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Saudi Journal of Kidney Diseases and Transplantation
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RENAL DATA FROM ASIA - AFRICA  
Year : 2013  |  Volume : 24  |  Issue : 6  |  Page : 1280-1284
Intercity deceased donor renal transplantation: A single-center experience from a developing country


1 Department of Anesthesia and Critical Care, G. R. Doshi and K. M. Mehta Institute of Kidney Diseases and Research Center (IKDRC) - Dr. H. L. Trivedi Institute of Transplantation Sciences (ITS) Civil Hospital Campus, Asarwa, Ahmadabad, Gujarat, India
2 Department of Nephrology and Transplantation Medicine, G. R. Doshi and K. M. Mehta Institute of Kidney Diseases and Research Center (IKDRC) - Dr. H. L. Trivedi Institute of Transplantation Sciences (ITS) Civil Hospital Campus, Asarwa, Ahmadabad, Gujarat, India
3 Department of Urology, G. R. Doshi and K. M. Mehta Institute of Kidney Diseases and Research Center (IKDRC) - Dr. H. L. Trivedi Institute of Transplantation Sciences (ITS) Civil Hospital Campus, Asarwa, Ahmadabad, Gujarat, India
4 Department of Pathology, Laboratory Medicine, Transfusion Services and Immunohematology, G. R. Doshi and K. M. Mehta Institute of Kidney Diseases and Research Center (IKDRC) - Dr. H. L. Trivedi Institute of Transplantation Sciences (ITS) Civil Hospital Campus, Asarwa, Ahmadabad, Gujarat, India

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Date of Web Publication13-Nov-2013
 

   Abstract 

In a developing country such as India, deceased donor renal transplantation (DDRTx) accounts for only about 1% of all renal transplants (RTx). Our institute initiated an intercity DDRTx in the year 2006, which significantly increased the number of RTx. We retrieved 74 kidneys from 37 deceased donors from various cities of Gujarat from January 2006 to December 2009. We transplanted the allografts in 66 recipients and a retrospective analysis of the donor profile and management and recipient outcome was performed. The mean age of the donors was 43.3 ± 18.8 years. The causes of death included road traffic accident in 51.35% of the donors and cerebrovascular stroke in 48.65% of the donors; 83.78% of the donors required ionotropes for hemodynamic stability in addition to vigorous intravenous fluid replacement. The average urine output of the donors was 350 ± 150 mL. The organs were perfused and stored in HTK solution. The mean cold ischemia time (CIT) was 9.12 ± 5.25 h. The mean anastomosis time in the recipient was 30.8 ± 8.7 min. 57.6% of the recipients established urine output on the operating table and 42.4% developed delayed graft function. At the end of 1 month after transplantation, the mean serum creatinine was comparable to the Ahmadabad city DDRTx, although the CIT was significantly longer in the intercity patients. Intercity organ harvesting is a viable option to increase the donor pool. Distance may not be an impediment, and good recipient outcome is possible in spite of prolonged CIT in case of proper harvesting and preservation.

How to cite this article:
Mehta T R, Shah V R, Butala B P, Parikh G P, Parikh B K, Vora K S, Modi M P, Bhosale G P, Kadam P G, Shah P R, Gumber M R, Patel H V, Kute V B, Modi P R, Rizvi S J, Vanikar A V, Trivedi H L. Intercity deceased donor renal transplantation: A single-center experience from a developing country. Saudi J Kidney Dis Transpl 2013;24:1280-4

How to cite this URL:
Mehta T R, Shah V R, Butala B P, Parikh G P, Parikh B K, Vora K S, Modi M P, Bhosale G P, Kadam P G, Shah P R, Gumber M R, Patel H V, Kute V B, Modi P R, Rizvi S J, Vanikar A V, Trivedi H L. Intercity deceased donor renal transplantation: A single-center experience from a developing country. Saudi J Kidney Dis Transpl [serial online] 2013 [cited 2019 Aug 25];24:1280-4. Available from: http://www.sjkdt.org/text.asp?2013/24/6/1280/121283

   Introduction Top


Renal transplantation (RTx) is the best therapeutic modality for end-stage renal disease (ESRD). In India, the crude and age-adjusted incidence rates of ESRD are estimated to be 151 and 232 per million population, respectively. [1] The majority of the ESRD patients (>90%) in India and in other South Asian countries die within months of diagnosis as renal replacement therapy is not affordable or is not available. [2] The rate of RTx performed yearly in India translates to 3.25 per million population; the deceased donation rate is 0.08 per million population per year. [3]

The overall potential of organ donation following brain death in India is extremely high. The number of deaths due to road traffic accidents (RTAs) has increased in the recent years, and exceeds 110,000 per year. [4] If the current donation rate is pushed from 0.08 to 1 million population, it would provide all the livers, hearts and lungs that are required in the country and, to some extent, would satisfy the kidney shortage.

