| Abstract|| |
We reviewed the records of the renal transplant patients followed at our hospital to determine short-term outcome and complications. Sixty-five renal transplant patients, followup for two years were included in this study. Of these patients 40 (61.5%) were males, 33 (50.7%) were Saudis with mean age of 37.2 ± 11.7 years. Donors were living related (LRD) in 23 (35%), living non-related (LNRD) in 27 (42%) and cadaveric (CAD) in 15 (23%). Thirtytwo transplants were carried out at Medinah, 21 in India and the rest in other centers inside Saudi Arabia. Immunosuppression was based on a triple therapy (Cyclosporin, Azathioprine, and Prednisone). At two years, 52 (80%) patients were alive, with functioning graft in 31 (58%). Causes of death among 13 patients (11 LNRD & 2 CAD) were infections in 7 (54%), immediate post transplant in three (22.7%), acute myocardial infarction in two (15.7%), CVA in one (7.6%). Complications encountered were acute rejection (23 episodes) in 18 923.6%) patients, infections in 19 (25%), chronic rejection in 16 (21.5%), surgical in 13 917.1%), diabetes mellitus in 5 (6.5%) primary non-function in three (3.8%) and Kaposi Sarcoma in two (2.4%). Twenty-six (81.25%) out of 32 transplants performed in Madinah were functioning, four (12.5%) patients returned to dialysis and two (6.25%) patients died. Among the 21 transplants done in India 11 (52%) patients died, six (28.6%) returned to dialysis, and four (19.4%) had function deteriorated in all patients. We conclude that despite limitations, results of renal transplantation carried out at Madinah are encouraging on short-term basis. Live related transplant has a very good outcome, while commercial transplantation carries poor prognosis.
Keywords: Renal transplantation, Living non-related, Living related, Cadaveric, Short-term outcome.
|How to cite this article:|
Bernieh B, Nezamuddin N, Sirwal IA, Wafa A, Abbade M A, Nasser B, Al Razzaz Z. Short-tem Post Renal Trasplant Follow-up at Madinah Al Munawarah. Saudi J Kidney Dis Transpl 1999;10:493-7
|How to cite this URL:|
Bernieh B, Nezamuddin N, Sirwal IA, Wafa A, Abbade M A, Nasser B, Al Razzaz Z. Short-tem Post Renal Trasplant Follow-up at Madinah Al Munawarah. Saudi J Kidney Dis Transpl [serial online] 1999 [cited 2019 Jul 18];10:493-7. Available from: http://www.sjkdt.org/text.asp?1999/10/4/493/37207
| Introduction|| |
Renal transplantation has become a successful modality of treatment for patients with end-stage renal disease (ESRD)  The annual number of ESRD patients accepted for renal replacement therapy by hemodialysis (HD) or peritoneal dialysis (PD) is steadily increasing. Coupled with the shortage of available kidneys for transplantation in Saudi Arabia, many of our ESRD patients went abroad for paid renal transplantation from living non-related donors (LNRD). Renal transplantation program in our center succeeded in the last two years to carry out 32 operations. The aim of this study is to determine the patients and graft survival, complications and factors affecting short-term outcome in patients transplanted inside and outside Saudi Arabia and followed up at our institute.
| Materials and Methods|| |
Sixty-five post-renal transplant patients followed for a period of up to two years from 1996-1998 were included in this retrospective study. Of these patients 40 (61.5%) were males, 33 (50.7%) were Saudis with mean age of 37.2 ± 11.7 years. The mean duration of follow-up was 12 ± 6.5 months (123 months). The original kidney disease in the recipients of these renal transplants was unknown in37 (57%) patients, diabetes mellitus in seven (10.8%), obstructive uropathy in six (9.2%) hereditary polycystic kidney disease in four (6.1%), hypertension in three (4.6%) and analgesic nephropathy in one (1.5%).
Of the 65 renal transplants, 35 were performed at King Fahd hospital in Madinah, Saudi Arabia, 21 in India and remaining nine at different places both inside and outside the kingdom. Donors were living related (LRD) in 23 (35%) transplants, living nonrelated (LNRD) in 27 (42%) and cadaveric (CAD) in 15 (23%).
Immunosuppression was based on triple therapy (cyclosporine, azathioprine, and prednisone). Patients were regularly followed up in the nephrology/transplantation clinic on monthly basis with complete physical examination, hematological, biochemical, and cyclosporine (CSA) level monitoring.
