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Saudi Journal of Kidney Diseases and Transplantation
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RENAL DATA FROM ASIA-AFRICA  
Year : 2011  |  Volume : 22  |  Issue : 1  |  Page : 174-178
A two-year retrospective analysis of renal transplant patients in Sri Lanka


1 Department of Clinical Medicine, Faculty of Medicine, Colombo 08, Colombo, Sri Lanka
2 Western Infirmary, Colombo 08, Colombo, Sri Lanka

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Date of Web Publication30-Dec-2010
 

   Abstract 

This retrospective analytical study aimed at making a database of patients who underwent renal transplant from 31 December 2004 to 31 December 2006 under the Faculty of Medicine renal transplant program. The objective was to build a profile of renal transplant patients with focus on post KT infections and complications of renal transplants. An interviewer administered questionnaire was used. A total of 72 patients were studied; 18 (25%) had died by February 2007. Forty-three patients (58.3%) were interviewed in person, 17 were interviewed over the phone and 12 patients could not be contacted. Of those who were interviewed, 28 (38.9%) were on azathioprine, prednisolone and cyclosporine, while 15 (20.8%) were on predni­solone, cyclosporin and mycophenolate mofetil. Four patients had symptomatic cytomegalovirus infection and five had tuberculosis post transplant. Of all infections, the most commonly reported was urinary tract infection (11 cases). Thirty-three (45.8 %) had received induction therapy with either basiliximab (n = 8) or daclizumab (n = 25). Acute rejection was the most commonly en­countered complication, with nine cases (12.5%) being reported over the study period. Of late complications, most were due to immunosuppression. Overall, the 2-year survival was 75%. There was no significant difference between the centers of transplant.

How to cite this article:
Rodrigo C, Sheriff R, Rajapakse S, Lanerolle RD, Sheriff R. A two-year retrospective analysis of renal transplant patients in Sri Lanka. Saudi J Kidney Dis Transpl 2011;22:174-8

How to cite this URL:
Rodrigo C, Sheriff R, Rajapakse S, Lanerolle RD, Sheriff R. A two-year retrospective analysis of renal transplant patients in Sri Lanka. Saudi J Kidney Dis Transpl [serial online] 2011 [cited 2019 Sep 21];22:174-8. Available from: http://www.sjkdt.org/text.asp?2011/22/1/174/74354

   Introduction Top


Sri Lanka has a well established renal trans­plant program that has been functioning for more than two decades, pioneered by the Faculty of Medicine (University of Colombo) kidney transplant program. A significant num­ber of patients have undergone renal transplan­tation in both government and private sectors in the private-public sector partnership pro­gram. Transplants are performed in two centers under the program; the National Hospital of Sri Lanka (state sector) and Western Infirmary (private sector). In view of the increasing incidence of chronic renal failure in Sri Lanka and the possibility of dealing with a massive demand for transplantation, it is important to evaluate the outcome of current transplant pro­grams. Our objective of this study was to create a data base for renal transplant patients, in­cluding the demographics, immunosuppression used, acute rejections, infections and survival of renal trans-plant patients, while comparing the outcome in government versus private sector.


   Methodology Top


All the patients transplanted over a 2-year pe­riod starting from 1 January 2005, under the Faculty of Medicine kidney transplant program, were included in the study (N = 72). We looked at various aspects of the transplant process, but focused mainly on post transplant tuberculosis (TB) and cytomegalovirus (CMV) infections and other post transplant complications.

The patients were either interviewed in per­son or over telephone, and in cases where they were lost to follow-up, past medical records were used as a source of information. Infor­mation was entered on a pre-tested interviewer administered questionnaire and later entered into a computer database. Statistical analyses was done using SPSS statistical package.


   Results Top


Of all the patients transplanted under the pro­gram, 54 (75%) were males. Forty-five (62.5%) of the transplants were done in the National Hospital of Sri Lanka (NHSL), while 27 (37.5%) were done in the private sector hospital, Wes­tern Infirmary (WI).

Of the 72 patients transplanted during the 2­year period, 18 (25%) had died by February 2007. It was impossible to retrieve any de­tailed clinical information on these patients. Of those who were surviving, 43 (58.3%) were interviewed in person or over the phone. Their records were complete and up to date. Eleven people were lost to follow-up and could not be contacted. In this category, two were Maldivian transplant recipients.

