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Saudi Journal of Kidney Diseases and Transplantation
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RENAL DATA FROM THE ASIA - AFRICA Table of Contents   
Year : 2010  |  Volume : 21  |  Issue : 3  |  Page : 559-564
Renal transplantation in Nepal: The first year's experience


1 Urology Unit, Department of Surgery, Tribhuvan University Teaching Hospital, Maharajgung, Kathmandu, Nepal
2 Nephrology Unit, Department of Medicine, Tribhuvan University Teaching Hospital, Maharajgung, Kathmandu, Nepal
3 Department of Surgery, Royal Melbourne Hospital, Melbourne, Australia

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Date of Web Publication26-Apr-2010
 

   Abstract 

A successful renal transplantation service was started in Nepal at the Tribhuvan Univer­sity Teaching Hospital in August 2008, and a continuing regular service is being provided currently to needy people. We report here our experience in thirty five end stage renal disease patients who re­ceived kidneys from close relatives during a one year period. The mean age of donors was 46.7 years. Seventeen (49%) donations were from parents, 13 (37%) from spouses, four (11%) between siblings and one (3%) between mother and daughter in law. Although the left kidney was given preference, right sided donor nephrectomy was needed in five (14%) cases. Six (17%) donors had minor post­operative problems. The mean age of recipients was 33.2 years, four (11%) of whom had pre-emptive renal transplantation. Recipients were immunosuppressed with dacluzimab, prednisolone, mycophena­late, and cyclosporine or tacrolimus. The average time taken for graft implantation was 137 minutes. The mean cold ischemia time and second warm ischemia time were 133 and 36 minutes respectively. Four (11%) patients developed urinary tract infection, three (9%) had significant hematuria, one (3%) developed a peri-transplant abscess, and one (3%) had ureteric ischemia and urine leak which required re-exploration in the early post-operative period. Four patients (11%) developed acute rejection of which three were cell- mediated rejection and one was antibody-mediated. There were two (6%) deaths, one due to transplant-related sepsis and the other due to subarachnoid hemorrhage following rupture of a posterior communicating artery aneurysm. No kidney has been lost otherwise.

How to cite this article:
Chalise PR, Shah DS, Sharma UK, Gyawali PR, Shrestha GK, Joshi BR, Kafle MP, Sigdel M, Raut KB, Francis DM. Renal transplantation in Nepal: The first year's experience. Saudi J Kidney Dis Transpl 2010;21:559-64

How to cite this URL:
Chalise PR, Shah DS, Sharma UK, Gyawali PR, Shrestha GK, Joshi BR, Kafle MP, Sigdel M, Raut KB, Francis DM. Renal transplantation in Nepal: The first year's experience. Saudi J Kidney Dis Transpl [serial online] 2010 [cited 2018 Aug 15];21:559-64. Available from: http://www.sjkdt.org/text.asp?2010/21/3/559/62728

   Introduction Top


Organ transplantation has a long history, be­ginning with skin autografting in India during the sixth century BC. [1] However, the first suc­cessful renal transplant took place on 23 rd De­cember 1954, in Boston by surgeon Joseph Mur­ray who performed a transplant between iden­tical twin brothers. [2] This historic landmark brought about a new era in organ transplan­tation, together with many and varied chal­lenges.

Fifty four years after the first successful renal transplantation (RT), this service was started successfully for the first time in Nepal at Trib­huvan University Teaching Hospital (TUTH), Kathmandu, on 8 th August 2008, immediately after obtaining a license from the government, although live donor RT has been legalized in Nepal since 2000. [3] Previous efforts at RT in Nepal had been unsuccessful (3 transplant in one of the nursing home in 1996 and 1 at cen­tral government hospital in November 2004), [4] the details of which are not known. Finally, after RT was established successfully at TUTH, this service was also started in December 2008 at Bir Hospital, Kathmandu, which became the second hospital in the country to successfully carry out kidney transplantations. [5] Nepali law only permits the transplantation among close relatives, and potential kidney donor's can be the father, mother, sister, brother, husband, wife, son, daughter, uncle, aunt, mother-in-law, father­in-law, step father/mother or adopted children. [3] This strict legislation is to prevent the possible organ trade and foul play in procuring the organ. The aim of this study was to share our first year's experience of renal transplantation in Nepal.


