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Saudi Journal of Kidney Diseases and Transplantation
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COUNTRY REPORT Table of Contents   
Year : 1996  |  Volume : 7  |  Issue : 4  |  Page : 404-408
Renal Replacement Therapy in Pakistan

Sindh Institute of Urology and Transplantation, Dow Medical College and Civil Hospital, Karachi, Pakistan

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How to cite this article:
Rizvi S A, Anwar Naqvi S A. Renal Replacement Therapy in Pakistan. Saudi J Kidney Dis Transpl 1996;7:404-8

How to cite this URL:
Rizvi S A, Anwar Naqvi S A. Renal Replacement Therapy in Pakistan. Saudi J Kidney Dis Transpl [serial online] 1996 [cited 2022 Jun 28];7:404-8. Available from: https://www.sjkdt.org/text.asp?1996/7/4/404/39414

   Introduction Top

The evolution of renal replacement therapy in any country and its associated problems can only be understood by keeping the socio­economic problems of that country in mind. Pakistan with a population of 130 million, is the tenth most populous country in the world. Annual population growth is 3.1% and the per capita income is about US $ 400 per annum. The Government spends less than 1% of the gross national product (GNP) on health, and there is a marked urban bias in health planning.

The annual incidence of end-stage renal disease (ESRD) in Pakistan is estimated at about 100 per million populations. A large number of patients do not have access to health-care centers because of an inadequate health infrastructure. A conservative estimate is that less than 25% of the ESRD populations have access to renal support in the form of dialysis and transplantation [1] . The etiology of ESRD in many cases is based on clinical assessment, as most of the patients present very late to specialist centers. The common causes of ESRD seen in a study of 400 cases were chronic glomerulonephritis, hyper­tension, diabetes mellitus and chronic pyelonephritis [Table - 1]. Additionally, ESRD following neglected renal stones constituted 8% of the patients reflecting the endemicity of stone disease in Pakistan [2] .

   History of Renal Replacement Therapy in Pakistan Top

The first peritoneal dialysis facility in Pakistan was established in 1970 at the Civil Hospital, Karachi. Subsequently, this facility became available in hospitals attached to the various medical colleges in the country. Hemodialysis was started at the Military Hospital in Rawalpindi in 1972. Currently, there are over 50 dialysis centers in both public and private sectors having from 3-30 stations in each center [Figure - 1]. The Sindh Institute of Urology and Transplantation (SIUT) in Karachi is the largest dialysis center in Pakistan performing about 28,000 dialysis sessions each year.

In the early days, Scribner shunt was the common mode of vascular access. Now, acute dialysis is performed using subclavian or femoral vein double-lumen catheters. Long­-term vascular access is in the form of an arteriovenous fistula. Erythropoietin is administered to about 5% of the patients with severe anemia while the remaining receive blood transfusions at an annual rate of 5-15 units. Nearly 40% of the patients on hemodialysis are hepatitis C virus (HCV) antibody positive while 15% are positive for hepatitis B surface antigen (HBsAg) [3] . There is a limited reuse of dialyzers in some larger centers. Recently, continuous ambulatory peritoneal dialysis (CAPD) has been started at SIUT.

Non-availability of adequate dialysis facilities and lack of health education has prompted people to seek help from practitioners of unscientific medicine. Also, the prevalence of non-compliance to therapy is high because many patients do not have access to proper centers or have to travel long distances to get appropriate therapy. Renal Transplantation in Pakistan

The ever-increasing number of patients on maintenance dialysis therapy necessitated the starting of a renal transplant program in Pakistan. The first renal transplant in Pakistan was performed in Rawalpindi in 1979. Since then, the renal transplantation program has gone through various stages of development [Table - 2]. Currently, there are nine transplant centers in Pakistan, five in the public and four in the private sectors [Figure - 1]. The annual transplant rate today is about 300 which is less than 3 per million population. A total of 1,400 renal transplants have been performed from inception, two thirds of which are from living related donors. All the living unrelated transplants (LURT) that have been performed are in the private sector and a few, in a neighboring country. The main problems noted with LURT are exorbitant costs, poor donor selection, lack of proper follow-up and non-compliance to medicines.

Most of the published material on transplantation from Pakistan relates to live related renal transplants (LRRT) performed at the SIUT, which is the largest public sector center in the country. A total of 400 LRRT have been performed at SIUT with the mean age of the recipients being 32 years (range 5­57 years). The male to female ratio of the recipients is 3:1. The donor population comprised of siblings (54%), parents (29%), children (8%) and spousal and cousin donors (9%). Tissue matching of donors and recipients revealed that 69% were haplo­identical and 17% had full house match. Immunosuppression consisted of the triple regimen including prednisolone, 0.3 mg/kg/day, cyclosporine 10 mg/kg/day and azathioprine 3 mg/kg/day. The overall graft survival for LRRT is 92% at one year, 89% at two years, 82% at three years and 80% at five years [3] . These good results achieved at SIUT can be attributed to good patient and donor selection, close follow-up and ensuring good compliance to drugs.

The degree of tissue matching had a major impact on the number of rejection episodes, graft function and patient survival in our experience. Overall, only 7% of the HLA-­identical transplants experienced rejection episodes in the first six months post-transplant as compared to 45% of the one-haplotype matched pairs. At two years post-transplant, 89% of the two-haplotype matched transplants had serum creatinine levels of < 177 /imol/L as compared to 76% for one-haplotype matched transplants. Graft survival at five years was 90% for two-haplotype matched transplants as compared to 78% for the one haplotype matched pairs. Also, we noted that donors older than 60 years and female donors gave poorer graft function. In the donor age-group 20-40 years, 85% of the recipients of kidneys from male donors had serum creatinine of less than 177 µmol/L compared to 67% of the recipients of female donor kidneys.

