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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2007  |  Volume : 18  |  Issue : 3  |  Page : 432-438
Characteristics of Kidney Transplantation in Baghdad: An Epidemiological Study


Nephrology and Renal Transplantation Department, Alkramah Hospital, Baghdad, Iraq

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   Abstract 

Kidney transplantation remains the optimal therapy for patients with end-stage renal failure. The kidney transplantation program in Iraq has finished its third decade, and this study was performed to assess the characteristics of this program. This study was performed, from early 2004 to mid-2005, on all patients who underwent renal transplantation and were residing in Baghdad. All the subjects were subjected to full examination and detailed investigations at the Al-Karamah Hospital, Baghdad. A total of 512 patients (males, 69.7%), all of whom were residing in Baghdad, underwent kidney transplantation from 1979 to 2005. The donor source was living donors in 55.7% of these patients, living unrelated donors in 42.6% and emotionally related donors in 1.7%. The recipients' age range was from 7 to 64 years with a mean age of 41 years. The patient survival rates at 6, 12 and 18 months were 91, 91 and 89% respectively, while the graft survival rates in the same periods were 89, 89 and 82% respectively. The annual incidence of renal transplant in our study was 15.4 per million people. About 55% of the transplants were performed in private hospitals and 41% in Government hospitals; the others (3.5%) were performed abroad. We conclude that this study is an initial step to assess the renal transplant activities in Iraq, and we hope that this will act as a launching pad for future studies.

How to cite this article:
Al-Jebory HM, Abd KH, Mahmood S, Jabur WL, Al Khyat QJ. Characteristics of Kidney Transplantation in Baghdad: An Epidemiological Study. Saudi J Kidney Dis Transpl 2007;18:432-8

How to cite this URL:
Al-Jebory HM, Abd KH, Mahmood S, Jabur WL, Al Khyat QJ. Characteristics of Kidney Transplantation in Baghdad: An Epidemiological Study. Saudi J Kidney Dis Transpl [serial online] 2007 [cited 2020 Jan 26];18:432-8. Available from: http://www.sjkdt.org/text.asp?2007/18/3/432/33766

   Introduction Top


Renal transplantation is one of the several modalities of renal replacement therapy, and successful transplantation is considered the most satisfactory treatment for end­ stage renal failure. [1] This is because it offers the patient a better quality of life and also, perhaps, improves survival compared to dialysis patients. [2] During the last decade, important changes in renal transplantation have occurred. New and more effective immunosuppressant drugs have been introduced, resulting in reduction in the prevalence of acute rejection as well as improved graft survival rates. [3],[4],[5]

Renal transplantation was first performed in Iraq in 1973, and the transplant program in this country has some unique features:

a) The donor source is almost always living donors, as cadaver transplantation is not practiced due to legislative and social difficulties. Thus, living donors are the only available source for kidney transplantation in Iraq.

b) Most of the transplantations are performed in Baghdad, both in governmental and private hospitals, and this means that the follow-up of the patients, particularly from peripheral areas, depends entirely on patient compliance.

c) The donor selection is based only on HLA class I compatibility, and class II antigens are not tested for regularly.

d) Cyclosporine assay is still not available in our country, and adjustment of the dose of cyclosporine depends largely on the policy of the individual center.

e) Frequent damages that most of the hospitals experienced and the loss of patients' data made their follow-up rather difficult and depended mostly on sporadic investigations kept by the patients themselves.

f) About 11 transplant centers were included in this study, and they represent the only centers doing renal transplantation in Iraq; and these are all located in Baghdad. Five of these centers are governmental; and six, private. Due to the circumstances prevailing now, three governmental and five private centers have stopped their transplantation programs due to lack of adequate medical and technical staff. Thus, presently there are only three functioning transplant centers in Iraq. We performed this study to assess all renal transplant recipients who were alive at the time of the study and residing in Baghdad to enable us to organize their follow-up sheets and data. We hope to build up a national kidney transplantation registry in the near future. The study was carried out between January 2004 and June 2005 in one center in Iraq, which caters to the maximum number of transplant patients in terms of follow-up.