   Materials and Methods Top


This clinical study was conducted in the Renal Transplant Unit from August 2008 for a one year period. The first 35 consecutive end stage renal disease (ESRD) patients who un­derwent live related RT at our institute were included in this study. All recipients and do­nors underwent detailed clinical history and examination. They all were subjected to routine medical and surgical assessment, routine and special investigations, vaccination, economic and social assessment, and transplant educa­tion. Clearance from the hospital legal commi­ttee was obtained in all cases before surgery, to ensure a close biological or legal rela­tionship existed between donor and recipient. Donors were evaluated with complete blood picture, bleeding profile, renal and liver func­tion tests, urine routine and culture,  Pap smear More Details and mammography in females and prostate spe­cific antigen in males aged more than 35 years, electrocardiogram, chest x-ray, echocardiogra­phy, ultrasonogram of the abdomen, renal CT angiography and DTPA scan whenever nece­ssary. The left kidney was chosen whenever possible because of the longer length of the renal vessels. Open donor nephrectomy was carried out through a lateral incision along the line of the 11 th rib using a standard technique.

Recipients were evaluated with all the routine investigations including urine and stool cul­tures, and screened for tuberculosis with a Mantoux test and sputum examination for acid fast bacilli. HLA typing and tissue cross mat­ching between donor and recipient was carried out three times, and a final cross match was obtained within one week of RT.

Immunosuppression with mycophenolate mo­fetil and cyclosporine or tacrolimus was star­ted 48 hours prior to transplantation. Interlu­kein-2 (IL-2) inhibitor (daclizumab @ 1 mg/kg) was given as induction before surgery and a second dose was given on day 14 post-opera­tively. Methyl prednisolone (MP) 500 mg was given immediately before surgery. All the pa­tients received prophylactic ceftriaxone one gram and flucloxacilline one gram before the pro­cedure. First, donor nephrectomy was carried out; the removed kidneys were perfused im­mediately through the renal artery using cold Collins solution and kept immersed in sterile ice solution until implantation. Recipients were taken up for surgery only after donors were extubated. Kidneys were transplanted extra­peritoneally in the contralateral iliac fossa. In all cases, the renal vein was anastomosed to the external iliac vein and the renal artery to the external iliac artery in an end to side fa­shion using a continuous 5/0 polypropylene suture. Ureteroneocystostomy (UNC) was per­formed using Lich-Gregoir technique with dou­ble J (DJ) stent in all cases, and biopsy of the renal allograft was taken before wound clo­sure. A single suction drain was placed in the transplant fossa in all cases. Recipients were treated intensively with intravenous fluids du­ring the operative period so as to ensure a good urine output from the transplanted kidney: ini­tially, patients received normal saline 10-15 mL per kg body weight per hour, and then replace­ment of urine volume +/- 30 mL per hour de­pending on the volume of the diuresis once established. Routine full blood count and renal function tests were performed daily and when­ever indicated, and drug levels were performed weekly subject to availability. Post-operative re­nal transplant imaging was not performed rou­tinely. After discharge from TUTH, out-patient follow up of recipients was undertaken daily for the first four weeks and then attendance was less frequent if patient health and kidney function remained satisfactory.


   Results Top


Thirty five live related kidney transplants were carried out during the one year study period from 8 th August 2008. Twenty one donor/reci­pient combinations (60%) were genetically re­lated, 13 (37%) were between spouses and one (3%) was between mother and daughter in laws. Seventeen (49%) donors were parents and four (11%) were siblings [Figure 1]. Among the recipients, 25 (71%) were male, whereas 25 (71%) donors were female [Figure 2]. The mean age of donors was 46.7 ± 9.2 years. Left kidney was given preference as far as possible. Right donor nephrectomy was performed in five (14%) cases because of accessory renal ar­teries to the left kidney (four cases); we chose to transplant one right kidney because it con­tained a cortical cyst and also had a suspicion of a four mm renal calculus. The average time taken to complete the donor nephrectomy ope­ration was 109 ± 19.6 minutes with no critical events during the procedure. Six (17%) patients had minor post-operative problems: three pa­tients had post-operative fever for short dura­tion and one each had superficial wound in­fection, chest infection and severe pain at in­cision site. The mean duration of hospital stay for the donors was 7.6 ± 1.9 days.

