Year : 1996 | Volume
: 7 | Issue : 2 | Page : 153--156
Renal Transplantation at the Jeddah Kidney Center
Faissal A.M Shaheen, Iftikhar Ahmed Sheikh, Abdullah Fallatah, Ahmed Bayoomi Shehab, Lubna Al-Menawy, Abdullah Awad, Nabeel Nezamuddin
Jeddah Kidney Center, King Fahd Hospital, Jeddah, Saudi Arabia
Faissal A.M Shaheen
Director & Consultant Nephrologist, Jeddah Kidney Center, King Fahd Hospital, Jeddah
Renal transplantation is the optimal treatment for patients with end-stage renal failure. During the period 1991 to 1995, a total of 279 renal transplantations were performed at the Jeddah Kidney Center. They included 115 kidneys from cadaveric donors and 164 living related donor transplants. There were 160 males and 119 females; age of the patients ranged between 4 and 45 years. During the follow-up period, 32 grafts were lost and 26 patients died. The overall 5-year graft and patient survival rates were 79.2% and 90.7% respectively. Sepsis and pulmonary embolism constituted the common causes of death.
|How to cite this article:|
Shaheen FA, Sheikh IA, Fallatah A, Shehab AB, Al-Menawy L, Awad A, Nezamuddin N. Renal Transplantation at the Jeddah Kidney Center.Saudi J Kidney Dis Transpl 1996;7:153-156
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Shaheen FA, Sheikh IA, Fallatah A, Shehab AB, Al-Menawy L, Awad A, Nezamuddin N. Renal Transplantation at the Jeddah Kidney Center. Saudi J Kidney Dis Transpl [serial online] 1996 [cited 2020 Mar 31 ];7:153-156
Available from: http://www.sjkdt.org/text.asp?1996/7/2/153/39518
Renal transplantation is unique among organ transplantations because living donors are available. This, among other reasons, has resulted in the enormous experience that has been gained by physicians in recent years in the follow-up of renal transplant patients. Every nephrology center of repute has an active renal transplant program and in many centers, transplantation is the main activity. With improvement in the success rate that has been achieved so far, renal transplantation has become the optimal treatment for patients with end-stage renal disease; also, the absolute contraindications to renal transplantation are very few.
The major problem confronting us is that the number of new patients requiring renal replacement therapy each year has far outnumbered the dialysis slots available as well as the number of donor organs available, Non-availability of donor organs is thus, the limiting factor for renal transplantation and the present trend at our center is to request the patients' family for kidney donation soon after he/she is started on dialysis treatment. It is our experience that the donors come forward readily to donate, as the family is sympathetic towards the patient at this Stage.
In this brief report, we will summarize our activity during the period from 1991-1995 in the field of renal transplantation.
Materials and Methods
The King Fahd Hospital at Jeddah, is one of the major organ donating hospitals in the Kingdom. On many occasions, organs including liver, heart and kidneys have been flown from this hospital to other parts of the Kingdom for patients requiring urgent transplantation. During the period 1991 to 1995, a total of 279 kidneys have been transplanted at our center. In 1991, only 19 renal transplants were performed of which, 14 kidneys were procured from cadaveric donors while five were donated by living donors. In 1992, the renal transplant program received a boost when a renal transplant team was created locally including two renal transplant surgeons. Towards the end of that year, the difference was clear and the number of renal transplants doubled, compared to the previous year. Thus, in 1992, a total of 44 renal transplants were performed. Of these, 16 kidneys were obtained from cadaveric donors and 28, from living related donors.
When the patients on regular hemodialysis treatment at our center watched the improvement in quality of life of the patients following renal transplantation, many of them started to bring their family members as donors. It gave a further boost to the renal transplant program and in 1993, 71 kidneys were transplanted including 45 from living donors. In 1994, the number of renal transplants performed at our center reached a peak of 73, which was the highest number on record from any single center in the Kingdom during that year. The performance in 1995 continued to be good and a total of 72 renal transplants were performed.
All renal transplant patients are followedup by the transplant team in the transplant clinic regularly; once a week in the first month post-renal transplant and fortnightly for the next three months. Thereafter, the patients are seen by their respective group consultants in their clinics every 4-6 weeks. We have collected the data after a 5-year follow-up of our patients.