Aim of the Study

The aims of the study included the following:

a) To study and share the unique features of the renal transplant program in Iraq and draw a general picture about this program, its resources and achievements.

b) To assess the patient and graft survival rates following renal transplantation among patients living in Baghdad.

c) To start the process of building up a national kidney transplantation registry for future studies.


   Patients and Methods Top


In our study, we retrospectively reviewed the outpatient medical records of 545 patients who had undergone renal transplantation and were residing in Baghdad. The study period was from January 2004 to July 2005 (18 months). During this period, the patients had their routine follow-up and received immunosuppressive therapy from our trans­plant clinic. The study patients had received 578 grafts (33 patients (6.05%) had received second transplant and were excluded from this study). The renal transplantation of the study group was performed between 1979 and 2005. There were 155 females (30.3%) in the study; the age of the patients at transplant ranged from 7 to 64 years (mean 33.1 years), and the follow-up period ranged from 3 to 18 months with a mean follow-up of 9.5 months.

The donor source was living related donors in 285 patients (55.8%), living unrelated donors in 218 patients (42.5%), and 9 patients (1.8%) received organs from emotionally related donors (including spouses and breastfed relatives) The immunosuppressive therapy comprised of prednisolone and azathioprine till 1984, when cyclosporine was added to the arsenal. More recently, in 2004, mycophenolate mofetil (MMF) was added to the immunosuppressive regime in some centers. All patients received methyl­prednisolone at induction; and basiliximab (20 mg at day zero and four), in addition, was introduced at the induction phase in governmental hospitals since early 2004. The use of tacrolimus began by the end of 2005.

All patients were examined by at least two doctors, one of them being a nephrologist; each patient was examined at least twice during the period of follow-up. During each follow-up, all patients underwent a detailed clinical examination, including blood pressure and body weight monitoring. Urine and blood samples were collected, and the following parameters were estimated: hemoglobin (Hb), blood urea (BU), serum creatinine (CR), fasting blood sugar (FBS), general urine examination (GUE), total cholesterol (Chol), low-density lipoprotein (LDL), triglycerides (TG), uric acid (UA), hepatitis B surface antigen (HBsAg) and hepatitis C antibody (HCV Ab).


   Results Top


The patient survival at the end of 6 months was 91%, which decreased to 89% by the end of 18 months. Also, graft survival at the end of 6 months was 89%, which decreased to 82% by the end of 18 months [Figure - 1]. Both patient and graft survival reached a plateau in the period from 6 to 12 months, and a sudden drop was noted after that.

The distribution of the recipients and the donors according to age groups showed that most (78.5%) of the transplantations were performed on patients aged between 20 and 49 years, while less than 20% of them were done on patients outside this range, showing clear preference for the younger age group [Figure - 2].

The age of recipients at transplantation ranged from 7 to 64 years with a mean of 33.1 years (SD 11.6). Regarding the donors, the story was different; donors above 40 years of age constituted only 8.8% of the cases, which points to a preference by the transplant team for younger donors. The age of the donors ranged from 16 to 57 years with a mean of 27.5 years (SD 8.7), and donors less than 18 years old were reported in only 13 cases. Female donors outnumbered female recipients; female recipients constituted 30.3% of the study cases, while males constituted 69.7% of the recipients [Figure - 3].

Among the donors, related donors constituted 55.8%, followed by the rapidly growing group of unrelated donors; while emotionally related donors constituted only 1.8% [Figure - 4]. The Al-Khayal Hospital was the leading center in number of transplants performed (51.9%), followed by the Al-Karamah Hospital (14.5%) and the Al-Jerahat Hospital (10.6%).

[Figure - 5] shows how transplantation from unrelated donors is increasing rapidly, especially in the private centers. They represented more than 67% of transplants at the Al-Khayal Hospital and about 26% in the governmental centers. [Figure - 6] shows the rapidly increasing number of transplants from unrelated donors during the last five years; these constitute more than 55% of the cases now.

It is clear from [Figure - 6] how much the embargo has affected the number of transplants performed during the period 1990-1999 as compared to the numbers before and after that period, mainly in the governmental hospitals.


   Discussion Top


Renal transplantation is the preferred method of treating patients with end-stage renal failure, and in this study we have attempted to draw a picture about renal transplantation programs in Iraq; and we aim to take an ambitious step towards starting an annual report about renal transplantations in our country.

