RENAL DATA FROM THE ASIA - AFRICA
Year : 2006 | Volume
: 17 | Issue : 1 | Page : 77--81
The spouse as a donor in renal transplants
Amitava Mukherjee, Nitin S Kekre, Ganesh Gopalakrishnan
Department of Urology, Christian Medical College and Hospital, Vellore, Tamilnadu, India
Department of Urology Christian Medical College Dr. Ida Scudder Road, Vellore - 632 004, Tamilnadu
Most renal transplants performed in India are from live related donors. The mother is the most frequent donor. In India, the Transplantation of Human Organs Act, which was passed in 1994, allowed organ procurement from «DQ»near relatives«DQ» live donors. In the period between 1999 and 2003 we performed in our center 41 spouse to spouse transplants, and 356 transplants among the live genetically related. The two groups showed comparable mean creatinine at one (136 ± 38 µmol/L vs. 151 ± 53 µmol/L) and three years (136 ± 41 µmol/L vs. 154 ± 53 µmol/L). The spouse allograft recipients had 26% incidence of acute rejections vs. the genetically related recipients who had 22% incidence over a similar period. We believe that though spouse donated kidneys survive comparably with those from genetically related donors; strict criteria for their acceptance should be enforced considering the social background in India, in order to prevent exploitation of female spouses from coercion of donation. In addition to our results, we discuss our policy for accepting the spouse as a kidney donor.
|How to cite this article:|
Mukherjee A, Kekre NS, Gopalakrishnan G. The spouse as a donor in renal transplants.Saudi J Kidney Dis Transpl 2006;17:77-81
|How to cite this URL:|
Mukherjee A, Kekre NS, Gopalakrishnan G. The spouse as a donor in renal transplants. Saudi J Kidney Dis Transpl [serial online] 2006 [cited 2020 Jul 10 ];17:77-81
Available from: http://www.sjkdt.org/text.asp?2006/17/1/77/32451
The majority of renal transplants performed in India are live related transplants. With the effective use of cyclosporine based immuno-suppression, the influence of HLA matching on the outcome seems to have become less important. 
Accumulated evidence suggests that the results of the spouse to spouse renal transplantation are comparable to those of the genetically related. ,
The Transplantation of Human Organs Act was passed in India in 1994. It allowed "near relatives" live related transplantation from the spouse, son, daughter, father, mother, brother and sister. All other live donations required the prior approval by an authorization committee appointed by the central or respective state government.
In this study, we analyze the results of renal transplants performed at our center and compare the spouse to spouse transplantation with the other groups of renal transplantation.
Materials and methods
We retrospectively reviewed the renal transplant patients performed between 1999 and 2003.
We began accepting the spouse as a donor at our center in 1999 and followed very clearly laid down criteria for accepting the spouse as a donor. For patients with heritable metabolic disorders such as diabetes mellitus, polycystic kidney disease or Alports syndrome, only a family member older than the prospective recipient and believed to be unlikely to develop the disease would be evaluated as a potential donor. In case of a family of diabetics, a non diabetic prospective donor would be accepted as having a low risk of developing diabetes mellitus, if he was at least ten years older than the oldest member diagnosed with the disease. If no compatible related donor could be found in a family on the basis of these criteria, the spouse would be accepted for work-up as a donor. For the non-heritable diseases, if no compatible sibling or parent was identifiable, and if the patient had a documented stable marriage for a period of at least seven years, then spouse to spouse renal allograft donation would be considered. We have been following these criteria to avoid possible marriages with the intention of renal allograft donation from the spouse.
Our study group consisted of spouse renal allograft recipients, who were compared with first-degree related (parent or sibling donor), non-first degree related (relatives such as aunts, uncles or cousins as donors) and cadaver recipients.
The compared parameters included HLA distribution, nadir creatinine level, time to nadir creatinine, creatinine at one and three years, rejection episodes and graft loss.
