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Saudi Journal of Kidney Diseases and Transplantation
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RENAL DATA FROM THE ARAB WORLD Table of Contents   
Year : 1999  |  Volume : 10  |  Issue : 4  |  Page : 526-530
Experience with Renal Transplantation at Al-Mouassat University Hospital, Damascus


1 Department of General Surgery, Renal Transplantation Unit, Al-Mouassat University Hospital, Damascus, Syria
2 Department of Nephrology, Renal Transplantation Unit, Al-Mouassat University Hospital, Damascus, Syria

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   Abstract 

Between October 1985 and the end of 1998, 259 renal transplantations were performed at Al-Mouassat University Hospital in Damascus, from living related donors (LRD). The age of the patients ranged from 14 to 57 years with a mean age of 31.1 years. There were 208 (80.3%) males and 51 (19.7%) females. The follow-up ranged from 1-159 months. The immunosupression therapy was azathioprine and prednisone in 71 patients, and cyclosporine, azathioprine and prednisone in 188 patients. The one, three and five year graft survival was 98.2%, 92.1% and 85.8% respectively. The one, three and five year patient survival was 99%, 97.2% and 90.1% respectively. The ten years overall patient survival was 70.2%. The incidence of complications encountered was acceptable and similar to that reported in the literature. Our study shows that the efficacy of the overall results in our center is comparable to that published in the western world.

Keywords: Renal transplantation, Living donors, Al-Mouassat Damascus University Hospital.

How to cite this article:
Al-Habash MM, Al-Shaer MB, Othman MI, Sabbag A, Ojeilie I. Experience with Renal Transplantation at Al-Mouassat University Hospital, Damascus. Saudi J Kidney Dis Transpl 1999;10:526-30

How to cite this URL:
Al-Habash MM, Al-Shaer MB, Othman MI, Sabbag A, Ojeilie I. Experience with Renal Transplantation at Al-Mouassat University Hospital, Damascus. Saudi J Kidney Dis Transpl [serial online] 1999 [cited 2020 Jun 2];10:526-30. Available from: http://www.sjkdt.org/text.asp?1999/10/4/526/37216

   Introduction Top


The first renal transplantation in Syria was performed in 1978. There are only two renal transplant centers in Syria and both are in Damascus. All renal transplantations in Syria have been performed from living related donors (LRD). There is no cadaver renal transplant program and living unrelated renal transplantation is prohibited. [1]

The renal transplant program at Al­Mouassat University Hospital started in October 1985. Since then, 259 patients have undergone renal transplantation.

This report describes the overall results of living related renal transplantation in Damascus University Hospital.


   Materials and Methods Top


From October 1985 up to the end of 1998, 259 renal transplants were performed at our center. They were all from LRD donors. There were 208 (80%) male and 51 (19.7%) female recipients. The age of recipients ranged from 14 to 57 years with a mean age of 31.1 years. All the patients were hepatitis B and C negative and no donor specific transfusion (DST) was given to the patients. The donors were evaluated by a thorough medical history, physical examination, complete laboratory analysis and selective renal angiography.

Most of the kidney donors (58%) were brother and sister followed by mother in 25.9%, while second degree related donors and spouses accounted for only 4.2%. Tissue matching between donors and recipients were HLA haplo-identical in 207 (79.9%) patients, and HLA-identical in 52 (20.1%) patients.

The number of transplants varied from year to year (mean 19.5 per year), with a significant increase in the last three years (39.4% of the total) [Figure - 1]. The follow up period ranged between (1-159) months.

Immunosuppression

Two immunosuppressive protocols were used. The first (azathioprine and prednisone) was used from the start of the program up to October 1989. In this group (71 patients), azathioprine was given two days before the operation in a dose of 4 mg/kg orally and reduced to 2 mg/kg intra-venously on the first post-operation day and thereafter continued orally. The daily dose of azathioprine was modified according to the white cell count. Prednisone was started one day before operation at a dose of 100 mg and at a dose of 500-1000 mg on the operation day. The prednisone dose was 2 mg/kg post-operatively and tapered by 10 mg every other day until reaching 30 mg per day. Then reduced 5 mg every five days until we reach the dose 10-15 mg per day.

Since October 1989, the protocol consisted of triple drug therapy in the form of Cyclosporin, Azathioprine and Prednisone. For this group (188 patients) cyclosporine in a dose of 10 mg/kg orally used to be started in the pre-operative day and continued post-operatively and tapered to 5-7 mg/kg after 15 days. Thereafter, it was adjusted according to the cyclosporine trough level. Azathioprine was given in a dose of 1-2 mg/kg on the operative day and thereafter in a maintenance dose of 1-1.5 mg/kg/day. Prednisone was started by a dose of 500-1000 mg on the operative day, reduced to 1.5 mg/kg post operatively and tapered by 10 mg every day until the maintenance dose of 10-15 mg per day was reached.

For acute rejection episodes methyl­prednisolone pulse therapy (500-1000 mg) was given intravenously for three days. We have never used ALG or ATG. OKT3 was used only in two cases of acute vascular rejection successfully.

Surgical Techniques

Based on selective renal angiography, donor's left kidney was used in 214 (82.6%) patients, while the right kidney was used in 51 (19.7%). In all the patients, we performed an end to side venous anastomosis between renal vein and iliac vein.

