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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE Table of Contents   
Year : 2000  |  Volume : 11  |  Issue : 4  |  Page : 553-558
Living Unrelated Renal Transplant: Outcome and Issues


1 College of Medicine, King Saud University, Riyadh, Saudi Arabia
2 Department of Medicine, Security Forces Hospital, Riyadh, Saudi Arabia
3 Family Community Medicine, King Saud University, Riyadh, Saudi Arabia

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   Abstract 

Living unrelated transplantation (LURT) is emerging as a practical option in renal transplantation due to shortage of living related and cadaver donors. We report a six-years (December 1991 to December 1996) follow-up of 60 LURT patients. The majority of these patients (95%) were transplanted outside the Kingdom of Saudi Arabia; 37 in India, 14 in Egypt, five in the USA and one in Pakistan. Only three patients (emotionally related) were transplanted in Saudi Arabia. Before transplantation, 50 (83.4%) patients were on chronic hemodialysis, three (5%) on peritoneal dialysis and three (5%) were transplanted pre-emptively. Post-operatively, the majority of the study patients were on three drug immunosuppressive therapy. One and five year graft survival was 93.0% and 59.6%, while patient survival at one and three years was 93.7% and 81%, respectively. Surgical complications included lymphocele in 10% of the study patients, urinary leak in 8.3%, and bleeding from the vascular anastomosis in 6.6%. There were eight episodes of acute rejection in eight (13.3%) patients and all episodes were successfully treated; two patients required monoclonal anti-lymphocyte antibodies (OKT3). Eleven (18.3%) patients developed chronic rejection, which resulted in the loss of ten (90%) allografts. Infection was the commonest cause for hospital admission; urinary tract infection (UTI) being responsible for 40% of admissions. Three patients had Cytomegalovirus pneumonia, one had Pneumocystis Carinii pneumonia and one had candida pneumonia. Two (3%) patients developed Kaposi's sarcoma. We conclude that LURT can help in overcoming the shortage of organs for transplant, however, commercial transplantion in developing countries is associated with high morbidity and mortality.

Keywords: Kidney transplant, Living unrelated donors, Complications, Survival.

How to cite this article:
Al-Wakeel J, Mitwalli AH, Tarif N, Malik GH, Al-Mohaya S, Alam A, El Gamal H, Kechrid M. Living Unrelated Renal Transplant: Outcome and Issues. Saudi J Kidney Dis Transpl 2000;11:553-8

How to cite this URL:
Al-Wakeel J, Mitwalli AH, Tarif N, Malik GH, Al-Mohaya S, Alam A, El Gamal H, Kechrid M. Living Unrelated Renal Transplant: Outcome and Issues. Saudi J Kidney Dis Transpl [serial online] 2000 [cited 2020 Jan 23];11:553-8. Available from: http://www.sjkdt.org/text.asp?2000/11/4/553/36642

   Introduction Top


Hemodialysis is the main renal replacement therapy for the majority of chronic renal failure patients. Current advances in renal transplantation have resulted in better graft and patient survival, and the improved quality of life has made renal transplan­tation a favored option by the end-stage renal disease (ESRD) patients. [1],[2],[3] Despite the continued increase in renal transplants needed annually, there is no matching increase in the donor pool and there is an ever widening gap between supply and demand that has become the major limiting factor in renal transplantation today. [1],[4],[5],[6],[7] Transplant of cadaveric kidneys is currently the main donor pool in the USA. [4],[7] Living related transplants (LRT) are increasing and recently living unrelated transplantation (LURT) has also been increasing. [1],[2],[4],[6],[7],[8],[9],[10] This trend is supported by the follow-up studies in kidney donors where donor and renal survival was excellent and no progressive renal dysfunction was noted. [11]

In this report, we present our experience with the patients who had LURT on commercial or non-commercial basis and followed-up by us.


   Patients and Methods Top


We reviewed the out-patient clinic and all hospitalization records of 64 LURT patients identified during chart review of follow-up patients over a period of six years (1990 - December 1996). Complete clinical and laboratory data were available for analysis on only 60 patients. Laboratory data are reported in the international system units. Cyclosporine (CSA) levels are presented in pg/L. CSA levels were performed using monoclonal fluorescence polarization immunoassay (FPIA) and were available only over the last three years of the study, therefore, CSA data for that period only is included in analysis.