Routinely, the HLA-A and HLA-B antigens would be identified in all prospective donors. In the event of three or four antigen mismatch in prospective donors who claimed to be genetically related to the recipients, HLADR would also be tested. No attempt was made to confirm relations by genetic testing. Original documents with photographs as issued by various government bodies (like passports and social security cards) and separate interviews of the recipient and donors to evaluate their knowledge of each others family, relatives and other personal data were used to verify relationships. However, the HLA-DR was not assessed in the prospective spouse donors. Since the program of cadaver organ sharing is still in its infancy in our country, most organs are transplanted loco-regionally. Accordingly, the HLA status is not tested in cadaver transplants.
We used routinely triple immunosuppression with cyclosporine, azathioprine and prednisolone in most of our patients. However during the period of the study, a number of ongoing drug trials resulted in some patients receiving other immunosuppressants including rapamycin, mycophenolate mofetil (MMF) or ketoconazole.
The patients were followed up in our center six months. They were seen three times a week for the first two months, twice a week for the next two and once weekly for the subsequent two. They were seen thereafter at nine and twelve months and whenever required. Acute rejections are confirmed by core biopsy and graded according to the Banff criteria. Pulse methyl prednisolone (total 2.0 grams over three days) was used to treat rejections. Steroid resistant rejections were treated with monoclonal antibodies (OKT3).
The four study groups were compared statistically for each variable using the ANOVA test, while the Bonferroni post hoc test was used for identifying the differences between the individual groups.
Of the total of 443 renal transplants performed during the study period; 24 were cadaver transplants. The remaining 419 were living related renal transplants of which 356 were first degree live genetically related, 41 were spouse related, while 22 donors were non-first-degree related. We compared the spousal transplant recipients to only 82 randomly selected first degree live genetically related renal allograft recipients.
The native kidney disease was diabetic nephropathy in 26 of 41 spouse kidney recipients, while it was so only in three of the first degree related and cadaver transplants and one of the other live related category.
The distribution of native kidney disease, mean age of the recipients and donors, immunosuppression use and the HLA distribution are shown in [Table 1]. Twenty-six of 41 spouses had total HLA mismatch; 10 pairs were mismatched for three antigens. The mean follow-up was 22.9 ± 22.7 months in cadaver transplants and 29.7 ± 21.9 months in live related transplants. Sixty-six (80.5%) first degree live genetically related transplant recipients versus 40 (49%) of spouse transplant recipients had triple conventional (TC) immunosuppression.
The nadir creatinine achieved, the time to nadir creatinine, and creatinine at one, two and three years in the various groups are shown in [Table 2]. Three years follow-up data were available for 26 spousal transplants, 56 first degree related transplants, and 17 in each of the other two groups.
Twenty six percent of spouse organ recipients had acute rejections as compared to 22% patients in each of the two related transplant groups. The number of episodes of acute rejection per patient was 0.38 in spouse transplants while it was 0.32 and 0.36 in first degree related and non first degree live related groups, respectively.
There were three recorded deaths at three years in each of the live related groups and five deaths in the cadaver transplant groups over the same period. Six spouse renal allograft recipients expired with normal graft function by three years. The cause of death in this group was sepsis in two cases while acute myocardial infarction, chronic liver disease, head injury and unknown cause accounted for one each. Sepsis was also the most common cause of death in non first-degree related transplants and in cadaver organ recipients.
There were no deaths due to graft loss in the spouse group, while two grafts in each of the other two live related groups and three cadaver grafts failed during this period.