An end to end anastomosis of the renal artery to the hypogastric artery was used in 247 (95.3%) patients and an end to side anastomosis of the renal artery to the external iliac artery in 12 (4.7%) patients. Ten donor kidneys had two renal arteries and one had three renal arteries. In the last three transplants we have used a vascular clipping system (Auto Suture Co. Norwalk, and CT) for arterial and venous renal anastomosis. [2] Ureteroneocystomy of Politano-Leadbetter was performed in 158 patients until January 1996. Thereafter, an extravesical anastomosis of Lich-Gregoir has been done in 101 patients and the ureter was stented with a polyurethane ureteric double "J" stents. A Foly's catheter inserted at time of operation used to be removed 48­72 hours after transplantation.


   Results Top


Patient and Graft Survival

The overall patient survival at one, three and five years was 99%, 97.2% and 90.1% respectively, while the graft survival for all transplants at one, three and five years was 98.2%, 92.1% and 85.8% respectively [Figure 2]. A total of 51 patients died yielding a 10-years overall patient survival of 70.2%. In our study, cardiovascular disease was the cause of death in 25 (49%) patients, followed by infection in 15 (29.4%) and malignancy in 8 (15.7%), [Table - 1].

Chronic rejection remains the most common cause of graft loss accounting for 35 (13.5%) patients.

Acute Rejection

There were 88 (34%) episodes of acute rejection diagnosed clinically and/or by graft biopsy. The immunosuppressive protocol used in our patients had a significant role on the number of rejection episodes. In the first group of patients who used azathioprine and prednisone, there were 38 (53.5%) episodes of acute rejection, compared to 50 episodes (29.3%) of acute rejection in those who used cyclosporine, azathioprine and prednisone.

Surgical Complications

There were 40 surgical and urological complications encountered in our patients [Table - 2]. There were 16 urinary leaks prior to 1996. Only two urinary leak episodes have been seen since extravesical anastomosis and insertion of a polyurethan ureteric double "J" catheters were adopted. We had a loss of one graft due to urinary leak. The episodes of peri­renal hematomas, Lymphocele, urinary leaks and twisted ureters were corrected surgically. One graft with renal vein thrombosis was saved with urgent reoperation.

Medical Complications

There were 130 patients with medical complications. The most common medical complication was infection which was encountered in 47 (36%) patients, followed by post transplant hypertension in 41 (31.5%) patients, diabetes mellitus in 15 (11.5%) patients, myocardial infarction in 10 (7.7%) and malignancy in 9 (6.9%) upper gastrointestinal bleeding in four (3%), cerebrovascular accident in two (1.5%), pericarditis in one (0.75%) and acute pancreatitis in one (0.75%).


   Discussion Top


Graft and patients survival rates in our program are comparable to that reported by European and North American renal transplant centers.[3],[4]

The incidence of acute rejection decreased significantly after using of cyclosporine in the immunosuppressive regimen.

The adoption of a new uretero-vesical anastomotic surgical technique has decreased significantly the incidence of the urinary leaks, similar to the experience by others.[5],[6]

The rate of malignancy in our series was 3.5%, which was similar to that reported in the literature if the malignancies of the skin were excluded. [7] Furthermore; we have noted like others an increased frequency of Kaposi Sarcomas. [8]

Our patients had an increase in digestive malignancies: two digestive lymphoma (one ileal and one rectal non-Hodgkin's lymphoma), one hepatocellular carcinoma and one esophageal carcinoma. The digestive malignancies in our study composed 55% of the total malignancies encountered in our patients as compared to 20% reported in the literature. [9]

In conclusion the success and improvement of LRD renal transplantation in our hospital was multifactorial, which met the need of patients to have an opportunity for successful renal transplantation.

We hope to have the chance to begin with cadaveric transplantation program in Syria, in order extend our donor resources for the increasing number of patients with end­stage renal disease patients.

 
   References Top

1.Ayash Z. Renal replacement therapy in Syria. Saudi J Kidney Dis Transplant 1997; 8(4):436-7.  Back to cited text no. 1    
2.Mital D, Foster PF,JensikSC,etal. Renal transplantation without sutures using the vascular clipping system for renal artery and vein anastomosis a new technique. Transplantation 1996;62(8): 1171 -3.  Back to cited text no. 2    
3.Morris PJ. Kidney Transplantation: results of renal transplantation 4 th ed. Philadelphia: W.B. Saunders 1994;506-7.  Back to cited text no. 3    
4.Pretagostini R, Alfani D, Poli L, Berloco P, Celonello M, Cortesini R. Kidney transplantation from living donor, results of 531transplants. Proceedings of 35 Congress of the European Renal Association. Italy 1998;390.  Back to cited text no. 4    
5.Nicol DL, P'ng K, Hardie DR, Wall DR, Hardie IR. Routine use of indwelling ureteral stents in renal transplantation. J Urol 1993;150:1375-9.  Back to cited text no. 5  [PUBMED]  
6.Benoit G, Blanchet P, Eschwege P, Alexandre L, Bensadoun H, Charpentier B. Insertion of a double pigtail ureteral stent for the prevention of urological complications in renal transplantation: a prospective randomized study. J Urol 1996;156(3):881-4.  Back to cited text no. 6    
7.Penn I. The incidence of malignancies in transplant recipients. Transplant Proc 1975; 7:323-6.  Back to cited text no. 7  [PUBMED]  
8.Butkus DE, Kirchner KA, Neil J, Raju S. Kaposi's Sarcoma in transplanted kidney. Transplantation 1989;48(1): 146-9.  Back to cited text no. 8    
9.Morris PJ. Kidney transplantation: cancer in dialysis and transplant patients. 4 th ed. Philadelphia: WB Saunders 1994;393-4.  Back to cited text no. 9    

Top
Correspondence Address:
Mohammed Mustafa Al-Habash
Department of General Surgery, Renal Transplantation Unit, Al-Mouassat University Hospital, P.O. Box 30129, Damascus
Syria
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PMID: 18212464

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