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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
RENAL DATA FROM THE ARAB WORLD  
Year : 2012  |  Volume : 23  |  Issue : 4  |  Page : 853-859
Short- and long-term outcomes of kidney donors: A report from Tunisia


1 Department of Medicine, Hedi Chaker Hospital, Sfax, Tunisia
2 Department of Pediatrics, Hedi Chaker Hospital, Sfax, Tunisia
3 Department of Urology, Hedi Chaker Hospital, Sfax, Tunisia
4 Department of Nephrology, Hedi Chaker Hospital, Sfax, Tunisia
5 Department of Urology, Fattouma Bourguiba Hospital, Monastir, Tunisia
6 Department of Nephrology, Fattouma Bourguiba Hospital, Monastir, Tunisia
7 Department of Cardiovascular Surgery, Military Hospital, Tunis, Tunisia
8 National Centre for Promotion and Organ Transplantation, Tunis, Tunisia

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Date of Web Publication9-Jul-2012
 

   Abstract 

Kidney transplantation remains the best treatment option of end-stage renal disease. Kidney donations are of particular interest with the currently increasing practice of living-donor transplantation. The purpose of this study was to analyze retrospectively the general health status as well as renal and cardiovascular consequences of living-related kidney donation. A total of 549 living-related kidney donors had donated their kidneys between 1986 and 2007. We attempted to contact all donors to determine short- and long-term outcome following kidney donation. All kidney donors who responded underwent detailed clinical and biochemical evaluation. The data were compared with age-matched health tables of the Tunisian general population. In all, 284 donors (52%) had a complete evaluation. They included 117 men and 167 women with a mean age of 42 ± 12 years. The major peri­operative complications that occurred in these donors included four cases of pneumothorax, six cases of surgical site infection, one case of phlebitis and one case of pulmonary embolism. None of the study cases died. The median length of hospital stay after donor nephrectomy was 6.5 days (range: 3-28 days). The median follow-up period was eight years. The mean creatinine clearance after donation was 90.4 ± 25 mL/min in men and 81.5 ± 27.2 mL/min in women. Proteinuria was >300 mg/24 h in 17 cases (5.9%). Fifty-eight (20.4%) donors became hypertensive and 19.6% of the men and 37.2% of the women became obese. Diabetes mellitus developed in 24 (8.4%), and was more common in patients who had significant weight gain. Our study suggests that kidney donors have minimal adverse effects on overall health status. Regular follow-up identifies at-risk populations and potentially modifiable factors. Creation of a national registry of living donors and their monitoring are an absolute necessity.

How to cite this article:
Helal I, Abdallah TB, Ounissi M, Tahar G, Cherif M, Boubaker K, Karoui C, Hamida FB, Adberrahim E, El Younsi F, Kheder A, Sfaxi M, Derouiche A, Chebil M, Hachicha J, Mehiri MN, Skhiri H, Elmay M, Harzallah K, Elmanaa MJ, Hmida J. Short- and long-term outcomes of kidney donors: A report from Tunisia. Saudi J Kidney Dis Transpl 2012;23:853-9

How to cite this URL:
Helal I, Abdallah TB, Ounissi M, Tahar G, Cherif M, Boubaker K, Karoui C, Hamida FB, Adberrahim E, El Younsi F, Kheder A, Sfaxi M, Derouiche A, Chebil M, Hachicha J, Mehiri MN, Skhiri H, Elmay M, Harzallah K, Elmanaa MJ, Hmida J. Short- and long-term outcomes of kidney donors: A report from Tunisia. Saudi J Kidney Dis Transpl [serial online] 2012 [cited 2014 Sep 20];23:853-9. Available from: http://www.sjkdt.org/text.asp?2012/23/4/853/98187

   Introduction Top


Kidney transplantation, particularly from a living donor, is the treatment of choice for most patients with end-stage renal disease (ESRD). [1] The first successful kidney trans­plant from a living donor was performed in the United States in 1954 by Joseph Murray in Boston, Massachusetts. Today, living-donor kidney transplantation is a well-established treatment of choice for the ever-increasing number of patients with ESRD, offering longer survival and a better quality of life at a lower cost than dialysis. [2],[3],[4],[5]

The number of living donors has been increa­sing worldwide. It remains the predominant source of organs in developing countries where cadaveric transplantation has yet to establish roots, because of the lack of infrastructure or implementation of appropriate legal criteria for brain-death. Even in developed countries, the increasing demand for kidneys has resulted in the growth of unconventional living-donor transplantation (LDT) in recent years.