Triple immunosuppression with prednisolone, azathioprine and cyclosporine (P/A/Cy) was used in 28 (38.9%) patients, while 15 (20.8%) patients were on prednisolone, cyclosporine and mycophenolate mofetil (P/Cy/MMF). The re­gimen was unknown in 29 (40%) patients.

Post transplant infections

In our study, four cases of CMV infections (4/43, 9.3%) and five cases of post transplant TB (4/43, 11.6%) were diagnosed. All four ca­ses of post transplant CMV was diagnosed by serology. Three presented with undifferentiated fever and one presented with retinitis. Three of the patients were on P/A/Cy regime, while the other was on P/Cy/MMF. All the cases had responded to valganciclovir oral medication.

Of the TB patients, all presented with pul­monary manifestations of TB and contracted the disease within four months of transplan­tation. All but one had a past history of TB. No one had a contact history of TB. One patient was on P/Cy/MMF, while all others were on P/A/Cy. Sputum for acid fast bacilli was ne­gative in all cases, while the culture was posi­tive in one patient. The rest were diagnosed on clinical grounds and treated empirically. All but one responded to standard anti-TB treatment. The non-responder died of disseminated TB. The reported incidences of other infections are shown in [Table 1].
Table 1: Post transplant infections (exclusive of tuberculosis and cytomegalovirus infection) of patients on two immunosuppressant regimes.

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Three patients had severe fungal infections. Two were on the P/Cy/MMF regime. The other one had died of the infection and records were not available.

Induction therapy and its implications

All the patients who received induction the­rapy in our sample were given IL-2R antago­nists. Of the 72 patients, thirty-three (45.8%) had received induction therapy. Of all patients receiving induction therapy, 8 (24.2%) were on basiliximab and the rest (75.8%) were on daclizumab. Nine reported cases of acute re­jection were observed, while six (66.6%) of these were from the group that received induc­tion therapy. Four of them were on daclizumab and two were on basiliximab. The incidence of acute rejection did not vary significantly bet­ween the patients who received induction the­rapy and those who did not (Chi-square value: 1.79, P > 0.05). Also, the rate of acute rejection did not vary significantly between the basili­ximab and daclizumab groups (Chi-square va­lue: 0.33, P > 0.05).

Other complications of renal transplants

One objective of the study was to identify the complications after renal transplants. They were divided into two categories as early (within the first 30 days of transplant) and late compli­cations.

Early complications

A total of 15 patients (20.8%) had an early complication [Table 2]. The most commonly seen postoperative complication was acute re­jection, followed by urinary tract infection, urinary retention and wound infection.
Table 2: Incidence of early complications of post KT patients.

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Late complications (excluding infections)

Of the late complications [Table 3], most can be attributed to post transplant immunosupres­sants. There were two patients who had post transplant diabetes and two developed erythro­cytosis. Many patients complained of various skin eruptions also.
Table 3: Late complications of post KT patients.

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Government sector performance versus private sector performance

Of all 73 transplants during the study period, 45 (62.5%) were done at NHSL and 27 (37.5%) were done at WI [Table 4].
Table 4: Comparison of mortality after transplant at two institutions.

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Eleven patients had died from the NHSL group and seven had died from the WI group by Feb­ruary 2007 (Chi-square value: 0.02, P > 0.05).

Comparing the surgical complications, 22% of NHSL patients suffered from at least one complication, while the figure was 18.5% for the WI sample. The single perioperative death in the sample was reported from WI. Severe sepsis after transplant was the cause of death [Table 5] Overall, there was no statistically significant difference between the two insti­tutions in relation to complication rates (Chi­square value: 0.14, P > 0.05)
Table 5: Comparison of surgical complications at two institutions.

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   Discussion Top


Various studies conducted elsewhere have quoted different incidence rates of post trans­plant TB. A retrospective study involving 359 transplant patients in Tunisia recorded a post transplant TB infection in 9 (2.5%) patients. [1] Similarly, a study in Brazil involving 982 pa­ients over 21 years recorded a TB infection rate of 7.5%. [2] Both the studies have concluded that the risk of post transplant TB was signi­ficantly high. The risk of contracting TB de­pends on many factors other than immunosup­pression alone. In affluent countries with a low rate of TB in the community and better health care for transplant recipients, a lower rate of post transplant infections can be expected. This fact is high-lighted in a study carried out in Minnesota, USA, where out of 3921 patients transplanted over 18 years, only 18 (0.45%) had developed any type of mycobacterial infec­tion. [3] Adding a different dimension to the issue is the effect of immunosuppressant regime on vulnerability to TB. A retrospective study in Turkey on 443 post transplant patients showed that those who are on immunosuppresants such as tacrolimus or mycophenolate mofetil are sig­nificantly more vulnerable to develop post trans­plant TB earlier than those on azathioprine. However, there was no significant difference between the two groups regarding clinical and radiographic presentations or outcomes. [4]

