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Saudi Journal of Kidney Diseases and Transplantation
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Year : 1996  |  Volume : 7  |  Issue : 2  |  Page : 149-152
Experience with Renal Transplantation in the Eastern Province of Saudi Arabia


Department of Urology and Nephrology, King Fahd Military Medical Complex, Dhahran, Saudi Arabia

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   Abstract 

We evaluated our experience with renal transplantation to determine its safety and efficacy. Of the 47 renal transplants performed at our institution from June 1992 to December 1995, 29 were performed from living related donors and 18 from cadaveric donors. The age of the patients ranged from 17 to 65 years with a mean age of 32.2 years. Patient survival, allograft survival and the incidence of complications were used as determinants of successful outcome. Patient survival was 100% for both groups. The allograft survival was 100% for living related donor recipients, with 90% of the cases having normal graft function and 96% for cadaveric recipients with 78% of the cases having normal graft function after a mean follow-up of 24 months (range 3 to 42 months). The incidence of complications encountered was similar to that reported from European and North American renal transplant centers. Our study shows the safety and efficacy of the renal transplantation program in the Eastern Province of Saudi Arabia.

Keywords: Renal transplantation, Saudi Arabia.

How to cite this article:
Al-Dayel A, Ezzibdeh M, Daoud M, Egail S, Guella A, Al-Oraifi I, El-Sayed E, Zallat AA. Experience with Renal Transplantation in the Eastern Province of Saudi Arabia. Saudi J Kidney Dis Transpl 1996;7:149-52

How to cite this URL:
Al-Dayel A, Ezzibdeh M, Daoud M, Egail S, Guella A, Al-Oraifi I, El-Sayed E, Zallat AA. Experience with Renal Transplantation in the Eastern Province of Saudi Arabia. Saudi J Kidney Dis Transpl [serial online] 1996 [cited 2020 Apr 6];7:149-52. Available from: http://www.sjkdt.org/text.asp?1996/7/2/149/39517

   Introduction Top


The population of the Eastern Province of Saudi Arabia is approximately 1.5 million.

A total of 420 - patients are on hemodialysis distributed among nine centers in this pro­vince. New patients (between 70 to 80) are being added every year to the dialysis pool which indicates a steady increase in the number of patients waiting for renal trans­plantation. Before the start of a renal trans­plant program in this province, patients had to be transplanted either in Riyadh or abroad and follow-up for such patients was difficult.


   Materials and Methods Top


Between June 1992 and December 1995, 47 renal transplantations were performed at our center, 29 from living related donors and 18 from cadaveric donors. The age of the recipients ranged from 17 to 65 years (mean 32.2 years); there were 24 males and 23 females. Of these 47 patients, 45 had received hemodialysis and two had not yet required dialysis, prior to transplantation. The duration on dialysis of these patients was 3 to 132 months (mean 27 months). The etiology of renal failure was chronic glomerulonephritis in 17, interstitial nephritis in two, hereditary nephritis in one and was unknown in 27 patients [Table - 1]. A total of 25 patients were viral hepatitis B and C negative, three were positive for hepatitis B surface antigen (HBsAg), 18 positive for hepatitis C virus (HCV) antibodies and one patient was HbsAg and anti-HCV positive.

All the patients were evaluated by a team comprising of a nephrologist, urologist and a psychiatrist prior to transplantation. Patients transplanted with living related donor kidneys received donor specific transfusions (except when donor and recipients were HLA identical) while patients recei­ving cadaver donor kidneys received third party transfusions. Living related donors were evaluated by a thorough medical history (donors with history of hypertension or diabetes mellitus were excluded), physical examination, complete laboratory analysis (complete blood count, coagulation profile, serum chemistry profile and creatinine clearance) and selective renal angiography. The donors were admitted to the hospital the evening before scheduled donor nephre­ctomy at which time the final cross-match was performed and intravenous hydration instituted. Cadaveric donor management was organized according to standard protocol.

Intra-operatively, all recipients were given a bolus of 250 mg of intravenous (i.v.) methyl prednisolone and i.v. cyclosporin (4 mg/kg body weight). Post-operatively, patients were placed on anti-lymphocytic globulin (4 mg/ kg/day), given for 14 days for cadaveric donor recipients, 10 days for HLA haplo-identical donors and seven days for HLA identical donors. Prednisolone was given in a tapered dose schedule to reach 25 mg/day on day-eight post-transplantation. Oral cyclosporin was started on the second post-transplant day in a dose of 8 mg/kg/ day administered in two divided doses. Azathioprine was started on the fifteenth post-transplant day in a dose not exceeding 100 mg/day. Acute rejection was diagnosed by elevation of serum creatinine, presence of fever and graft tenderness, and/or based on renal scan findings. Methyl prednisolone was administered as an i.v. infusion in a dose of 10 mg/kg body weight for three successive days as the initial treatment for acute rejection. Steroid resistant rejection, confirmed by a percutaneous biopsy, was treated with the monoclonal antibody OKT3 administered for 10 days.