Recipient Characteristics

One of the characteristics seen in the study was the preference shown towards the younger recipients, since 65% of the recipients operated during the period 2004­2005 were between the ages of 20 and 40 years. These results are similar to the Saudi experience [6] Saudi Center for Organ Transplantation (SCOT) annual report, 2002) and that of the USA [7] (OPTN/SRTR 2004 annual report). Male recipients dominated in our program - 69.7% of the recipient were males; while in the USA, it was 58.5% ; in Kuwait, 58.7% [8] ; and in the UK, male recipients represented 61% of the cases. [9] This pattern is mostly seen because young age-group patients have less co­morbidity and cardiovascular complications, which make them better candidates for acceptance of the graft. Male predominance may be because most families prefer to donate their kidneys to their male members rather than their female patients, and thus females are transplanted less frequently. [10] This has been noticed in the Saudi and the USA renal transplant programs as well. [6],[7]

Although male recipients constituted 69.7% of the cases, male donors constituted only 59.9% of the cases. This is mainly due to two factors. Firstly, most of the donors in private hospitals are unrelated. When the data were taken from the patients, it was surprising that 21.1% were not aware of the gender of their donor, 44.5% did not know the age of the donor, and 32.6% did not know even the name of the donor.

Patient and Graft Survival

The incidence of kidney transplantation in Baghdad is about 15.4 per million of population (PMP) per year, a figure that is higher than the mean incidence in the other MESOT countries, which is 9 PMP. [11] However, if we assess the transplants performed in Iraq as a whole, this figure will get decreased. The reported incidence rates for renal transplantation in some other countries/registries are 24 PMP in Iran, [12] 13.5 PMP in Yugoslavia [13] and 35 PMP in the EDTA registry. [14] [Figure - 7] shows patient and graft survival rates in different countries and compares them with the results of our study. It clearly shows that patient and graft survival at first year in our study closely matched the results from other reports.

The patient and graft survival rates in our series are comparable to the 97.6 and 94.6% patient and graft survival rates respectively, reported from the USA, at one year [7] ; and the 95.8 and 91% patient and graft survival rates respectively, reported from Kuwait. [8] The survival rates in this series are higher than the results of Iqdam KS et al., [15] which show that one-year patient and graft survival rates were 83.5 and 82.9% respectively. This difference may be largely related to the use of newer generation of immunosuppressive drugs like simulect and MMF and, more recently, tacrolimus, in the induction and maintenance therapy, pushing the graft and patient survival rates higher. Another reason could be that the results of Iqdam et al. are from a single center while our data are collected from all transplant centers in Baghdad. It is worthwhile mentioning that the ASNRT, in 1999, [16] reported that the average graft survival in Arab countries was 87% while patient survival was 96%. The difference in graft survival between the ASNRT report and our series is again probably due to the use of the newer drugs in transplantation.

Both patient and graft survival rates show a plateau effect starting from 3 months to 1 year post-transplantation; this has been also mentioned by Richard et al. [17] This initial steady state, followed by rapid rise in both graft and patient loss, may be due to the protocol of our study; since we examined the patients initially at 3 months after transplantation and then 6, 12 and 18 months after transplantation. Another contributory factor could be noncompliance, since most patients attend regular follow-up only in the first 3-6 months after transplantation. Another factor could be that, while closely following the allograft function, we may be ignoring other associated complications like hypertension, diabetes mellitus, and hyperlipidemia.

Donor Characteristics

In Iraq, cadaver donor transplants are yet to be performed in comparison to Saudi Arabia, where 58 kidneys from brain-death patients were transplanted in the year 2002. [6] Data from other MESOT countries show that cadaver kidneys represented 15% of the total transplants performed. [18] Reports from Kuwait show that 29.7% of the kidneys were from cadavers [8] ; while in the UK, about 73% of kidneys were from cadaver donors [9] ; and in the USA, 49% of the kidneys were from cadaver donors. [7]

In our series, most of the donors were in the age range of 20 to 45 years. Donors above 50 years represented only 2.1% of the total donor pool. The use of unrelated donors is increasing in number in both governmental and the private hospitals in Iraq. Another observation is that the number of male donors is increasing, and this may well be correlated with the marked increase in unrelated donations, suggesting that more men are donating their kidneys to unrelated recipients.