If the organ donation rate is increased to 2/million, we can replace the living related source with a deceased donor program. However, there are many obstacles in the development of this program, such as lack of awareness, religious stigmas, emotionally difficult situation, lack of trained personnel to run the infrastructure logistics, lack of a common platform to structure a collaborative work and lack of resources and an organ sharing network. Deceased donor renal transplantation (DDRTx) in India is low despite tremendous potential. Our DDRTx program can be considered fairly successful for the Indian context due to the active steps taken by our institute in the form of increased public awareness on need for organ donation, participation of general hospitals in the identification of potential donors, reduction in transplantation cost, early brain death identification, committed and integrated rapid response team capable of transporting potential donor to hospitals in a timely manner, improvement in transportation, communication network, successful organ retrieval, adequate hospital infrastructure and support logistics, inclusion of expanded criteria donors and positive support from the local government and non-government organizations.

We initiated an intercity organ harvesting program in the year 2006 and our team went to the different cities of Gujarat for organ procurement. This significantly increased the number of DDRTx to 45 cases/year.

We aim in this study to evaluate the intercity organ harvesting program and its contribution to the total deceased organ procurement.


   Materials and Methods Top


This is a retrospective analysis of our intercity DDRTx from January 2006 to December 2009. We procured kidneys from 37 deceased donors from various cities of Gujarat and transplanted them in 66 recipients.

When volume resuscitation was not sufficient to improve the blood pressure of the donor because of a loss of vascular tone, ionotropic pressor support in the form of dopamine, dobutamine or noradrenaline or vasopressin were administered. A heparin dose of 25000 units was infused in all donors. Ventilation support was withdrawn when the aorta was clamped and in situ perfusion was started.

The procured kidneys were perfused and preserved in HTK solution till the beginning of vascular anastomosis in the recipient. Post-transplant graft function was monitored using clinical and serum creatinine (SCr). The patients were considered to have delayed graft function (DGF) if they required hemodialysis within the first week of RTx. The 1-month SCr levels were obtained in the recipients. Data were compared with the Ahmadabad city DDRTx.

All recipients received a single dose induction with rabbit-anti-thymocyte globulin (r-ATG) (1.5 mg/kg) and methylprednisolone (MP) 500 mg intravenously, and MP was continued for 3 days post-operatively. Maintenance immunosuppression consisted of prednisolone (20 mg/day tapered to 10 mg/day at 1 - 3 months post-transplantation and 5 - 10 mg/day continued thereafter), mycophenolate mofetil (MMF) (2 g/day) and calcineurin inhibitors (CNI) [cyclosporine (CsA) 5 mg/kg body weight/day or tacrolimus 0.08 mg/kg body weight/day]. Doses of CNI were adjusted as per trough levels (C0) by the fluorescence polarization immunoassay (FPIA) method in the initial 2 - 3 months; thereafter, it was performed in the event of graft dysfunction due to economic constraints. Cyclosporine dosing was adjusted to achieve target C0 concentrations of 200 - 300 ng/mL during the first 2 - 3 months after transplantation, 100 - 250 ng/mL up to 6 months after transplantation and ~100 ng/mL thereafter. Tacrolimus dosing was adjusted to achieve target C0 concentrations of 5 - 15 ng/mL during the first 2 - 3 months after transplantation and 4 - 8 ng/mL thereafter. All patients received prophylaxis against cyto-megalovirus infection (gancyclovir 1 g thrice a day × 3 months), fungal infections (fluconazole 100 mg once a day × 6 months) and Pneumocystis carinii pneumonia (trimethoprim/sulfamethaxazole 160/800 mg once a day × 9 months).


   Statistical Analysis Top


Statistical analysis was performed using SPSS Version 12. Data were expressed as mean ± SD for continuous variables and number (%) for categorical variables. Continuous variables were compared using the independent t-test with two-tail significance. P-values <0.05 were considered to be statistically significant.


   Results Top


The mean age of the donors was 43.3 ± 18.8 years (range of 5 - 82 years); 22 donors were male and 15 were female. The cause of death was RTA in 51.4% of the donors and cerebrovascular accidents (CVA) in 48.7% of the donors. The average duration of ventilator support was 3.5 ± 1.5 days and duration of vasopressor was 1.5 ± 0.6 days. Average SCr at the time of harvesting was 1.5 ± 0.3 mg/dL, and 83.8% of the donors were on ionotropes. The average urine output was 350 ± 150 mL and the average fluid infused was 2.5 ± 1.5 L [Table 1].
Table 1: Deceased donor demographics.

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The mean age of the recipients was 36.3 ± 14.5 years (8 - 70 years) and 48 of the participants were male while 18 were female. A total of 11 patients underwent a second transplant, and in eight patients dual transplantation was performed. The mean anastomosis time was 30.8 ± 8.7 min, and in 57.6% (n = 36) the urine output was established on table immediately after clamp release [Table 2]. A total of 42.4% (n = 28) patients developed DGF. At the end of 1 month, the mean SCr was comparable to the Ahmadabad city DDRTx, although the CIT was significantly longer in the intercity patients [Table 3].
Table 2: Recipient demographics.