In Tunisia, the incidence of ESRD is esti­mated to be 158.8 per million population, and the major source of donor organs is from a living person. [6] There are five transplant cen­ters offering renal transplantation. The transplant program was started at the Charles Nicolle Hospital in 1986 and, till 2007, of the 745 kid­ney transplantations performed, 549 (73.7%) were LDT.

Long-term renal and cardiovascular morbi­dity among kidney donors have been minimal according to numerous reports from developed regions. [7],[8],[9] The situation is different in deve­loping countries, and warrants a careful approach. [10] For these reasons, we decided to assess the short- and long-term health status of kidney donors for effects on blood pressure (BP), renal function and the development of proteinuria, diabetes and obesity after kidney donation.


   Materials and Methods Top


Study population

This is a retrospective multicenter study, in­volving all LDT performed between June 1986 and December 2007 in Tunisia. During this period, 549 LDT were performed; among them, 284 donors (52%) were available for partici­pation in the study.

To ascertain long-term outcomes, we attemp­ted to contact all donors (or their families) to ask about their current physical status. We then asked the graft recipients to ask the do­nors to fill out a questionnaire regarding cur­rent health. This questionnaire included the following: whether they were dead or alive, presence or history of renal problems (i.e., elevation of serum creatinine level or proteinuria), presence or history of other physical pro­blems including detection by periodical check­up and presence of hypertension, diabetes or hyperlipidemia at the time of inspection.

Hypertension was defined as systolic BP of >140 mmHg or diastolic BP >90 mmHg on more than one occasion. Proteinuria was de­fined as protein excretion >300 mg over 24 h. Diabetes was diagnosed according to the WHO criteria and obesity was defined as a body mass index (BMI) of >30 kg/m 2 , and over­weight as a BMI of 25-30 kg/m 2 .

Creatinine clearance (CrCl) was estimated using the Cockcroft and Gault formula. [11]


   Statistical Analysis Top


All these data were statistically analyzed by StatView 5 software. Categorical variables are presented as percentages, and continuous va­riables as means and standard deviations. We compared cardiovascular risk factors for kidney donors with those for the general population. [12]

For all analyses, P-values of less than 0.05 were considered to indicate statistical signi­ficance.


   Results Top


Data at the time of transplantation

In all, 284 donors (167 females, 58.8% and 117 males, 41.2%) were assessed at 2-15 years after donation, with a median follow-up of eight years. The mean age was 42 ± 12 years (range, 20-67 years); 164 donors were between 21 and 55 years, 31 were ≥55 years and in 89 donors, the age was not known at the time of donation [Table 1].
Table 1: The principle variables before donation in the 284 study patients.

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The educational level of donors was as fol­lows: no formal education in 84 cases (29.4%), primary education in 70 cases (24.6%), secon­dary education in 72 cases (25.3%), university education in 45 cases (15.8%) and unspecified in 14 cases (4.9%). Their marital status was as follows: married in 201 cases (70.9%), single in 57 cases (20%), divorced in four cases (1.4%) and widowed and unspecified in 11 cases each (3.9%). The occupational classification was as fol­lows: housewife, 118 cases (41.7%); manual or intellectual work, 118 (41.4%); unemployed 13 (4.5%); students, seven (2.5%); and not specified in 28 cases (9.9%).

Twenty-three donors (24.4) had a history of hypertension, six had anemia (2.1%) and four donors had pulmonary tuberculosis (1.4%).

A total of 61 cases (21.5%) had a family history of hypertension, 23 cases (8.2%) had family history of diabetes, 49 cases (17.2%) had family history of both hypertension and diabetes and 16 cases (5.6%) had family his­tory of chronic kidney disease.