The protocols for the immunosuppressive and anti-rejection treatments were decided at the beginning of the renal transplant program. We have used different protocols for different groups of patients as follows:
a) Living donor transplants with fullhouse HLA match:
Conventional immunosuppression [Table 1]
b) Living related donor with one haplotype match and cadaveric donor transplants with unknown HLA match:
Triple drug immunosuppressive treatment was used as follows: Pre-operative: Cyclosporin (5 mg/kg/ day) and azathioprine 50 mg daily. Peri-operative: Methyl prednisolone 500 mg intravenous
Post-operative: Methyl prednisolone 250 mg for 3 days and tapered every 2 days, azathioprine 1-3 mg/kg/day, cyclosporin 8 mg/kg/day
c) Pediatric renal transplants, living or cadaveric donor:
Pre-operative: Cyclosporin 5 mg/kg/day, Azathioprine 50 mg daily Peri-operative: Methyl prednisolone 500 mg
Post-operative: Methyl prednisolone 5 mg/kg/day for 3 days and tapered every 2 days, azathioprine 1-3 mg/kg/day, cyclosporin 12 mg/kg/day in 2 or 3 divided doses
d) High-risk patients and patients receiving second or third graft: Pre-operative: Cyclosporin 5 mg/kg/day, azathioprine 50 mg daily Peri-operative: Methyl prednisolone 500 mg
Post-operative: Methyl prednisolone 250 mg daily for 3 days, and tapered every 2 days, cyclosporin 6 mg/kg/day, azathioprine 1 mg/kg/day, ATG 3 mg/ kg/day for 10-14 days.
Anti-rejection Treatment Protocol
We have used three options for antirejection treatment. As the first line, methylprednisolone pulse therapy, 500 mg/day was used, given for 3-5 days. If no improvement was noted, the patients were subjected to graft biopsy and second line of antirejection treatment started in the form 'of ATG/ALG in a dose of 3-5 mg/kg/day administered for 10-14 days depending on the response of the patients. The third line of anti-rejection treatment was OKT3 and was used only for resistant rejections. A few of our patients were also subjected to plasmapheresis for specific indications like histological evidence of vascular rejection or in high-risk patients.
A total of 279 renal transplants were performed between the years 1991-1995. The transplants included 164 from living related donors and 115 from cadaver donors. The age of the patients ranged between four and 45 years; there were 160 males and 119 females.
A total of 58 grafts were lost during this period yielding a 5-year graft survival of 79.2%. There were 26 deaths yielding a 5year patient survival of 90.7%. The causes of death in these patients are listed in [Table 2].
Renal transplantation is the best option for patients with end-stage renal disease and is the only way to decrease the overload in dialysis units. Our center, which has 68 dialysis machines, is still unable to provide satisfactory dialysis treatment to all the patients. At present, we dialyze the patients in three shifts and a fourth shift is under consideration to accommodate new patients.
The renal transplant program which was started in 1992 has definitely made a good impact in reducing the number of patients on regular hemodialysis treatment. A total of 279 patients transplanted in a 5-year period, from cadaveric and living related donor kidneys, is a reasonable achievement for a newly established transplant center.
Analyzing the 5-year results of our transplant program, we found a 88.5% graft survival (excluding patient death with functioning graft) and 79.2% (including patient death with functioning graft). The 5year patient survival was 90.7%. Our results are comparable to the latest patient and graft survival figures from around the world. With the use of newer immunosuppressive and anti-rejection armaments, we expect better patient and graft survival in future years.
The specific problem-areas we have encountered include the following:
a) Many of our patients are illiterate and as such they find it difficult to take their immunosuppressive treatment as advised.
b) Some of the patients who were transplanted were non-Saudi, who returned to their native countries since then, and could not maintain their graft function due to specific conditions prevailing there.
c) Two of our transplant patients were positive for HbsAg and anti-HCV prior to transplantation, with normal liver function and histology. However, both these patients developed hepatic failure two and three years post-transplant respectively.
The immunosuppressive protocol we follow has proved to be very effective because the number of acute rejections we encountered in the first three months post-transplant were minimal. The anti-rejection treatment protocol also proved successful in all the patients. Only four of our patients required 0KT3, the third line anti-rejection treatment. However, the incidence of infection was high among the patients who received anti-rejection therapy.
We transplanted a total of 17 children. All the pediatric transplant patients, except one, did well. One pediatric recipient of a cadaveric graft had primary dysfunction of the graft requiring graft nephrectomy. There was no mortality among this group of patients and all of them have maintained excellent graft function till the last followup. An interesting observation in pediatric transplant patients was that they required relatively higher dose of immunosuppressive drugs compared to the adult group. This is probably due to their very active immune system combined with a quick break-down of immunosuppressive agents through well functioning liver.