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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2005  |  Volume : 16  |  Issue : 4  |  Page : 584-585
Lebanese Experience in Renal Transplantation: Protocol and Complications


Nephrology and Transplantation Unit, Rizk Hospital, Beirut, Lebanon

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How to cite this article:
Stephan AG. Lebanese Experience in Renal Transplantation: Protocol and Complications. Saudi J Kidney Dis Transpl 2005;16:584-5

How to cite this URL:
Stephan AG. Lebanese Experience in Renal Transplantation: Protocol and Complications. Saudi J Kidney Dis Transpl [serial online] 2005 [cited 2014 Oct 20];16:584-5. Available from: http://www.sjkdt.org/text.asp?2005/16/4/584/32849
The first kidney transplant was performed in Lebanon in 1972. The donor was a live related donor and the results were satisfactory.

However, it was not until 1985 that the first kidney transplant unit was created at Rizk hospital. It fulfilled all the requirements of the Lebanese organ transplant law of 1983. The donors were all living related donors and the immunosuppressants used, then, were steroids and azathioprine, with anti-lymphocyte globulin for induction (ALG - BioMerieux).

The results were excellent and most of the patients transplanted during the first five years are still living and doing well. (Patient and graft survival at 15 years are 83% and 66% respectively).

In 1990, we performed at the Rizk Hospital, our first cadaveric kidney transplant (the first in Lebanon too). The recipients are still living with a functioning graft (serum creatinine 1.3 mg %) 15 years later.

Since then, 36 cadaveric kidney grafts have been performed in our unit (for a total of 172 cadaveric transplants in Lebanon).

In 1989, we started accepting living unrelated donors. Since then, we have performed 338 kidney transplants from living donors (related and unrelated).

Our total combined graft survival at 5-years is 86% and patient survival is 96% (from cadaver, living related and unrelated donors).

Our present protocol varies according to the source of the kidney and we believe strongly in tailoring immunosuppression to fit the requirements of each individual.

For non HLA-identical transplantations, we are using primarily rabbit anti-thymocyte globulin (Fresenius) for induction. The dose and frequency are adjusted according to lymphocyte cell counts, white blood cell count and platelet counts.

Calcineurin inhibitors are withheld until the serum creatinine drops under 2 mg% which occurs usually by the third post-transplant day.

Mycophenolate Mofetil (MMF), at a dose of 2 gm/day, is started on the eve of transplant­ation. The dose is usually reduced to 1.5 gm daily 2 months later.

Three injections of 500 mg solumedrol per day are given initially on days zero, one and two post-transplant. Oral prednisone sub­sequently replaces solumedrol and the dose is tapered rapidly to reach 10 mg per day by the end of the first month post-transplant. By the sixth post-transplant month, steroids are reduced further to 7.5 mg and 5 mg per day.

For maintenance immunosuppression, we still rely primarily on calcineurin inhibitors but we are trying to minimize their doses, counting on MMF to prevent rejections. This strategy has been adopted in our unit several years ago because of our conviction that the nephrotoxicity of the calcineurin inhibitors will ultimately damage the graft. Recent reports of biopsy-proven, calcineurin inhibitor nephrotoxicity, affecting almost all renal grafts after ten years of exposure have strengthened our convictions. Our calcineurin inhibitor minimizing protocol has not been associated with the appearance of clinical rejections. However, no protocol graft biopsies have been carried out so far to rule out sub­clinical rejections.

Patients who do not tolerate calcineurin inhi­bitors (22 pts) have been converted to sirolimus in association with MMF.

We have not, however, been able to use more than 2-3mg/day of sirolimus, because of the appearance of arthralgias, edema, pulmonary toxicity, and recurrent upper respiratory tract and urinary tract infections. The hematological complications and the dyslipidemia frequently associated with sirolimus use have not, on the other hand, been a special problem in our experience.

We like to treat our patients with angiotensin receptor blockers or angiotensin II converting enzyme inhibitors. We believe that blocking angiotensin II, besides lowering blood pressure has a renoprotective effect that is beneficial in patients with reduced nephron mass exposed to calcineurin inhibitors.

Most of our patients are also on statins to take advantage of their lipid lowering, ancillary, and potential immunosuppressive effects. We have, so far, had no problems with liver toxicity or rhabdomyolysis. Experience with transplantation is also develop­ing in other centers in Lebanon. In 1992, a second transplantation center was started at the Hotel Dieu de France hospital. It has an active pediatric transplant unit and does not accept living unrelated donors.

In 1997, two other centers started performing transplantation, one at the St. Georges Hospital of Beirut and another at the American University of Beirut. In 2004, a fourth kidney transplant center was inaugurated in Sidon.

The vast majority of our donors are still living donors (20 per million inhabitants) but we have committed ourselves to devote more efforts to encourage cadaveric donation (only 2-4 per million inhabitants so far).

In 1999, under the auspices of NOOTDT (the National Organization for Organ and Tissue Donation and Transplantation), we established the Lebanese model of organ allocation and procurement.

In 2000, we started a series of yearly transplant procurement management courses in Lebanon and some other Middle Eastern countries.

Transplantation in Lebanon is an expensive, only partially reimbursed treatment. Chances of re-transplantation are limited. Thus, we, more than anybody else, cannot afford to loose our first transplants. This has been our permanent obsession. In 2005, our first patients will finish their 20th year of successful graft survival.

I have only discussed the protocol followed in our unit. A proposed national transplant registry will soon be available. This will facilitate all inquiries about other modalities of therapy and their results.

We are convinced, however, that no universal protocol can be blindly applied and suit all patients. Recommended doses and levels do not fit, usually, our local population. The available drug monitoring techniques are unsatisfactory and represent at best rough guidelines for drug use.

We strongly believe that immunosuppression should be tailored, and we are trying to find the best way to safely monitor this tailoring.

The most plausible method so far consists essentially of determining drug levels at their desired site of action i.e. the lymphocyte.

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Correspondence Address:
Antoine G Stephan
Nephrology and Transplantation Unit, Rizk Hospital, P.O. Box 11-3288 Beirut
Lebanon
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PMID: 18202513

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