Infectious episodes also adversely affected graft function. The serum creatinine at 2-years post-transplant was less than 177 jUmol/L in 82% the recipients who had no infections post-­transplant, 66% in recipients with one infectious episode and 45% in those with two episodes of infection. The main causes of infection post-transplant were bacterial (65%), viral (20%), protozoal (8%) and fungal (7%). The common sites of infection were urinary and respiratory tracts [Table - 3]. Thirteen percent of the transplanted patients developed tuberculosis and over half of them had extra­pulmonary lesions [4] . The frequency of diagnosis of Cytomegalovirus (CMV) infection has increased with the availability of estimation of serological markers, both IgM and IgG. Our initial results with ganciclovir against CMV are encouraging with a 65% success rate in terms of response to therapy.

The main causes of graft loss included chronic rejection (63%), acute rejection (4%), infection (20%), vascular complications (7%) and recurrent disease (6%) [Figure - 2]. Of the infections, tuberculosis and CMV were responsible for 5% of graft loss. The commonest cause of death was infection, which accounted for 68% of deaths with functioning grafts and 46% of deaths with failed grafts [5] . Other causes of death with functioning grafts included cardiovascular diseases. (17%), malignancy (5%), and uncertain causes (12%).

Hepatitis C virus (HCV) infection has become a common problem in our dialysis population. Exclusion of such patients from transplantation would compromise further the already limited dialysis facilities. Thus, transplantation of HCV antibody positive recipients was started in 1994. All such patients were subjected to liver, biopsy and the decision to transplant them was taken only when biopsy showed normal histology or chronic persistent hepatitis, together with normal transaminase levels. All patients with chronic active hepatitis and cirrhosis were excluded. Our initial results are good with two-year patient and graft survival of 85% and 81% respectively [6] . However, long-term follow-up is essential to determine the true outcome.

Graft dysfunction occurring in the- first six months post-transplant poses a diagnostic dilemma with the possible causes being rejection, infection and cyclosporine toxicity. Several non-invasive techniques have now become available to diagnose the cause of graft dysfunction. At SIUT, a comparative correlation of different markers with graft histology, showed that diuretic renography (DTPA) was able to diagnose acute rejection in 50% of cases, color doppler imaging (CDI) in 80% and T-lymphocyte subset and activation markers (CD4, CD8, CD3+DR+, CD3+CD25+, TH4+, CD254) in 75% of the cases. Cyclosporine toxicity as a cause of graft dysfunction could be diagnosed in 71% of cases by DTPA scan, 65% by CDI and in 83% by CD markers. Also, the CyA levels were high in 50% of the cases with CyA toxicity. In cases with chronic vascular rejection, DTPA was helpful in 67%, CDI in 58% and CD markers in 50% of the cases.

   The SIUT as a Role Model Top

Given the socio-economic backdrop of Pakistan, one has to take cognizance of the ability of patients to afford renal replacement therapy. Dialysis in private centers costs between US $5000-7000 per year and renal transplantation, about US $6000. Understandably, the vast majority of patients simply cannot avail facilities at private centers. The public hospitals are therefore overwhelmed with an increasing input of patients from remote places where such facilities are either non­existent or only available at exorbitant costs. The SIUT has shown the way by involving the community to support the renal replacement program through public donations. The SIUT carries out more than 28,000 dialysis sessions and about 80 renal transplants each year, all of which are provided free of cost to the patients. Government funding was slow to come by in the beginning, but as the planners became convinced of the need to support such activities, over 40% of the cost of SIUT's renal replacement program is now being supported through governmental funds. Not only has the SIUT program broken the inertia of health planners in the public sector, but the ripple effect has also helped in the establishment of such programs in other teaching hospitals in the region.

The present need of organs for ESRD patients is about 6,500 each year and the current annual transplant rate of 300 is far from adequate. One way of increasing transplant activity is by boosting the development of the public sector by state funding.

   References Top

1.Rizvi SA, Naqvi SA. Resistance to cadaveric organ donation. Experience in a developing country in organ replacement therapy. Ethics, Justice and Commerce. (Eds) W. Lanel and JB. Dossetor. Springer-Verlag Berlin. 1991;300-2.  Back to cited text no. 1    
2.Hussain M, Lai M, Ali B, et al. Management of urinary calculi associated with renal failure. J Pak Med Assoc 1995;45:205-8.  Back to cited text no. 2    
3.Naqvi SA, Rizvi SA. Renal transplantation in Pakistan. Transplant Proc 1995;28:2778.  Back to cited text no. 3    
4.Naqvi SA, Hussain M, Askari H, et al. Is there a place for prophylaxis against tuberculosis following renal transplantation? Transplant Proc 1992;24-1912.  Back to cited text no. 4    
5.Rizvi A, Naqvi A, Hussain I, et al. Problems of renal transplantation in Pakistan. Transplant Proc 1990;22:2269.  Back to cited text no. 5  [PUBMED]  
6.Askari H, Abidi S, Abbas K, et al. Early experience of renal transplantation in hepatitis C  Back to cited text no. 6    

Correspondence Address:
S A Anwar Naqvi
Sindh Institute of Urology and Transplantation, Dow Medical College and Civil Hospital, Karachi- 74400
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Source of Support: None, Conflict of Interest: None

PMID: 18417773

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