The mean systolic blood pressure (SBP) was 119.8 ± 13.5 mmHg and the mean diastolic blood pressure (DBP) was 72.1 ± 10.1 mmHg. The mean BMI was 25.1 ± 4.1 (range, 16.6- 37.6) among men and 27.4 ± 4.8 (range, 19.5- 41) among women. The distribution of BMI was as follows: 26.9 in less than 44%, between 26.9 and 29 in 17.6%, higher than 30 in 15.5% and unspecified in 22.9% of the cases.

The mean serum creatinine level at the time of donation was 85.2 ± 15.6 μmol/L for men and 70.8 ± 13.4 μmol/L for women. The mean CrCl was 113.7 ± 28.6 mL/min (range: 60.7- 174.3 mL/min) for men and 104.9 ± 30.5 (range: 53.6-173.6 mL/min) for women. The majority of donors had CrCl greater than 80 mL/mn, while 27 (9.5%) had a CrCl that was less than 80 mL/min.

Of the 284 donors studied, three had macro-albuminuria and three other donors had blood sugar greater than 6.9 mmol/L.

Peri-operative complications

Serious complications were encountered in 18 cases (9%), and included the following: pneumothorax in four cases, surgical site infection in six cases, phlebitis in one case, incisional hernia in two cases, pulmonary em­bolism in one case and miscellaneous compli­cations in four cases.

None of the study patients died. The mean length of hospital stay after donor nephrectomy was 6.5 days (range, 3-28 days).

The long-term complications

The median follow-up period was eight years [Table 2]. The mean BMI at final evaluation was 26.2 ± 4.5 (range, 16-40.4) among men and 29 ± 5.7 (range, 16.9-46.8) among women; 36.3% of donors had BMI lower than 26.9 kg/m 2 , 18% between 26.9 and 29.9 kg/m 2 , 25.3% greater than 30 kg/m 2 and unspecified in 20.4%.
Table 2: Current health status of the living kidney donors at the time of study.

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The mean SBP was 131.7 ± 21 mmHg and the mean DBP was 77.8 ± 11.4 mmHg. Infor­mation on BP before and after nephrectomy was available in 192 cases (26.2%); 50 donors (19.7%) had hypertension at the time of this review (after mean follow-up of 100.1 ± 61.8 months) [Table 2].

The mean serum creatinine at last follow-up was 100 ± 19.3 μmol/L (range, 57-182) among men and 85.5 ± 30 μmol/L (range, 54-317) among women. The mean CrCl was 90.4 ± 25 mL/min (range, 36.7-162.2) in men and 81.5 ± 27.2 mL/min (range, 20.4-170.9) in women; 152 (54%) donors had CrCl greater than 60 mL/min, 59 between 30 and 59 and one donor had CrCl lower than 30 mL/min (this patient had an initial CrCl >80 mL/min).

Two donors required dialysis for ESRD three and six years after donation. The chronic renal failure was probably caused by nephrosclerosis. Seventeen donors (5.9%) developed proteinuria with an average of 0.7 ± 0.5 g/24 h (range, 0.6-1.7).

Diabetes mellitus type-2 was detected in 24 patients (8.4%). In the questionnaire designed to clarify renal problems, 17 of the 284 kidney donors answered that they had a renal pro­blem; some donors found that the information provided before transplantation was inade­quate and/or were not satisfied with the con­ditions of hospitalization.

Compared with the Tunisian general popu­lation [Table 3], the prevalence of hyperten­sion at last follow-up in both male (14.7%) and female donors (23.3%) was significantly lower than in the general population (35.9% and 46.2%, respectively). In addition, the pre­valence of diabetes mellitus or cardiovascular morbidities in kidney donors was similar to the age- and sex-matched general Tunisian popu­lation.
Table 3: Comparison of cardiovascular risk factors in living kidney donors and general population.

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   Discussion Top


The shortage of cadaveric organs has increased the number of living-related renal transplan­tations in our country as well as all over the world. [13],[14] The important factors predicting a successful outcome after living-related renal transplantation include strict donor selection criteria to minimize the risks to the donor, meticulous surgery and close follow-up of both donor and recipient.

