sep 22];7:145-8. Available from: http://www.sjkdt.org/text.asp?1996/7/2/145/39516
| Background|| |
It is generally accepted that renal transplantation (RTx) is the best form of renal replacement therapy for patients with endstage renal failure (ESRF) . There was a real need to establish a renal transplant unit in the North-West area of Saudi Arabia and provide a convenient arrangement for patients and relatives alike. This new facility would reduce the need for patients from this region to travel to Riyadh or Jeddah for RTx as well as post-transplant follow-up. This was not only inconvenient but also expensive, in terms of travel costs and time off-work, Establishing a renal transplant program in this region was all the more important considering that there were more than 85 patients on dialysis in Tabuk alone, The administration of the North-West Armed Forces Hospitals (NWAFH) Program took up the issue of providing this service to the military and civilian population of the North-West area of Saudi Arabia. The program provided medical expertise and financial support to undertake such a commitment
| The Foundation Needed to Start a Renal Transplant Program|| |
A senior nephrologist with experience in renal transplantation was chosen to be the driving force behind the program. His initial responsibility was to lay the foundation starting with a program of rehabilitation for patients on dialysis in the North-West Armed Forces Hospital and assess their fitness and suitability for RTx. Attention was also given towards improving the compliance of patients not only with medication, but also with regular attendance to the dialysis unit and with fluid and dietary restrictions, with the support offered by an experienced dietitian  . The nephrologist would also assess the patients medically while completing their detailed renal transplant evaluation  , and help in establishing a strong link with the Saudi Center for Organ Transplantation (SCOT)  . It was very important to consolidate and improve patient-doctor relationship and confidence in the hospital expertise as a whole.
Great importance was accorded to social support with special attention being paid to socio-economic and marital problems as well as sexual difficulties of the patients with ESRF. An experienced social worker was appointed to talk to the patients and render appropriate help. Also, psychological support was provided for patients on dialysis with the help of an Arabic-speaking psychiatrist, since a fair number of these patients suffer from depression  .
The availability of recombinant human erythropoietin helped in reducing the need for blood transfusions in patients, with its attendant risks including the risk of developing cytotoxic antibodies  .
Recruitment of an Experienced Transplant Surgeon
The difficulties in recruiting a trained renal transplant surgeon were recognized. The possibility of flying qualified surgical staff in and out of Tabuk was not considered ideal and would hardly be expected to be effective in the long-term. To ensure a continuing successful RTx program, having a Saudi surgeon was considered the best option. Fortunately, two well trained consultant surgeons in our institution expressed their keenness to be involved in renal transplant surgery. Initially, a transplant surgeon from Ireland was recruited to provide support to our surgeons who had limited prior exposure to transplant surgery. Since then, these two surgeons have proved to be an asset to the program.
A Program of Education
One of the problems facing the renal transplant program was lack of trained nurses with transplant experience. An intensive education program was provided to a selected number of nurses who were keen to be involved with the program. Regular lectures were organized. Also, an intensive course was provided to the ICU nursing staff to facilitate identification and management of suitable brain-dead patients. The doctor in-charge of the ICU provided adequate medical support to such patients until organ retrieval could be performed.
The local brain-death committee, consisting of an intensivist, nephrologist, neurologist and neurosurgeon have regular meetings in order to consolidate the efforts, both locally in our hospital and in the civilian hospital which accommodates a major ICU department. The committee members provide help in the diagnosis and management of braindeath.
A team, comprising of a transplant coordinator and a religious scholar was created to promote communication with the other hospitals in the area and also help, in coordination with SCOT, to obtain consent for organ donation from relatives of the brain-dead patients. However, great difficulty was faced in the Tabuk area initially in obtaining consent because of lack of public awareness and education. Although a fair number of brain-death cases were reported from our center to SCOT, the number of successful consents for organ donation has been unfortunately disappointing.
An education program was started for the patients, before and after RTx, with emphasis on compliance to medication, clinic attendance, fluid intake, diet, personal hygiene and reporting any side-effects of the medications used.
Tissue Typing Laboratory
It took us some time to establish a tissue typing laboratory. In the first eight months, we had to rely on the laboratory at the Riyadh Armed Forces Hospital for providing tissue typing results, as well as cytotoxic antibody titers. Although, not having this facility in our center caused some difficulty, it did not prove to be a major impediment to launch a transplant program.
Other Support Services
The departments of biochemistry and microbiology are well established in our hospital providing very high standards of service. All the various tests including cyclosporin levels, virus studies and detailed biochemical tests are available locally. The NWAFH Program has allocated the financial support needed to have available all the various immunosuppressive drugs including anti-thymocyte globulin (ATG) , and monoclonal antibodies (0KT3) , .
We are fortunate to have a state-of-the-art radiology department with a full complement of facilities including computerized axial tomography (CAT) scan, magnetic resonance imaging (MRI) and isotope scanning. This department is fully equipped with all the necessary imaging techniques needed for a renal transplant program.
| Two-Year Follow-up Results of the New Renal Transplant Program|| |
Twenty five patients have undergone RTx (11 cadaveric and 14 living related donor) in our institution till the end of 1994. Their mean age was 35.4 + 1.6 (range 29-62 years); there were 10 females and 15 males.
A total of 18 patients were followed-up for 15.9 ± 1.7 months (range 3-24 months), from November 1992 to November 1994. They were on hemodialysis for 23.9 + 2.7 months before being transplanted. The cause of renal failure was unknown in 15 of these patients, while in one patient each, ESRF was due to chronic glomerulonephritis, chronic pyelonephritis and hypertensive nephrosclerosis.
