Year : 1996 | Volume
: 7 | Issue : 2 | Page : 139--144
Some of the Lessons Learnt from Renal Transplant Recipients Cared-for at the Riyadh Armed Forces Hospital
Abdullah A Al-Khader, Mohamed H Al-Sulaiman, Dujana H Mousa, Fahad Al-Hawas
Department of Nephrology, Armed Forces Hospital, Riyadh, Saudi Arabia
Abdullah A Al-Khader
Director of Nephrology, Riyadh Armed Forces Hospital, P.O. Box 7897, Riyadh 11159
The first-ever renal transplantation in Saudi Arabia was carried out at the Riyadh Armed Forces Hospital in March 1979. Since then, 480 renal transplants have been performed in our institution and we have also followed-up many patients who have been transplanted outside the Kingdom. Over 85% of our patients are on cyclosporin-based immunosuppression and the mean follow-up was 3.4 years. In this paper, we summarize our experiences and findings in the field of renal transplantations.
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Al-Khader AA, Al-Sulaiman MH, Mousa DH, Al-Hawas F. Some of the Lessons Learnt from Renal Transplant Recipients Cared-for at the Riyadh Armed Forces Hospital.Saudi J Kidney Dis Transpl 1996;7:139-144
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Al-Khader AA, Al-Sulaiman MH, Mousa DH, Al-Hawas F. Some of the Lessons Learnt from Renal Transplant Recipients Cared-for at the Riyadh Armed Forces Hospital. Saudi J Kidney Dis Transpl [serial online] 1996 [cited 2020 Apr 2 ];7:139-144
Available from: http://www.sjkdt.org/text.asp?1996/7/2/139/39515
In March 1979, a girl donated her kidney to her father and the transplantation was carried out at the Riyadh Armed Forces Hospital (RAFH). This was the first-ever renal transplant to be carried out in the Kingdom of Saudi Arabia. Development of renal transplantation at RAFH has occurred in planned phases starting with a live related transplant (1979), cadaveric kidneys donated from abroad (1983), pediatric renal transplantation (1983) and transplantation from locally harvested cadaveric kidney (1984)  . Our institution is honored to have been the pioneer in the Kingdom in all above categories. Concomitant with the above clinical achievements, the RAFH managed, very earlier on, to have Saudi medical staff responsible for looking after all aspects of renal transplantation. By the end of 1995, 480 renal transplants have been performed in our institution. A large sum of experience has accumulated in dealing with renal transplantation performed in RAFH as well as the large number of renal transplant recipients returning from various countries notably USA, Europe and India who have been followed-up at our center. Additionally, the center has progressed from a purely clinical oriented service to a center providing clinical research on specific problems related to Saudi patients as wel1 as animal based experiments, started two years ago, related to aspects of immunosuppression. This paper describes in brief, what we have learned over the last 15 years from looking after over 1000 renal transplant recipients, whose mean follow-up period is 3.4 years. Only 5% of the patients received more than one transplant and over 85% of the patients are on cyclosporinbased immunosuppression. This paper is not meant to review the literature but to summarize our experience and findings in this field.
Graft and Patient Survival: Influence of Various Factors
We were fortunate to have had access to cyclosporin (CyA) from 1982. One of our earliest studies regarding outcome comparing azathioprine and CyA in live related transplants was published in 1987  [Figure 1]. We have noticed an improvement in oneyear graft survival of 11.4% in patients on CyA; however, no difference was noted in patient survival between the two groups. Another significant observation was that the incidence of rejection episodes dropped from 40% to 10% with the use of CyA as compared to conventional immunosuppression.
We have recently, together with Dr. Shaheen's group looked into the results of 406 live related transplants after a mean follow-up period of 4.6 years for the effect of disparity in HLA matching, gender, age and weight between donor and recipient. The overall patient and graft survival were 92.4% and 84.5% respectively. We found no significant difference in graft survival between zero haplotype, one haplotype and two-haplotype matched transplants. Also, we found no difference regarding gender, weight or age of donor and recipient (in press).
One unique experience we had to deal with was the kidneys donated from Europe, between the years 1983 to 1987, which were engrafted after a very long cold ischemia time (mean 46.6 hrs; range 24 to 70). We looked into the short-term results in these patients  and found that the 6month graft survival was 88% and patient survival was 92%, even with no attention being paid to the degree of HLA matching. Analysis of the long-term results in these kidneys with long cold ischemic time showed three-year graft and patient survival to be 70.2% and 91.4% respectively in those patients whose grafts survived longer than one year  [Figure 2].
One of the problems associated with longterm use of CyA is chronic nephrotoxicity and possible poor long-term results. We analyzed our long-term results in CyAtreated living (n = 93; [Figure 3]) and cadaveric donor renal transplants (n = 130; [Figure 4]) in the grafts which survived more than one year  . The results were really impressive, showing 3-year graft survival rates of 92% and 95% in live donor and cadaveric donor transplants respectively.
A significant number of patients that we cared-for received their kidneys in India. Leaving aside the ethical aspects of such transplantations, we noticed, initially, high incidence of morbidity, mortality and HIV infection in patients returning from India after renal transplantation  . Our more recent observation, however, showed a very clear improvement in patient and graft survival as well as reduction in morbidity  . The pediatric age-group constitutes 50% of the total Saudi population. We have reported earlier our experience in caring for patients in this age-group  , wherein, amongst 25 children (mean age 10.3 yrs), we achieved one-year patient and graft survival of 100% and 75.2% respectively  . All the four neonatal kidneys used were lost which led us not to use neonatal kidneys anymore. Hereditary/congenital diseases were a major cause of renal failure in these patients. One point of particular interest is the development of in anti-GBM disease in the transplanted kidneys of two of our patients whose original renal disease was Alports disease  .