Attempts to reduce the cadaver waiting list have resulted in identification of novel donors in renal transplantation. Although spouse as a donor has been accepted since the late eighties, national legislation has legalized this form of donation in India only since 1994. In our study, the spouse to spouse renal transplantation showed the following main characteristics: first, the recipients were relatively young; second, while consanguineous marriages are not uncommon in the southern states of India, none of our spouse donors were genetically related; third mismatch of HLA antigens were prevalent; fourth, the achievement of acceptable allograft function and time to reach it were comparable with the other live related transplant groups and better than the cadaver group at three years due to the higher cold ischemia time and changes during the death of the donor in the latter. Finally, there was a significantly better immunosuppression used in the spouse group than the non first degree live related transplants, which could explain the worse renal function in the latter group, which had only two drug immunosuppression (MMF and prednisolone). This indirectly suggests that good immunosuppression can overcome significant HLA mismatches.
Terasaki et al  noted that at three years 85% of kidneys from spousal donors were functioning as compared to 81% from live unrelated donors. In our study, no spousedonated graft had failed at three years, and survival rate (due to six patients' mortality) was 84.6% at three years, which was close to 94.6% graft survival in the live related recipients. This difference is likely to be the result of a higher mean age and diabetes associated co-morbidities in the spousal organ recipients.  This difference was introduced by our selection protocol. A less stringent policy for accepting a spousal organ may improve the statistics of patient survival. The criteria for accepting a spouse organ could be only a proof of genuine spousal relationship.  However, these selection criteria may need to be modified according to the local social norms and practices.
Our retrospective study does suffer from some limitations such as a lack of standardization, of immunosuppression used that could have major impact on the survival rates.
The spouse can serve as an important source of donor kidney in the absence of a compatible genetically related donor, the majority of spousal donors would recommend other spouses to donate and the gift of life also results in better family and sexual relations and improved relations with children as concluded by similar studies to ours. ,
However, one needs to be very careful to ensure that our enthusiasm on this issue does not result in coercion of spousal donation in the presence of other compatible donors. Knowing that the spouse is the one who has the most to lose from the death of the prospective recipient, such a thing is a very real possibility. Transplant units need to have very clear guidelines in keeping with the socio-economic conditions in their regions, which will ensure that this source of organ supply is not misused. As nuclear families and increasing age at marriage become more common, it may become increasingly difficult to find willing siblings and fit parents to donate. A spouse donor may then have to be a more common alternative.
|1||Cecka JM. The UNOS Renal Transplant Registry. Clin Transpl 2002;: 1-20.|
|2||Gjertson DW, Cecka JM. Living unrelated donor kidney transplant-tation. Kidney Int 2000; 58(2): 491-9.|
|3||Tang S, Lui SL, Lo CY, et al. Spousal renal donor transplantation in Chinese subjects: a 10-year experience from a single centre. Nephrol Dial Transplant 2004 19(1): 203-6.|
|4||Anonymous. The transplantation of human organs act, 1994. www. medindia.net/tho /thobill1.asp.|
|5||Solez K, Axelsen RA, Benediktsson H, et al. International standardization of criteria for the histologic diagnosis of renal allograft rejection: the Banff working classification of kidney transplant pathology. Kidney Int 1993; 44: 411-22|
|6||Terasaki PI, Cecka JM, Gjertson DW, Takemoto S. High survival rates of kidney transplants from spousal and living unrelated donors. N Engl J Med 1995; 333:333-6.|
|7||Bhowmik D, Dash SC, Tiwari SC, et al. Spousal renal donor transplants in India. Nephrol Dial Transplant 1999; 14(8): 2052-3.|
|8||Tang S, Lui SL, Lo CY, et al. Spousal renal donor transplantation in Chinese subjects: a 10-year experience from a single centre. Nephrol Dial Transplant 2004 19(1): 203-6.|
|9||Mathieson PW, Jolliffe D, Jolliffe R, Dudley CR, Hamilton K, Lear PA. The spouse as a kidney donor: ethically sound? Nephrol Dial Transplant 1999; 14(1):46-8.|
|10||Terasaki PI, Cecka JM, Gjertson DW, Cho YW. Spousal and other living renal donor transplants. Clin Transpl 1997;: 269-84.|