The mean age of recipients was 33.2 ± 11.5 years. Four (11%) patients had pre-emptive re­nal transplantation (PRT) and the other 31 pa­tients had been on maintenance hemodialysis for average duration of seven months. All re­cipients who were on dialysis before transplan­tation had received blood transfusions before surgery. In 21 cases (60%), the exact cause for ESRD was not known and presumed to be due to glomerulonephritis. Hypertension was res­ponsible for ESRD in seven (20%) cases, glo­merulonephritis in three (8%) cases, renal stones in two (6%) cases and diabetes mellitus and nephrocalcinosis in one (3%) case each. The mean time taken to complete the recipient ope­ration was 137 ± 27.1 minutes. The mean first warm ischemia time, cold ischemia time and second warm ischemia time were 1.4 ± 0.5 mi­nutes, 133 ± 17.2 minutes, and 36 ± 8.5 mi­nutes respectively. DJ stents were removed between 15 and 41 days after transplantation, the average being 28 days. The median dura­tion of hospital stay for recipients was 11 (7­112) days. Four (11%) patients developed uri­nary tract infection in early post-operative pe­riod. Similarly, three (9%) patients had signi­ficant hematuria: one required re-exploration on the same day; another was managed with normal saline irrigation via a 3-way Foley's ca­theter, while the other required blood transfu­sion and cystoscopic evacuation of bladder clots under general anesthesia. One patient deve­loped peri-transplant infected hematoma and abscess which was drained percutaneously un­der ultrasound guidance. Another patient had ureteric ischemia and a urinary leak which re­quired re-exploration on the 7 th post-operative day; the patient was managed with percuta­neous nephrostomy and later found to have a distal ureteric stricture [Figure 3]. Antegrade DJ stenting was successful and patient is now in regular follow up with a normal creatinine level.

Acute rejection was seen in four (11%) trans­plant kidneys, three cases being cell-mediated rejection and one antibody-mediated. Cell-me­diated rejection was treated with MP 300 mg, 200 mg and 100 mg on consecutive days. Plas­mapheresis and MP were given for antibody­mediated rejection. One patient had an acute recurrence of the native kidney disease post­transplants and this was managed successfully with plasmapheresis. Post-transplant diabetes mellitus was seen in three (8%) patients and all were using tacrolimus as immunosuppression. Two (6%) patients died during the period of this study. One patient died due to overwhel­ming sepsis following treatment of acute rejec­tion which was secondary to refusal of immu­nosuppressants following severe depression. A second death was unrelated to transplantation and was due to subarachnoid hemorrhage after rupture of a posterior communicating artery aneurysm. No kidney was lost from rejection, recurrent disease or technical causes.


   Discussion Top


Renal transplantation is considered the opti­mum form of therapy for patients with stage V (GFR <15 mL/min/1.73m 2 ) chronic kidney di­sease because RT restores the quality of life, restores vitality, improves survival and is also very cost-effective. [6] Until recently, this service was not available in Nepal. Needy people had to travel aboard for life saving kidney trans­plantation and spend huge amounts of money. Those who could not afford to go aboard were forced to have other forms of renal replace­ment therapy, either hemodialysis (HD) or pe­ritoneal dialysis (PD). Dulal et al reported that of those Nepalese patients who had RT done aboard, unrelated transplantation (70%) signi­ficantly outnumbered related transplantations (30%), which indicates significant illegal acti­vity. [4] Now Nepalese people are able to get this life saving service in their own country, and even poor people who could not dream of ha­ving transplantation are being benefited by this service.

All the patients except four were in regular HD before RT in our series. Pre-emptive renal transplantation (PRT) has been controversial in the past because of paucity of clinical evi­dence to clarify the benefits vs. risks of this approach. [6] However, recent studies support the use of PRT as a more advantageous strategy for the patients than RT after initiation of dia­lysis. [7] Also, PRT prevents the need for dialysis access and potential complications of dialysis, and is less expensive for patients.

Females dominated over males in donation (25:10) [Figure 2]. This might be a reflection of a male dominated society. Similar findings also have been published in various literatures from the same region. Guleria et al [8] reported that out of 155 kidney recipients, 137 were male. In another series, Dulal et al [4] found 4.65% of wives donated kidney to their husband, but only 0.44% of husbands donated kidney to their wife.

The left kidney was chosen as often as pos­sible, but right donor nephrectomy was per­formed in five cases (14%). The reason was an accessory renal artery to left side in four cases; another patient had a renal cortical cyst with suspicion of a tiny stone on right kidney, so we decided to take the right one and leave the better kidney in the donor. One donor had bila­teral double renal artery; left donor nephrec­tomy was undertaken and arterial reconstruc­tion was performed during bench dissection.

Most donors were discharged from hospital without major complications and they all were in regular follow-up in transplant outpatient department. The long term effect of prolonged compensatory hyperfiltration to a single kid­ney is still to be evaluated in our population. Saran et al [9] followed up the living donors for a decade and concluded that the function of the solitary kidney is not adversely affected by pro­longed compensatory hyperfiltration, although there appears to be an increased prevalence of microalbuminuria and hypertension. Strict and regular follow-up of kidney donors is recom­mended in order to identify and manage their complications effectively. [10]