Specific Infections Encountered following Renal Transplantation
Tuberculosis is fairly common in the Kingdom of Saudi Arabia. It is, therefore, not surprising that we noted an increase in the incidence of tuberculosis following renal transplantation (4.1%)  . Since that report was written we have noticed that the incidence has remained the same. It is of interest to note that tuberculous interstitial nephritis, an unusual presentation in the general population, is a common finding in the transplant population and should be suspected in patients who present with pyrexia of unknown origin, unexplained graft function deterioration or weight loss, and can only be confirmed by renal histology. We noted earlier on, that rifampicin causes a marked drop in CyA levels and have found that, in order to keep CyA levels in the therapeutic range, one needs to quadruple the basal CyA dose and give it thrice daily  .
We had an epidemic of Pneumocystis carinii infection some years ago which occurred in patients within the first six months post-transplantation  . This infection is best diagnosed by bronchoalveolar lavage or lung biopsy. Over the last five years, we have routinely used cotrimoxazole prophylactically during the first six months post-transplantation. With this regimen, we had no new cases of Pneumocystis carinii. The prognosis of this infection is generally good if the diagnosis is made early and treatment with high dose co-trimoxazole is instituted.
Hepatitis B and C
Hepatitis B infection is common in the Kingdom of Saudi Arabia. Our experience is that it is safe to transplant patients who are hepatitis B surface antigen (HBsAg) positive provided that their liver biopsy is normal or shows minimal changes and that they are delta antigen negative  . We looked into 52 patients who were HBsAg positive and found that, provided they had normal liver biopsy prior to transplantation and were delta antigen negative, their graft survival was similar to HBsAg negative patients. Also, the liver disease did not progress significantly. If, however, they were delta antigen positive, there was almost universal progression of their liver disease.
Since HBsAg carrier rate in Saudi Arabia is high, we looked into the possibility of using such carriers as kidney donors. We found that it is safe to use HBsAg positive kidney donors, provided that, the recipient is immune. The recipient is given booster vaccination against hepatitis B virus as well as hyperimmune globulin just prior to the transplantation  . Hepatitis C virus (HCV) is a serious health problem as it occurs in 70% of our dialysis population  and can lead to serious consequences post-transplantation  . We have looked into our post-transplant population and found that 54% are HCV positive. Of these, 28% had evidence of chronic liver disease. Twenty three of these patients were biopsied and significant histological abnormalities were found in 15 patients , . It is, therefore, advisable to subject HCV positive recipients to liver biopsy and, if significant liver pathology is found, interferon therapy should be given until evidence of persistent remission is detected.
Human Immunodeficiency Virus (HIV)
Earlier on, between the years 1980 and 1988, we had a number of HIV infected dialysis and transplant patients (due to kidneys or blood received from abroad). Fortunately, this number is diminishing. Our experience in HIV infection post-transplantation and in patients on dialysis has been described earlier  . We discovered that transmission does not occur through dialysis. Since we wrote that report all the patients with HIV infection have died.
A diarrheal disease we commonly encountered post-transplantation is non-typhoid salmonellosis  . This was usually associated with fever and a high white cell count. It was at times, associated with renal function deterioration (often temporary) and in 25% of the cases, it was recurrent. Amoxycillin and ciprofloxacin for prolonged periods were effective in treating this infection. In recurrent cases, carrier status (gall bladder disease or urinary tract abnormality) should be excluded. We also encountered cases of Campylobacter jejuni infection presenting with diarrhea  .
Deep Fungal Infections
Surprisingly, fungal infections are rare in our transplant population. We have seen only nine cases of deep fungal infections. These included; five cases of nocardiosis (two skin and one each of lung, brain and abdomen), one case of aspergillosis (orbital), two cases of mucormycosis (one lung and one naso-pharyngeal) and one case of cryptococcosis (central nervous system). Apart from the cases with nocardiosis and the case with nasopharyngeal mucormycosis, all the remaining died as a result of the infection.
Malignancy post-transplant is well known. Our experience shows that the prevalence of post-transplant malignancies is 6.5%  . The majority was due to Kaposi's sarcoma (75% of all cases); others were solid tumors and non-Hodgkin's lymphoma was seen in four cases  . We have developed a method for assessment and therapy of Kaposi's sarcoma based mainly on reduction or cessation of the immunosuppressive therapy ,, . Children with Kaposi's sarcoma seem to be particularly prone to pulmonary Kaposi without skin involvement and the prognosis in them is poor  .
We have a unique experience in dealing with pregnancy post-transplantation; 50 pregnancies in 45 patients , . With careful follow-up by the nephrologist and the obstetrician it is possible to attain good results for both mother and the fetus, although there is an increased incidence of hypertension and urinary tract infection in the mother as well as pre-term delivery by cesarean section. There is also an increase in the requirement for CyA in the second trimester of pregnancy. It seems that there are no long-term adverse effects of CyA use during pregnancy on the renal function of the offsprings  .
Fasting and Renal Transplantation
With increasing experience post-transplantation, it is now clear that kidney transplant recipients with good graft function, operated on at least 6-12 months earlier, can fast during Ramadan with no adverse effects  . In collaboration with Dr. Shaheen (unpublished data) we have studied 58 patients post-transplantation during Ramadan by weekly measurement of blood pressure, weight, renal function, urinary osmolality and sodium. Their mean plasma creatinine at the beginning of the study was 136 µmol/L (range 74 to 209). We could not detect any deterioration in renal function in any of the patients due to fasting.
Finally, renal transplantation In the Kingdom of Saudi Arabia is now a practical and feasible proposition especially with the tremendous efforts of the Saudi Center for Organ Transplantation. Our patients have taught us a great deal both in terms of human and medical endeavors. We are grateful and dedicate this paper to them.
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