   Results Top


All patients were alive at the time of reporting and all but one had a functional renal allograft. One cadaveric graft failed four days after transplantation due to throm­bosis of the graft renal artery. Analysis of the 29 living related donor kidney recipients revealed that 28 had grafts with normal function (serum creatinine less than 135 µmol/L), while one had serum creatinine greater than 180 µmol/L after a mean follow­up of 24 months (range 3 to 42 months). Of the 18 recipients of cadaver kidneys, 11 had normal graft function, three had serum creatinine between 135-150 µmol/L and three others had serum creatinine more than 180 µmol/L after a mean follow-up of 20 months (range 13 to 37 months) [Table - 2].

Eleven of the study patients (four living related and seven cadaveric donors) had one episode of acute rejection each, and were treated with methyl prednisolone. One living related transplant recipient had a steroid-resistant rejection which was treated successfully with OKT3 administered for 10 days. Twenty eight of the 29 patients receiving allografts from living related donors had immediate graft function while one patient needed eight sessions of hemo­dialysis before recovering graft function. Of the 18 patients receiving cadaveric renal allografts, 11 had immediate renal function and seven required two to five sessions of hemodialysis before recovering graft function.

Eleven patients (23%) had reactivation of CMV infection and all were positive for IgG before renal transplantation. This reactivation was diagnosed based on clinical and laboratory parameters ' (elevation of liver enzymes and serum creatinine, leucopenia and/or thrombocytopenia) and confirmed by elevated titers of IgM. All were treated with ganciclovir, the dose of which was adjusted to the creatinine clearance, for two to three weeks. One patient had herpes zoster infection and one other, herpes simplex. Four patients developed steroid-induced diabetes mellitus after renal transplantation and all four were well controlled with oral hypoglycemic drugs.

Three patients (two living related and one cadaveric) developed hemolytic uremic syndrome (HUS), most probably induced by cyclosporin A. This drug was disconti­nued, all patients were given fresh frozen plasma and one patient in addition, received six sessions of plasmapheresis. Cyclosporin A was subsequently re-started in all three patients without recurrence of HUS. One patient developed Kaposi's sarcoma of the palate without any visceral involvement. Azathioprine was discontinued and the patient was maintained on steroids and cyclosporin A.

Surgical complications were seen in seven patients (14%). Four had urinary leak, one each had peri-renal pyogenic collection, pelvic hematoma and lymphocele. All were managed successfully. One patient had bladder-neck obstruction requiring incision.


   Discussion Top


The average number of renal transplant­ations performed in our hospital thus far, is 14 per year. The urological complications seen in our series were comparable to publi­shed reports and all kidneys were saved due to immediate and careful management. It is difficult from this small series to draw conclusions regarding the role of HLA matching and the incidence of post-trans­plant viral infection but, we noticed that there was a higher rate of hemolytic uremic syndrome. No deaths were recorded among our patients and the graft survival for living related (100%) and cadaveric donors (94%) are similar to that reported for European and North American renal transplant centers.

Although these results are encouraging, severe shortage of organs remains a major unsolved problem plaugeing further growth in the number of transplants. About 70-80 new patients are being added each year to the transplant waiting list. Despite great efforts to increase the availability of cada­veric organs under the present procurement system, the waiting list of potential reci­pients continues to grow. We believe that the present procurement system, which is based on voluntary donation, can procure many more organs if public education programs are made more intensive. Also, more efforts should be made by the medical staff to encourage kidney transplantation from living related donors.

In conclusion, the early results of our study support the safety and efficacy of renal transplantation in our institution.[9]

 
   References Top

1.Dunn J, Golden D, Van Buren CT, Lewis RM, Lawen J, Kahan BD. Causes of graft loss beyond two years in the cyclosporine era. Transplantation 1990;49:349-53.  Back to cited text no. 1    
2.Smith AY, Van Buren CT, Lewis RM, Kerman RH, Kahan BD. Factors determining renal transplant outcome at the University of Texas at Houston. Clin Transpl 1987;155-66.   Back to cited text no. 2    
3.Renal transplantation: access and outcomes. Am J Kidney Dis 1991;18(2):61-73.   Back to cited text no. 3    
4.Benedetti E, Matas AJ, Hakim N, et al. Renal transplantation for patients 60 years of older. A single institution experience. Ann Surg 1994;220(4):445-58.  Back to cited text no. 4    
5.Fietze B, Prosch S, Reinke P, et al. Cytomegalovirus infection in transplant recipients. The role of tumor necrosis factor. Transplantation 1994,58(6):675-80.   Back to cited text no. 5    
6.Nelson SR, Snowden SA, Sutherland S, Smith HM, Parsons V, Bewick M. Outcome of renal transplantation in hepatitis BsAg-positive patient. Nephrol Dial Transplant 1994;9(9): 1320-3.  Back to cited text no. 6    
7.Randall T. Too few human organs for transplantation, too many in need. and the gap widens. JAMA 1991;265:1223-7.   Back to cited text no. 7    
8.Mundy AR, Podesla ML, Bewick M, et al. The Urological complications of 1000 renal transplantations. Br J Urol 1981;13:391-402.   Back to cited text no. 8    
9.Waltzer WC, Frischer Z, Shabtai M, et al. Early aggressive management for the prevention of renal allograft loss and patients mortality following major urologic complications. Clin Transplantation 1992;6:318-22.  Back to cited text no. 9    

Top
Correspondence Address:
Adel Al-Dayel
Consultant Urologist and Transplant Surgeon, King Fahd Military Medical Complex, P.O. Box 946, Dhahran 31922
Saudi Arabia
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PMID: 18417930

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