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Table 3: Post-transplant data.

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   Discussion Top


The initial function of the transplanted organ is the critical factor in the long-term outcome, which is influenced by the underlying injury processes in the deceased donor and organ preservation. [5],[6] Systemic hypotension is common with brain dead deceased donors (up to 80%), and may be caused by the lack of sympathetic tone, central diabetes insipidus, adrenal insufficiency and/or deliberate volume restriction prior to the determination of brain death. [5] Adequate volume resuscitation is therefore critically important to ensure donor viability and is the first step in correcting low blood pressure, and can be followed by the use of vasopressors; [6],[7] 80% of our deceased donors required vasopressor support.

The process of harvesting the donor kidney can give rise to direct renal injury and vasospasm, which in itself can cause damage to the kidney in the period following transplantation, resulting in acute tubular necrosis (ATN).

CIT is one of the main risk factors in determining renal function in intercity DDRTx, and is the most important independent predictor of DGF. [8] It has a deleterious effect on renal quality as it has a propensity to trigger acute rejection and ischemia reperfusion injury. The rate of DGF after DDRTx ranges between 15% and 30%. [8],[9] In general, the risk factors for early graft loss include re-transplantation, longer CIT and acute rejection episodes. [10] Forty percent of our patients had DGF; however, at the end of 1 month, their creatinine level was around 1.26 ± 0.5, which was comparable to intercity patients without DGF. At the end of 1 month, the SCr was comparable in all these patients.

The most commonly used solutions for allograft preservation include that of the University of Wisconsin, HTK, Eurocollins and Marshall. We have used HTK, with which we can safely increase the CIT up to 24 h. A large multicentric analysis has shown that with the currently used preservation techniques, a time interval of up to 18 h is safe for graft survival and graft function. [11] The reason for the association of anastomosis time with DGF may be re-warming. Alternatively, prolonged anastomosis time may reflect issues such as excessive handling of blood vessels, resulting in vasospasm and subsequent ATN. [12]

Finally, the centers usually report remarkable differences in the quality of kidney they harvest, which may contribute to differences in the long-term results. Intensive Care Unit care and skill of the donor maintenance and harvesting team may be a contributing factor.

We conclude that in the circumstances of organ shortage, an intercity deceased donor organ harvesting program has the potential to expand the donor pool and shorten the waiting list for RTx, especially in a developing country like India. Distance may not be an impediment and good recipient outcome is possible in spite of a prolonged CIT if proper harvesting and preservation are carried out.

 
   References Top

1.Modi GK, Jha V. The incidence of end-stage renal disease in India: A population-based study. Kidney Int 2006;70:2131-3.  Back to cited text no. 1
    
2.Abraham G. The challenges of renal replacement therapy in Asia. Nat Clin Pract Nephrol 2008;4:643.  Back to cited text no. 2
    
3.Khanna U.The economics of dialysis in India. Indian J Nephrol 2009;19:1-4.  Back to cited text no. 3
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4.Abraham G, Shroff S, Nayak KS, et al. Deceased donor renal transplantation program in India. Kidney Int 2010;77:378-80.  Back to cited text no. 4
    
5.Wood KE, Becker BN, McCartney JG, D'Alessandro AM, Coursin DB. Care of potential organ donor. N Engl J Med 2004;351: 2730-9.  Back to cited text no. 5
    
6.Smith M. Physiologic changes during brain stem death.-lessons for management of the organ donor. J Heart Lung Transplant 2004;23 (9 Suppl):S217-22.  Back to cited text no. 6
    
7.Szabo G. Physiologic changes after brain death. J Heart Lung Transplant 2004;23(9 Suppl): S223-6.  Back to cited text no. 7
    
8.Mikhalski D, Wissing KM, Ghisdal L, et al. Cold ischemia is a major determinant of acute rejection and renal graft survival in the modern era of immunosuppression. Transplantation. 2008;85(7 Suppl):S3-9.  Back to cited text no. 8
    
9.Quiroga I, McShane P, Koo DD, et al. Major effects of delayed graft function and cold ischaemia time on renal allograft survival. Nephrol Dial Transplant 2006;21:1689-96.  Back to cited text no. 9
    
10.Mani MK. Review article, development of cadaver renal transplant in India. Nephrology 2002;7:177-82.  Back to cited text no. 10
    
11.Opelz G, Döhler B. Multicenter analysis of kidney preservation. Transplantation 2007;83: 247-53.  Back to cited text no. 11
    
12.Renal injury and preservation in transplant-tation - Philip F. Halloen Chapter 6 - Kidney transplant rejection; diagnosis and treatment - 3 rd ed. 1998 p. 149-76.  Back to cited text no. 12
    

Top
Correspondence Address:
T R Mehta
Department of Anesthesia and Critical Care, IKDRC-ITS, Asarwa, Ahmadabad - 380016, Gujarat
India
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DOI: 10.4103/1319-2442.121283

PMID: 24231504

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