   Conclusion Top


Our study shows that renal transplantation in Iraq has several unique features: All donors are living donors, and no cadaver donor transplants have been performed yet in Iraq. The recipients are predominantly males (69.7%), and they belong to the young-age group. All transplants were performed in Baghdad, as unfortunately no transplant centers are available in other cities of Iraq. Donors are mainly live and related (55.7%), although unrelated donors (42.6%) have been increasing during the last five years. Private centers remain the leading centers performing renal transplantation (55.5%). Triple-drug immunosuppressive therapy remains the most popular regime used in our country (62.7%). Patient survival at 3, 12, and 18 months was 91, 91 and 89% respectively; while graft survival at 3, 12, and 18 months was 89, 89 and 82% respectively.

 
   References Top

1.Cecil essential of medicine fourth edition 1996, pp 248-51.  Back to cited text no. 1    
2.Foley RN, Parfery PS, Sarank MJ. Clinical epidemiology of cardiovascular disease in chronic renal disease. Am J Kidney Dis 1998;32:Suppl 3:S112-9.  Back to cited text no. 2    
3.Paul LC. Chronic allograft nephropathy. Kidney Int 1999;56:783.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]
4.Schartzberger G, Mayer G. Chronic allograft failure: a disease we don't understand and can't cure. Nephrol Dial Transplant 2002;17:1384-90.  Back to cited text no. 4    
5.Davis CL, Hricik DE. Transplant: immunology and treatment of rejection. Am J Kidney Dis 2004;43:1116-37.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]
6.SCOT; Saudi center for organ transplantation annual report 2002.   Back to cited text no. 6    
7.OPTN/SRTR 2004 Annual Report.  Back to cited text no. 7    
8.Samhan M, Almousawi M, Johny KV. Result in 310 renal transplantation in Kuwait (ASRNT2002 Manama, Bahrain (abstract ).  Back to cited text no. 8    
9.www.uktransplant.org.uk 2004 (internet web).  Back to cited text no. 9    
10.Praviz Khajehdehi. Living non-related versus related renal transplantation its relationship to the social status, age and gender of recipients and donors. Neprhol Dial Transplant 1999;14:2621-4.  Back to cited text no. 10    
11.Masri MA, Haberal MA, Shaheen FA, Stephan A, Mousawi MA. Middle East society for organ transplantation (MESOT) transplant registry. Exp Clin Transplant 2004;2(2):217-20.  Back to cited text no. 11    
12.Rezaei M, Kazemnejad A, Raeisi D, Babaei G. Survival analysis of renal transplant recipient in Kermanshah province in Iran. Behbood 2003;7(3):27-41.  Back to cited text no. 12    
13.Djukanovic LJ, Radovic M. Annual registry of dialysis and transplantation in Yugoslavia 1998.  Back to cited text no. 13    
14.Blagojevic-lazic R. Kidney transplantation in Yugoslavia and other Balkan countries Nephrol Dial Transplant 2001;16:suppl 6 :142-3.  Back to cited text no. 14    
15.Iqdam KS, Ihsan AS. Long term follow up of renal transplant patients - a single center experience in Iraq. Saudi J Kidney Dis Transpl 2005;16(1):40-5.  Back to cited text no. 15    
16.Shaheen FA, Souqiyyeh MZ. Survey of the current status of renal transplantation in the Arab countries. Saudi J Kidney Dis Transpl 1998;9(2):123-7.  Back to cited text no. 16    
17.Richard N, Formica JR . Long term medical management for patients with kidney transplants. Hospital Physician 2002.  Back to cited text no. 17    
18.Kessler M, Hestin D, Mayeux D, et al. Factors predisposing to post renal transplant erythrocytosis. Clin Nephrol 1996;45:83-9.  Back to cited text no. 18  [PUBMED]  

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Correspondence Address:
Hareth M.M. Saeed Al-Jebory
Nephrology Department, Al Qasmy Hospital, Al Sharja, United Arab Emirates

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    Figures

  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7]

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    Abstract
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    Results
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