   Statistical Analysis Top


All data are presented as mean ± standard deviation. Graft and patient survival was evaluated using Kaplan - Meier method using non-parametric estimate and censoring the data.


   Results Top


Of the 60 study patients, 45 (75.4%) were males and the mean age of the patients was 41.4 ± 16.6 years. Twenty-four (40%) patients had more than one renal transplant attempts; 17 (28.3%) had one prior transplant, five (8.3%) had two prior transplants, one patient had three and another patient had four transplants.

The etiology of ESRD was unknown in 24 (40%) patients, glomerulonephritis was the cause in 12 (20%) patients, diabetic nephro­pathy in five (8.3%), hypertensive nephro­sclerosis in four (6.6%) and miscellaneous causes in 15 (25%). In the pre-transplant period, 50 (83.4%) of the study patients underwent maintenance hemodialysis, three (5%) had peritoneal dialysis, three (5%) had pre-emptive transplantation and four (6.6) underwent transplantation before returning to dialysis after they had chronic rejection from previous transplantation.

Fifty-seven (95%) patients had renal transplantation performed outside the Kingdom of Saudi Arabia; 37 (61.6%) in India, 14 (23.3%) in Egypt, five (8.3%) in the USA, and one (1.6%) in Pakistan. Three (5%) patients had renal transplants from emotionally related donors in Saudi Arabia. Patients who were transplanted abroad registered at our transplant clinic immediately upon arrival. In most cases, pre-transplant evaluation, donor information and peri­operative medical records including immuno­suppressive regimen were not available.

At the time of presentation for follow-up, 38 (63%) patients were on triple drug immunosuppressive therapy (CSA, prednisone and azathioprine), 12 (20%) patients were on two drugs (prednisone and cyclosporine) and 10 (17%) patients were unaware of their immunosuppressive regimen.

The mean follow-up period was 29.8 months (range, 3 - 72 months; median of 33 months). The mean creatinine and urea at the first visit and last follow-up were 175 ± 119μmol/L, 12.0 ± 8.5 mmol/L, and 214 ± 191μmol/L, 12.0 ± 9.0 mmol/L, respectively.

Surgical complications included wound infections, lymphocele, urinary leak, bleeding from vascular anastomosis, uretheral obstruction and renal infarction [Table - 1]. None of the complications were noted in the eight (13.3%) patients who underwent surgery in the USA, Saudi Arabia or Pakistan.

In 36 (60%) patients, the serum creatinine at first evaluation was more than125 pmol/L and 30 (50%) remained at this level at the last follow-up. According to the blood levels of CyA, there were 22 (36.6%) patients who had elevated levels and ten (46%) of them had levels more than 400 pg/L at the first visit; 9/10 (90%) of these patients had serum creatinine more than 125 pmol/L. The proper dosage adjustment of those with CyA levels more than 400 pg/L helped in decreasing the creatinine levels in 5/10 (50%) to less than 125pmol/L.

There were 27 hospitalizations for suspected rejection episodes; eight (30%) patients had acute rejection and 19 (70%) had chronic rejection of whom 10 (53%) subsequently lost their grafts. The acute rejection episodes resolved completely with intravenous methylprednisolone in six patients, while the remaining two patients required mono­clonal anti-lymphocyte antibody (OKT3).

Of the total 175 admissions recorded during the 60-month follow-up period, infection was the commonest cause, being the reason for admission in 52 (29.7%) episodes. The urinary tract was the most frequent site of infection followed by pneumonia, hepatitis, tuberculosis and septicemia [Table - 2]. Three patients had CMV pneumonia, one had candida pneumonia and one had pneumocystis carinii pneumonia. Miliary tuberculosis occurred in two patients and tuberculous pericarditis was noted in another.

Post-transplant hypertension was noted in 34 (56.6%) of the study patients, steroid induced diabetes developed in 12 (20%), acute myocardial infarction occurred in seven (11.6%) and cerebrovascular accident occurred in one (1.6%). Four (6.6%) of the patients developed liver cirrhosis due to hepatitis and two (3.3%) neither of whom were HIV positive, developed Kaposi's sarcoma (KS). In one patient, KS was diagnosed three months after transplantation and was fatal; the other patient was diagnosed six months post-transplantation and responded to discontinuation of immuno­suppressive therapy but lost the allograft.