Following transplantation, 11 patients had hypertension. During follow-up, nine patients developed serious infection requiring hospitalization. Three patients had pneumonia, two patients each had wound infection with abscess formation, and septicemia secondary to ureteric obstruction and one patient each had infected urinary fistula, and pulmonary tuberculosis. All were managed successfully. Nine others had reactivation of CMV infection, caused by anti-rejection treatment. All were managed successfully with supportive treatment , . Three grafts were lost necessitating graft nephrectomy, one each due to accelerated rejection, renal artery stenosis causing significant renal function deterioration and renal artery thrombosis.
The mean number of rejection episodes was relatively low, 1.11 + 0.23 per patient. Consequently, the need for using powerful immunosuppressive drugs like ATG or OK3 was infrequent and was required in only three cases with steroid-resistant rejection. This low incidence of acute rejection episodes could partly be due to the fact that we insisted on good HLA match between donor and recipient. Mean serum creatinine at the end of follow-up was 152.7 + 16.9 umol/1 and mean blood urea was 8.2 + 0.97 mmol/1.
There were four deaths. One patient each died of massive pulmonary embolism, postoperative hemorrhage, graft rupture and hemorrhage, and Staphylococcus aureus septicemia and brain abscess.
The two-year graft survival was 83.3% and patient survival was 84%, results that are comparable with the best from Western European centers , . Considering the fact that ours is a new transplant program and there is a learning curve before consolidating the transplant clinical experience, these results are encouraging.
| Current Problems Facing the Program|| |
Despite constant efforts made by our program as well as by the Ministry of Health, public awareness for organ donation is relatively limited. Thus, intensive education is required in this area. We had a limited success in obtaining consent for organ donation from relatives, although we were able to provide the medical expertise for optimal management of brain-death cases. In this regard, we acknowledge the constant support rendered by SCOT to our program over the past two years.
Unfortunately, the number of cases being referred for living related renal transplantation from the local hospitals in the North-West area has been extremely limited. Taking into account the present hospital resources and the available medical expertise, we feel that we have been underused. We believe that promoting living related renal transplant will continue to be difficult so long as, buying a kidney abroad is easy and cheap  . All efforts are being made to discourage patients from going overseas for commercial renal transplantation, as their results are inferior  and such form of treatment might involve unethical exploitation of the donor  .
| References|| |
|1.||Burton PR, Walls J. Selection-adjusted comparison of life-expectancy of patients on continuous ambulatory peritoneal dialysis, haemodialysis and renal transplantation. Lancet 1987;l:1115-9. |
|2.||Smith MD, Kappell DF, Province MA, et al. Living-related kidney donors : a multicenter study of donor education, socioeconomic adjustment, and rehabilitation. Am J Kidney Dis 1986;8:223-33. |
|3.||Buszta C, Braun WE, Novick AC, Steinmuller DR. Kidney donor evaluation dialysis and transplantation 1982;ll:296-99. |
|4.||The directory of the regulations of organ transplantation in the Kindgom of Saudi Arabia. Saudi J Kidney Dis Transplant 1994;5:37-98. |
|5.||Simmons RG. Long-term reactions of renal recipients and donors. In levy NB (ed) Psychonephrology 2: Psychological problems in kidney failure and their treatment. Plenum, New York 1983; 275. |
|6.||Schaefer RM, Horl WH, Massry SG. Treatment of renal anaemia with recombinant human erythropoietin. Am J Nephrol 1989;9(5):353-62. |
|7.||Terasaki PI, Cats S, Cicciarelli JC, et al. Use of monoclonal antibodies for kidney transplant. Transplant Proc 1985; 17:1521. |
|8.||Thistlethwaite JR, Gaber AO, Haag BW, et al. OKT3 treatment of steroid-resistant renal allograft rejection. Transplantation 1987;43:176-84. |
|9.||Wechter WJ, Brodie JA, Morrell RM, Rafi M,Schultz TR. Antilymphocyte globulin in renal allograft recipients. Transplantation 1990;28:294. |
|10.||Kramer P, Broyer M, Brunner FP, et al. Combined report on regular dialysis and transplantation in Europe, XII, 1982. Proc Eur Dial Transplant Assoc 1982;19:4-8. |
|11.||Terasaki PI, Toyotome A, Mickey MR, et al. Patient, graft and functional survival rates. Clinical Kid Transplant, UCLA Tissue Typing Lab LA 1985:42-48. |
|12.||Hibberd, et al. Infectious disease. Approach to immunization in immunosuppressed host (Review) Clin N Am 1990;4:123-42. |
|13.||Peterson PK, Balfour HH Jr, Marker SC, Fryd DS, Howard RJ, Simmons RL. Cytomegalovirus disease in renal allograft recipients: a prospective study of the clinical features, risk factors and impact on renal transplantation. Medicine-Baltimore 1980;59:283-300. |
|14.||Daar AS, Salahudeen AK, Pingle A, Woods HF. Ethics and commerce in live donor renal transplantation: classification of the issues. Transplant Proc 1990;22(3):922-4. |
|15.||Salahudeen AK, Woods HF, Pingle A, et al. High mortality among recipients of bought living-unrelated donor kidneys. Lancet 1990;336 (8717):725-8. |
|16.||Mani MK. Kidney transplantation from unrelated living donors (Letter) N Eng J Med 1986;315:714-16. |
Consultant Nephrologist, North West Armed Forces Hospitals Programme, Tabuk