Parameters studied in all patients included: graft and patient survival, various complications (surgical and systemic), graft function at the time of initial discharge and subsequent hospital admissions.
| Statistical Analysis|| |
Statistically analysis were done on the Microsoft Excel 7 program using the chisquare with the Fisher exact test, the KaplanMeier analysis of actuarial patients and graft surviaval, and the Student "t" test. Results are expressed as mean ± standard deviation (SD), statistical significance was set at P <0.05.
| Results|| |
The overall cumulative patient's survival during follow up was 80%. There was death in 13 patients (11 LNRD, 2 CAD). The causes included primarily, infection in seven (54%) patients; two chest infection, two human immunodeficiency virus (HIV), one cytomegalovirus (CMV), one malaria and one septic shock. Immediate post transplantation death of unknown reasons was the cause of death in three (22.7%) patients, who all were transplanted in India, acute myocardial infraction in two (15.7%) and cerebrovascular accident in one (7.6%).
Six of the 13 patients who died had functional graft at the time of death.
Of 52 surviving patients 36 (69%) had functioning graft two years and 16 (31%) returned to dialysis. There were 29 graft losses. Causes of graft loss were death of patients in 13 (44.8%), chronic rejection in 13 (44.8%), primary non-functioning in two (6.9%) and graft artery thrombosis in one (3.5%).
Outcome of different subgroups according to type of donor is shown in [Table - 1]. Of 35 patients transplanted at Madinah (21 LRD + 14 CAD), 33 (84%) were alive at two years with functional grafts in 28 (85%). In comparison, the 30 transplants done at other centers (21 in India), there were 19 patients (64%) alive at two years with functional grafts in seven (23%), (p<0.01, p<0.02 respectively).
Various complications encountered in the studied patients are shown in [Table - 2]. They were acute rejection (23 episodes) in 18 (23.6%) patients, infections in 19 (25%), chronic rejection in 16 (21.5%), surgical in 13 (17.1%), diabetes mellitus in 5 (6.5%) primary non-function in three (3.8%) and Kaposi Sarcoma in two (2.4%).
There were 23 episodes of acute rejection in 18 patients diagnosed clinically and/or by graft biopsy. Most of rejection episodes occurred during mean follow up of 26 ± 24.7 weeks. There were 18 episodes of acute rejection of which 15 (83%) responded to first line steroid pulse therapy. Anti-T cell globulin (ATG) was used as first line anti rejection therapy in four episodes with improved graft function in all. One patients refused anti-rejection treatment.
Of 16 patients with chronic rejection eight returned to dialysis, four are still having reasonable graft function, whereas four patients died.
The infectious complication included, 11 cheat infections, five urinary tract four CMV, two HIV, one hepatitis C virus (HCV) and one malaria.
Five patients developed diabetes mellitus post transplant. One of those recovered after decreasing dose of steroids whereas other four required treatment.
Surgical complications included four wound infections, four urinary leaks, three obstructive uropathies, one lymphocele and one graft artery thrombosis.
Two patients developed Kaposi Sarcoma at four and five months post transplantation respectively (One had only skin lesion and the other had oral and gastrointestinal lesious). Immunosuppression was curtailed in both with good control of sarcoma without deterioration of graft function.
Five pregnancies occurred in four patients, three aborted and two had live habits. Graft dysfunction occurred in all and thee patients are already backs to hemodialysis.
| Discussion|| |
Patients and graft survivals re the main indicators of success of renal transplantation. In this study, we followed three different groups of renal transplant patients from LRD, CAD and LNRD. Among the LRD group, patient survival was 100% and graft survival was 91% at mean follow up of 13 ± 5.4 months. These results are comparable to both national and western reports. , Patient and graft survival at one year has been reported to be 98.5% and 89.7% at National Guard Hospital and 99% and 96% at King Faisal Specialist Hospital (KFSH), Riyadh, respectively. , The renal transplant registry of United Network for Organ Sharing reported a one-year graft survival of 95.7% and patient survival of 97.5. In our study, the two grafts lost in this group were carried out in high risk diabetic patients having advanced atherosclerosis.
The patient and graft survival for CAD transplants was 87% and 61.5% respectively. Huraib et al reported patient survival of 96% and graft survival of 81% among CAD transplant.  Similar results were reported from KFSH.  Many factors influenced relative poor outcome among our CAD transplants such as small number of cases, poor maintenance of cadaveric donors, dependence only on tissue negative cross-match before operation and frequent early non-functioning graft. Different authors have reported the beneficial effect of HLA matching , and adverse effect of early non-functioning graft. 