Fifty-one patients were alive at the end of the follow-up period, while 50 patients had functioning grafts. Patient survival was 93.7% at 12 months and 81% at 36 months. Graft survival was 93% at 12 months and 59.6% at 60 months. Out of the nine deaths, six patients had functioning grafts at the time of their death. The cause of death was overwhelming sepsis in three patients and one patient died of each of the following: acute respiratory distress syndrome, acute rejection, Kaposi's Sarcoma, liver cirrhosis, gastrointestinal bleeding and rupture of abdominal aortic aneurysm.


   Discussion Top


More than 50% of ESRD patients are on chronic hemodialysis world-wide. [5] A significant portion of health care cost is utilized for these patients. In the USA, since Medicare bears most of this cost, data analyses were, performed repeatedly and suggestions proposed to decrease this economic burden while providing quality care. In one analysis, renal transplantation was projected to save $ 42,000 per patient over a period of 10 years. [1]

The quality of life improves after renal transplantation compared to dialysis; and the majority of dialysis patients prefer renal transplantation. [6] In a survey of ESRD patients, 64% emphasized the need for more kidneys for transplantation. [12] In fact, the total number of organs donated increased by 20% over the years, however, the waiting list in the meantime increased by 76%. [7] In the USA, during the 1988-1995 period, the median waiting time for a renal transplant increased from 400 days to 842 days. [9] This severe shortage of organs has led to exploring ways and means to increase donor pool (marginal kidneys, higher donor age and non-heart-beating donors) and deve-lopment of effective immunosuppression. Furthermore, living organ donation is gaining acceptance and is most favored due to the excellent graft and patient survival. [1],[2],[3],[4],[5],[7],[8],[9] Data from United Network of Organ Sharing (UNOS) in the USA reported one year patient and graft survival of LRT around 97.5% and 95.7% compared to cadaveric renal transplant (CRT) of 94% and 84% respectively. [3]

In Saudi Arabia, 4861 patients were receiving dialysis in 1997 (4665 on hemo­dialysis and 196 on peritoneal dialysis). [13] In 1979, 11 living related transplants (LRT) were performed, which increased to a total of 36 in 1984 when the first cadaver renal transplant (CRT) was performed. Since then, the graph is gradually increasing; in 1997, a total of 99 CRT and 171 LRT were performed. [13]

LURT has been a subject of great debate due to involved ethical concerns. A recent survey in the USA, however, shows a greater interest in LURT. [1],[4] A questionnaire repeated after six years shows an increase in centers from 76% to 88% that would accept spouses for LURT. [4] During that same period there was an actual increase of 50% in the number of LURT performed. [4] In another survey, 90% of the responding centers accepted emotionally related donors and 60% actually encouraged the practice. [8] UNOS registry detected an increase in the frequency of performing genetically unrelated renal transplants from 4% in 1988-89 to 10% in 1994-95. [3] Graft survival was better in LURT than CRT, and HLA matching or donor specific transfusion were not significant factors in graft survival. [7],[10] However, more acute rejection episodes were noted in one study with HLA-DR mismatch. [7]

Due to the absence of national organ procurement organizations and the social and religious beliefs in the developing countries, CRT is rare and living donor transplantation is the only option in most of these countries. [5],[14],[15]

LURT, on one hand, would increase the donor pool and produce excellent graft and patient survival results. The practice, however, would lead to many concerns. An excellent review by Chugh and Jha describes the history and issues relating to ethical concerns regarding LURT in developing countries. [5] In Saudi Arabia, as mentioned earlier, there is a trend towards increasing the numbers of CRT and LRT. Most of the LURT, on the other hand, is done out of the country. In one report, during 1991-1993, LURT performed outside Saudi Arabia accounted for 28.7% of all renal transplants. [5]

Unfortunate fungating commercial centers in certain other countries had led to organ trading and substandard renal transplan­tation in back street clinics [5],[14],[15] Pre­transplant evaluation in many cases is incomplete and perioperative care is substandard. [5],[11] Sixty-percent of our study patients had serum creatinine more than 125 µmol/L at the first visit.