Urological complications are not uncommon in kidney transplantation, with reported inci­dences of 1-37%. Burmeister et al [11] studied 1065 kidney transplants performed at their cen­ter; 393 patients (36.9%) developed urological complications in the first 60 post-operative days. The incidence of urinary leak in their se­ries was 6.2%. The incidence of urological complications is influenced mainly by the sur­gical procedure of organ retrieval and UNC. Many studies have shown significantly lower rates of urinary leakage if extravesical UNC is performed with DJ stenting, but a higher rate of urinary tract infection is observed with the use of stents. [11],[12],[13] We used the Lich-Gregoire technique with DJ stenting in all cases for UNC, which was already claimed to be a tech­nically easy procedure with low complication rates. [14] Urinary complications occurred in one case (3%) in the present study: the patient developed a urinary fistula and underwent re­exploration of the transplant on the seventh post-operative day; a drain was placed close to the anatomical site of vesico-ureteric anasto­mosis and a percutaneous nephrostomy was inserted. After removal of the DJ stent, the pa­tient did well but subsequently developed a distal transplant ureteric stenosis [Figure 3] which was treated successfully with a percu­taneously inserted ureteric DJ stent.

In conclusion, a renal transplantation service has been started in Nepal and our preliminary results are very encouraging, although we have yet to see our long term outcomes. Additional necessary infrastructures and skilled manpower required for the transplant programme need to be developed further, so that the life saving programme will be continued, and more and more Nepalese people will benefit.


   Acknowledgement Top


The authors would like to thank all anesthe­siologist, radiologists, pathologists and nursing staff at the Operation Theater and Renal Trans­plant Unit. Without their immense support, the dream of transplantation in Nepal would not have come true.

 
   References Top

1.Thomas DJ. Renal Transplantation. June 8, 2007 [cited 2009 April 1]; [1 screens]. Available from: http://emedicine.medscape.com/article/ 430128- overview.  Back to cited text no. 1      
2.Muray J. Interview with Dr Joseph Murray (by Francis L Delmonico). Am J Transplant 2002; 2:803-6.  Back to cited text no. 2      
3.Kidney Transplantation Act 2058 (B.S.) in Compilation of Health Act and Regulations, Makalu publication, Dillibazar, Kathmandu, Nepal, 5th Ed., Reprint in Falgun 2064:277-93.  Back to cited text no. 3      
4.Dulal RK, Karki S. Nepalese kidney transplant recipient in a follow up clinic: Related and unrelated living donor. J Nepal Med Assoc 2008;47:98-103.  Back to cited text no. 4      
5.Health Times Correspondent. Bir Hospital suc­cessful in kidney transplant [Online]. Decem­ber 18, 2008 [cited 2009 April 23]; [1 screens]. Available from: =1&id=35.  Back to cited text no. 5      
6.Shrestha BM. Pre-emptive renal transplan­tation: Optimum treatment for end-stage renal disease? J Nepal Med Assoc 2008;47:44-6.  Back to cited text no. 6      
7.Innocenti GR, Wadei HM, Prieto M, et al. Preemptive living donor kidney transplan­tation: Do the benefits extend to all recipients? Transplantation 2007;83:144-9.  Back to cited text no. 7      
8.Guleria S, Kamboj M, Chaterjee A, et al. Ge­neric tacrolimus (Pan Graf) in renal transplan­tation: An experience of 155 recipients in India. Transplant Proc 2008;40:2237-9.  Back to cited text no. 8      
9.Saran R, Marshall SM, Madsen R, et al. Long­term follow-up of kidney donors: A longitu­dinal study. Nephrol Dial Transplant 1997;12: 1615-21.  Back to cited text no. 9      
10.Levidiotis V. Live Kidney donors: Assessment and follow up. Aust Fam Physician 2008;38: 316-20.  Back to cited text no. 10      
11.Burmeister D, Noster M, Kram W, et al. Uro­logical complications after kidney transplan­tation. Urologe A 2006;45:25-31.  Back to cited text no. 11      
12.Zavos G, Pappas P, Karatzas T, et al. Urolo­gical complications: Analysis and management of 1525 consecutive renal transplantations. Transplant Proc 2008;40:1386-90.  Back to cited text no. 12      
13.Rodriguez GV, Martinez RM, Arguinarena TF, et al. The use of double J stent for prevention of urological complication in kidney transplants. Actas Urol Esp 2008;32:225-9.  Back to cited text no. 13      
14.Al-Shaer MB, Al-Midani A. The management of urological complications in renal transplant patients. Saudi J Kidney Dis Transpl 2005;16: 176-80.  Back to cited text no. 14  [PUBMED]  Medknow Journal  

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Correspondence Address:
Pawan R Chalise
Urology Unit, Department of Surgery, Tribhuvan University Teaching Hospital, Maharajgung, Kathmandu, Nepal

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