We evaluated renal function, urinary protein excretion and blood pressure in 284 renal donors after a mean duration of eight years after nephrectomy. The study population repre­sented 52% of the live donor nephrectomy pool at Tunisia between 1986 and 2007. Because the patients who were not evaluated were similar to those who were, it is reasonable to gene­ralize conclusions for the entire group. Never­theless, it is possible that the relatively low sampling ratio could bias the results. Our results indicate that the cardiovascular risk factors in kidney donors are similar to that of persons who have not donated a kidney. The risk of ESRD does not appear to be increased among donors, and their current health seems to be similar to that of the gen­eral population. In addition, their quality of life appears to be excellent. These outcomes may be a direct consequence of routine scree­ning of the donors for important health condi­tions related to kidney disease at the time of donation. At follow-up, most of the donors in our study had a CrCl higher than 60 mL/min; only 5.9% had albuminuria. Moreover, the rate of change in the CrCl did not appear to accelerate over time. The prevalence of hypertension in kidney donors was similar to that in the general population who were matched for age and sex, even one decade after donation [Table 3].

The effects of kidney donation in different countries could vary owing to unique genetic backgrounds and ethnicities as well as environ­mental factors. [15] Most of the trials reviewed above were conducted in developed countries. Recently, the results of two studies from deve­loping countries have shown differences in donor outcomes. [4],[15]

Azar and colleagues, [4] in Iran, evaluated 86 donors after a mean of 17.24 months following nephrectomy. None of the study patients died, but there was a complication rate of 54.6%, including hypertension in 37.5%, half of whom had a positive family history. Although renal function was normal before donation, six pa­tients had a serum creatinine level of 1.4 mg/dL or more after the nephrectomy; micro-albuminuria was observed in nine patients and hematuria was observed in 12. The authors claimed to have observed a higher rate of donor hypertension and proteinuria compared with other studies, and concluded that dona­tion is "not so safe."

In a study from Sahay and associates looking at the "Indian Perspective," 50 donors were followed-up after a mean interval of 63 months following donor nephrectomy. They found that 22 had developed hypertension; these included seven donors who had a positive family his­tory of hypertension. Twenty of the donors had developed microalbuminuria and seven had developed overt proteinuria. There was a sig­nificant reduction in glomeral filtration rate (GFR) as well as increase in renal length after nephrectomy (P <0.05), but the changes in the creatinine levels were not significant. Although there were no deaths among the donors, hypothyroidism developed in one donor and type-2 diabetes mellitus developed in another. They concluded that kidney donation is safe and that Indian donors do not respond any differently after nephrectomy than their Western counter­parts. However, hypertension and renal func­tion abnormality seemed to be more common in Indian donors than in donors in the West. [15]

Although increased long-term mortality has not been reported in healthy persons after nephrectomy, [16] convincing data on long-term survival of kidney donors were first presented by Fehrman-Ekholm et al in 1997. [17] Twenty years after kidney donation, the observed to expected mortality of these 430 donors was 0.76 when compared with the general popu­lation adjusted for age and gender. In a larger series of 1332 Norwegian kidney donors followed-up for an average of 32 years, the relative risk of mortality was 0.7 for female and 0.5 for male donors compared with the general population. [18] An increased survival may not be surprising as the donors are posi­tively selected and screened for disease. [19] Therefore, it is of further interest that the Norwegian male donors had the same relative risk for mortality as in another screened popu­lation accepted for health insurance. Thus, there are no indications that kidney donation has any negative impact on long-term survival.

In conclusion, live kidney donation does not have a major detrimental effect on the health of the donor. Although renal function and blood pressure may worsen slightly, levels remain comparable to those of age-matched persons in the general population. With improved sur­gical techniques and medical therapy, live­donor transplant is set to be used even more frequently. However, there is a clear need for a more-thorough and structured follow-up proto­col for donors to ensure optimal care as well as for research purposes to provide increased information to help safely expand the donor pool. Clearly, transplant centers need to deve­lop a registry or some other system to ensure long-term follow-up of kidney function after living donation.