The incidence of post transplant CMV infec­tions varied from 24 to 92%, as reported in va­rious studies. Only 15-77% of patients showed clinical symptoms. [5] The problem in using serological tests to diagnose CMV infections is that they are positive in almost all people in the general population due to asymptomatic past infection (IgG positivity). In a prospective study done in Brazil involving 34 transplant patients, all the patients were shown to be in­fected with CMV prior to transplantation, by serological tests. However, only 7 (21.2%) people developed symptomatic post transplant CMV infections. [6]

Patient survival after transplantation is ano­ther issue considered in our study. This is inva­riably affected by the health care infrastructure of the country. In a retrospective analysis in­volving 2200 transplants in China, the 1-year patient survival rate was 85.4%. [7] A retrospec­tive study involving seven transplant centers in Europe revealed a 2-year patient survival ran­ging from 60.2 to 85.3% before risk strati­fication. Following risk stratification, it was shown that in the high-risk group, the 2-year survival was 27.4%, and for the low-risk group, it was 100%. Factors taken into consi­deration for risk stratification were comorbi­dities and age at which renal replacement therapy was started. [8]

Protection with a lymphocyte depleting agent (monoclonal or polyclonal antibodies) or an interleukin-2 (IL-2) receptor antagonist is known to reduce the rejection rates in the first few weeks following transplant. Since acute rejec­tion heavily influences graft survival, these drugs may contribute positively toward a better long-term outcome. However, it was signi­ficant to note that induction therapy did not lower the rate of acute rejection in our sample.

In conclusion, in this retrospective analysis, 2-year survival of recipients was 75%. The rate of post transplant TB was higher and a fewer CMV infections were noted in our pa­tients. Our study, being of smaller size, has many limitations; however, it is a step in main­taining the database and assessing the Sri Lankan renal transplant program.


   Acknowledgments Top


The authors would like to acknowledge the support of the staff of the Faculty of Medicine, University of Colombo, staff of ward 41 and 48B of the National Hospital of Sri Lanka and the staff and management of the Western In­firmary.

 
   References Top

1.Kaaroud S, Beji S, Boubaker K, et al. Tuber­culosis after renal transplantation. Transplant Proc 2007;39:1012-3.  Back to cited text no. 1
    
2.Matuk TA, Brasil P, Alvarenga Mde F, et al. Tuberculosis in renal transplants in Rio de Janeiro. Transplant Proc 2004;36:905-6.  Back to cited text no. 2
    
3.Jie T, Matas AJ, Gilingham KJ, et al. Myco­bacterial infections after kidney transplant. Transplant Proc 2005;37:937-9.  Back to cited text no. 3
    
4.Atasever A, Bacakoglu F, Toz H, et al. Tuber­culosis in renal transplant recipients on various immunosuppressive regimens. Nephrol Dial Transplant 2005;20:797-802.  Back to cited text no. 4
[PUBMED]  [FULLTEXT]  
5.Wienand P, Grundmann R, Runde A, et al. Cytomegalovirus infections after kidney trans­plantation and passive immunization. Immun Infekt 1985;13:203-9.  Back to cited text no. 5
[PUBMED]    
6.Aquino VH, Fiqueiredo LT. Cytomegalovirus infection in renal transplant recipients diag­nosed by nested-PCR. Braz J Med Biol Res 2001;34:93-101.  Back to cited text no. 6
    
7.Tang Y, Zhang Y, Jia B. Analysis of 2200 kidney transplantations. Zhonghua Yi Xue Za Zhi 2001;81:82-5.  Back to cited text no. 7
[PUBMED]    
8.Khan IH, Campbell MK, Cantarovich D, et al. Survival on renal replacement therapy in Europe: Is there a 'centre effect'? Nephrol Dial Transplant 1996;11:300-7.  Back to cited text no. 8
[PUBMED]  [FULLTEXT]  

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Correspondence Address:
Senaka Rajapakse
Professor in Medicine, Faculty of Medicine, University of Colombo, Colombo
Sri Lanka
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PMID: 21196641

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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    Abstract
    Introduction
    Methodology
    Results
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