All LNRD transplants were carried out in India. The patient and graft survival was 59% and 43.7% respectively. These results are very poor compared to LRD and CAD transplants. Poor outcome of LNRD transplants among our patients, also observed by other authors, , are related to many factors such as commercial transplantation carried out illegally in poor conditions, many transplants had been carried out among poor high-risk recipients and against the advice of treating nephrological, many patients had minimal pre-transplantation work-up, early discharge from hospital in spite of complications due to various reasons and frequent fatal infections (particularly) HIV, acquired from blood and donated grafts). Although LNRD transplantation is a controversial subject, some authors have similar observations like ours, ,, whereas others claim good results when compared to CAD transplantation. ,
Acute and chronic rejection was the commonest cause of graft loss among surviving transplant patients, this is similar to results reported by other authors. , Infection contributed to morbidity and mortality among transplant patients. Two of our patients contracted HIV and one had malaria resulting in their demise. Infections were more common in LNRD transplants compared to the two groups. Kaposi sarcoma has been reported to be a common malignancy in transplanted patients in Saudi Arabia  and this was confirmed by our results. One observation of interest was development of Kaposi sarcoma too early in two of our patients (4 and 5 months post transplant). Diabetes mellitus developed in five (7.7%) patients post transplant. Variable figures (4.7%, 9.2% and 14.9%) have been reported by authors from other centers in the Kingdom. ,, Pregnancy in early transplant period affects grafts and fetus adversely as observed by us and others.
We conclude that despite limitations, results of renal transplantation carried out a Madinah are encouraging on short-term basis. Live related transplant has a very good outcome, while commercial transplantation carries poor prognosis with increased likelihood of contracting fatal infections. Major causes of grafts loss were chronic rejection and death of patients.
| Acknowledgement|| |
We greatly appreciate the contribution of Dr. Jacob M.V. Mooji in producing the survival percentages of this study. And we would like to thank Mrs. Elena Canabe for her excellent secretarial assistance in preparation of this manuscript.
| 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;1:1115-9. |
|2.||Huraib S, Al Khudair W, Saleem H, et al. Renal transplant experience at King Fahad National Guard Hospital. Saudi J Kidney Dis Transplant 1996;7(2):157-63. |
|3.||Lundgren G, Alfurayh O, Akhtar M, et al. Kidney transplant at King Faisal Specialist Hospital and Research Centre. Ann Saudi Med 1994;14(1):5-11. |
|4.||Cecka JM, Terasaki PI. The UNOS Scientific Renal Transplant Registry. United Network for Organ Sharing. Clin Transpl 1994;1-18. |
|5.||Terasaki PI, Cecka JM, Cho Y, Takemoto s, Mickey MR. A report from the UNOS Scientific Renal Transplant Registry. Transplant Proc 1991;23:53-4. [PUBMED] |
|6.||Opelz G. HLA matching should be utilized for improving kidney transplant success rates. Transplant Proc 1991;23:46-50. [PUBMED] |
|7.||Bauma WD, Tang IY, Maddux MS, et al. Delayed graft function following cadaver renal transplantation in the cyclosporine era: analysis of acute rejection and graft survival. Transplant Proc 1989;21:1276-7. [PUBMED] |
|8.||The living non-related renal transplant study group. Physicians attitudes toward living non-related renal transplantation (LNRRT). Clin Transplant 1993;7:289-95. [PUBMED] |
|9.||salahudeen AK, Woods HF, Pingle A, et al. High mortality among recipients of bought living unrelated donor kidneys. Lanent 1990;336:725-8. |
|10.||Abu-Romeh SH, Osman N, Rashid A. Living non-related kidney transplantation in Bombay (letter). Lancet 1990;336:1584. |
|11.||Mani MK. Letter to the editor. N Engl J Med 1986;315:716. |
|12.||Sumrani N, Delaney V, Hong JH, Daskalakis P, Sommer BG. Renal transplantation from distant relatives. Transplant Proc 1991;23(5):2570-1. |
|13.||Al-Khader AA, Al-Sulaiman M. Dhar JM. Living non-related kidney transplantation in Bombay (letter). Lancet 1990;335:1002. |
|14.||Qunibi W, Akhtar M, Sheth K, et al. Kaposi's sarcoma: the most common tumor after renal transplantation in Saudi Arabia. Am J Med 1988;84(2):225-32. |
|15.||Basri N, Aman H, Adiku W, Baragdar A, Bonatero I, Nizamuddin N. Diabetes mellitus after renal transplantation. Transplant Proc 1992;24(5):1780-1. |
|16.||Salmela K, Kyllonen L, Hommberg C, et al. Impaired renal function after pregnancy in renal transplant recipients. Transplant Proc 1993;25:1302. |
Department of Nephrology, King Fahad Hospital, Madinah Al Munawarah
[Table - 1], [Table - 2]