 
   References Top

1.U.S. Renal Data System. USRDS 2007 annual data report: Atlas of chronic kidney disease and end-stage renal disease in the United States. Bethesda, MD: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, 2007.  Back to cited text no. 1
    
2.Hase NK. Living donor kidney transplantation­-is it safe? J Assoc Physicians India. 2007;55: 263-4.  Back to cited text no. 2
[PUBMED]    
3.Davis CL, Delmonico FL. Living-donor kid­ney transplantation: a review of the current practices for the live donor. J Am Soc Nephrol 2005;16:2098-110.  Back to cited text no. 3
[PUBMED]  [FULLTEXT]  
4.Azar SA, Nakhjavani MR, Tarzamni MK, Faragi A, Bahloli A, Badroghli N. Is living kidney donation really safe? Transplant Proc 2007;39:822-3.  Back to cited text no. 4
[PUBMED]  [FULLTEXT]  
5.Sener A, Cooper M. Live donor nephrectomy for kidney transplantation. Nat Clin Pract Urol 2008;5:203-10.  Back to cited text no. 5
[PUBMED]  [FULLTEXT]  
6.Counil E, Cherni N, Kharrat M, Achour A, Trimech H. Trends of incident dialysis patients in Tunisia between 1992 and 2001. Am J Kidney Dis 2008;51:463-70.  Back to cited text no. 6
[PUBMED]  [FULLTEXT]  
7.Ramcharan T, Matas AJ. Long-term (20-37 years) follow-up of living kidney donors. Am J Transplant 2002;2:959-4  Back to cited text no. 7
    
8.Fehrman-Ekholm I, Duner F, Brink B, Tyden G, Elinder CG. No evidence of accelerated loss of kidney function in living kidney donors: Results from a cross-sectional follow-up. Transplantation 2001;72:444-9  Back to cited text no. 8
    
9.Kasiske BL, Ma JZ, Louis TA, Swan SK. Long­term effects of reduced renal mass in humans. Kidney Int 1995;48:814-9.  Back to cited text no. 9
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10.Rizvi SA, Naqvi SA, Jawad F, et al. Living kidney donor follow-up in a dedicated clinic. Transplantation 2005;79:1247-1.  Back to cited text no. 10
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11.Cockcroft DW, Gault MH. Prediction of creatinine clearance from serum creatinine. Nephron 1976;16:31-41.  Back to cited text no. 11
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12.Ben Romdhane H, Grenier FR. Social deter­minants of health in Tunisia: The case-analysis of Ariana. Int J Equity Health 2009;8:9.  Back to cited text no. 12
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13.Matas AJ, Payne WD, Sutherland DE, et al. 2500 living donor kidney transplants: A single center experience, Ann Surg 2001;234:149-64.  Back to cited text no. 13
    
14.Vastag B. Living-donor transplants reexamined: experts cite growing concerns about safety of donors. JAMA 2003;290:181-2.  Back to cited text no. 14
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15.Sahay M, Narayen G, Anuradha. Risk of live kidney donation-Indian perspective. J Assoc Physicians India 2007;55:267-70.  Back to cited text no. 15
[PUBMED]    
16.Narkun-Burgess DM, Nolan CR, Norman JE, Page WF, Miller PL, Meyer TW. Forty-five year follow-up after uninephrectomy. Kidney Int 1993;43:1110-5  Back to cited text no. 16
    
17.Fehrman EI, Elinder CG, Stenbeck M, Tyden GT, Groth CG. Kidney donors live longer. Transplantation 1997;64:976-8.  Back to cited text no. 17
    
18.Holdaas H, Hartmann A, Leivestad T, Fauchald P, Brekke IB. Mortality of kidney donors during 32 years of observation. J Am Soc Nephrol 1997;8:685A.  Back to cited text no. 18
    
19.Evaluation and selection of donors: Living kidney donors. Nephrol Dial Transplant 2000; 15:47-51.  Back to cited text no. 19
    

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Correspondence Address:
Imed Helal
Department of Medecine A, Charles Nicolle Hospital, Boulevard 9 Avril, 1006 Tunis
Tunisia
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DOI: 10.4103/1319-2442.98187

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