There was a higher percentage of surgical complications in our patients that was comparable to those reported by others; this reflects the inexperience in surgical techniques. [5],[14] Ten percent of our patients had lymphocele and 8.3% had urinary leak, which is significantly higher than recent reports. [5],[14]

Pre-transplant evaluation of donor and recipient is incomplete in such clinics resulting in transfer of infection from donor. [5],[14] In our study, nine patients had hepatitis C type infection and four developed tuberculosis; two had miliary tuberculosis and one tuberculous pericarditis. These patients were successfully treated with anti­tuberculous medications for nine months.

The patients in our study were also discharged early from the transplanting center, between 6-25 days (mean 15.2 days) post transplant. Furthermore, the patients were not provided with medical records, the majority were not educated on how to cope with the post transplant issues, as most did not know the importance of immuno­suppression, dosage and timing of medications; the prescribed dosage was incorrect in many instances.

Overall graft and patient survival in these patients though less than LRT was comparable to CRT. [2],[3],[10],[16] This acceptable result in our patients, even with all the concerns and problems relating to unethical practices, again supports the notion that living donor transplantation fairs better than CRT.

In conclusion, the LURT patients seen at our clinic mostly underwent transplantation at commercial centers. There was a significantly high rate of surgical and medical complications. The patients were not counselled and dosage of immuno­suppressive was not proper. Overall graft and patient survival was less than LRT but comparable to CRT.

 
   References Top

1.Beasley CL, Hull AR, Rosenthal JT. Living kidney donation: a survey of professional attitudes and practices. Am J Kidney Dis 1997;30:4:549-57.  Back to cited text no. 1    
2.Lowell JA, Brennan DC, Shenoy S, et al. Living-unrelated renal transplantation provides comparable results to living-related renal transplantation: a 12-year single-center experience. Surgery 1996; 119:(5):538-43.  Back to cited text no. 2    
3.Cecka JM. The UNOS Scientific Renal Transplant Registry. Clin Transpl 1996:1-14.  Back to cited text no. 3    
4.Spital A. Unrelated living kidney donors. An update of attitudes and use among U.S. transplant centers. Transplantation 1994; 57:1722-6.  Back to cited text no. 4    
5.Chugh KS, Jha V. Commerce in transplan­tation in third world countries. Kidney Int 1996;49:1181-6.  Back to cited text no. 5  [PUBMED]  
6.First MR. Expanding the donor pool. Semin Nephrol 1997;17:(4):373-80.  Back to cited text no. 6    
7.First MR. Controversies in organ donation: minority donation and living unrelated donors. Transpl Proc 1997;29:67-9.  Back to cited text no. 7    
8.Spital A. Do U.S. transplant centers encourage emotionally related kidney donation. Transplantation 1996;61(3):374-7.  Back to cited text no. 8    
9.Harper AM, Baker AS. The UNOS OPTN waiting list: 1988-1995. Clin Transpl 1995;69-84.  Back to cited text no. 9    
10.Geffner SR, D'Alessandro AM, Kalayoglu M, et al. Living unrelated renal donor transplantation: the UNOS experience, 1987­1991. Clin Transpl 1994;197-201.  Back to cited text no. 10    
11.Kasiske BL, Ma JZ, Louis TA, Swan SK. Long term effects of reduced renal mass in humans. Kidney Int 1995;48:814-9.  Back to cited text no. 11  [PUBMED]  
12.Sehgal AR, LeBeau SO, Youngner SJ. Dialysis patient attitude toward financial incentives for kidney donation. Am J Kid Dis 1997;29(3):410-8.  Back to cited text no. 12    
13.SCOT Data. Saudi J Kidney Dis Transplant 1998;9(1):41-6.  Back to cited text no. 13    
14.Sever MS, Ecder T, Aydin AE, et al. Living unrelated (paid) kidney transplan-tation in third world countries: high risk of complications besides the ethical problem. Nephrol Dial Transplant 1994;9(4):350-4.  Back to cited text no. 14    
15.Davison AM. Commercialization in organ donation. Nephrol Dial Transplant 1994;9: 348-9.  Back to cited text no. 15  [PUBMED]  [FULLTEXT]
16.Huraib S, Al Khudair W, Saleem H, et al. Renal transplant experience in King Fahad National Guard Hospital. Saudi J Kidney Dis Transplant 1996;7(2):157-63.  Back to cited text no. 16    

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Correspondence Address:
Jamal Al-Wakeel
Department of Medicine, King Khalid University Hospital, P.O. Box 2925, Riyadh 11461
Saudi Arabia
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PMID: 18209344

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