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RENAL DATA FROM THE ARAB WORLD |
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| Year : 2007 | Volume
: 18
| Issue : 2 | Page : 265-269 |
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| Adult-to-Adult Living Related Donor Renal Transplantation in Yemen: The First Experience |
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Ibrahiem H El-Nono, Tawfiq H Al-Ba'adani, Abdulilah M Ghilan, Nagieb W Abu Asba, Gamil M Al-Alimy, Mokhtar M Al-Massani, Morshed A Noman, Soliman Al-Shargabe, Mohamed M Al-Mansour, Mogahed Y Nassar
Urology and Nephrology Center, Al-Thawra Modern General Hospital, Sana'a, Yemen
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 Abstract | | |
Between May 1998 and June 2006, 31 patients (21 males and 10 females) received a renal allograft from live-related donors at the Urology and Nephrology Center in the Al-Thawra Modern General Hospital Sana'a, Republic of Yemen. The cold ischemia time ranged between 48 and 68 minutes. The immunosuppressive protocol was double therapy (steroids and mycophenolate) in the first 8 cases. The subsequent cases received triple therapy with steroids, cyclosporine and mycophenolate. Episodes of acute rejection were treated with high dose steroids while anti-thymocyte globulin (ATG) was also used in cases of vascular or steroid resistant rejection. Primary graft function was achieved in 29 recipients (93.5%). The post-transplant complications, either surgical or medical, were comparable to those reported in the literature. The kidney transplantation program started sporadically in Yemen since 1998. However, a well-established program has been running regularly since the beginning of 2005. Keywords: Kidney transplantation, Yemen
How to cite this article:
El-Nono IH, Al-Ba'adani TH, Ghilan AM, Abu Asba NW, Al-Alimy GM, Al-Massani MM, Noman MA, Al-Shargabe S, Al-Mansour MM, Nassar MY. Adult-to-Adult Living Related Donor Renal Transplantation in Yemen: The First Experience. Saudi J Kidney Dis Transpl 2007;18:265-9 |
How to cite this URL:
El-Nono IH, Al-Ba'adani TH, Ghilan AM, Abu Asba NW, Al-Alimy GM, Al-Massani MM, Noman MA, Al-Shargabe S, Al-Mansour MM, Nassar MY. Adult-to-Adult Living Related Donor Renal Transplantation in Yemen: The First Experience. Saudi J Kidney Dis Transpl [serial online] 2007 [cited 2022 Jun 28];18:265-9. Available from: https://www.sjkdt.org/text.asp?2007/18/2/265/32324 |
| Introduction | |  |
Renal replacement therapy was first introduced in Yemen in 1978 in the form of hemodialysis. Twenty years later, the first renal transplantation was performed at the Al-Thawra Modern General Hospital, Sana'a. Since then, renal transplantation was performed sporadically over the next six years.
A regular renal transplantation program was started in the beginning of 2005 at the Urology and Nephrology Center in the Al-Thawra Modern General Hospital Sana'a, Republic of Yemen. The aim of this report is to provide information on the renal transplantation program in the Republic of Yemen.
| Patients and Methods | | |
Between May 1998 and June 2006, 31 kidney transplants were performed at the Urology and Nephrology Center in the AlThawra Modern General Hospital Sana'a, Republic of Yemen. The majority of patients were male (20) and their age ranged between 24 and 55 years. The primary pathologic process was chronic glomerulonephritis in 10 patients, chronic pyelonephritis in seven, chronic tubulo-interstitial disease in five, focal and segmental glomerulosclerosis in three, diabetic nephropathy in one, and unknown etiology in five.
The selection of recipients was based on a scoring system, taking into consideration the recipient's age, duration on dialysis, previous transplantation and proper tissue matching (HLA, DR and negative cross match). All kidneys were obtained from healthy related donors, who were 25 to 55 years old.
Primary transplantation was performed in all except one, who received a second allograft. The cold ischemia time ranged from 40 to 68 minutes. Induction of immunosuppression was performed with methylprednisolone in all patients.
During transplant surgery, the graft artery was anastamosed end-to-end to the internal iliac artery, while the renal vein was anastamosed end-to side to the external iliac vein. The ureter was implanted in the recipient's bladder using the Leich-Gregoir technique.
The immunosupressive protocol consisted of double therapy with steroids and mycophenolate mofetil (MMF) in the first eight patients and triple therapy with steroids, cyclosporine and MMF in the other patients. The patient with the second allograft received tacrolimus instead of cyclosporine.
Episodes of acute rejection were treated with high doses of methylprednisolone (500 mg/ day) for five days, while anti-thymocyte globulin (ATG-Fresenius) was used in combination with methylpredinisolone in cases of acute vascular or steroid-resistant rejection.
| Results | | |
The recipients were followed for 2 to 96 months after transplantation. Primary renal graft function was obtained in 29 recipients (93.5%). The post-transplant surgical complications encountered included: graft artery thrombosis and urine leak seen in three patients each; two of the latter group were treated conservatively while in the third patient, the graft ureter was re-anastamosed to the native ureter. A lymphocele was observed in one patient and was managed by laparoscopic marsupialization. Wound related complications were seen in three patients [Table - 1].
Non-surgical complications included the following: acute rejection in six patients, CMV infection followed eight months later by cutaneous Kaposi's sarcoma in one patient and acute tubular necrosis (ATN) requiring hemodialysis for two weeks in one recipient. Four recipients lost their grafts, three due to renal artery thrombosis and the fourth due to recurrence of primary disease (FSGS).
Three patients died from disseminated intravascular coagulation (DIC), heart failure and severe broncho-pneumonia, respectively. The fourth patient with recurrent FSGS died while on dialysis [Table - 2].
| Discussion | | |
The incidence of end-stage renal disease (ESRD) in Yemen is 120 cases per million per year, which is comparable to the reported incidence in other countries of the same region.[1],[2] Successful renal transplantation is considered the preferred and most cost effective method of treating patients with ESRD.[3]
Starting a program for regular kidney transplantation in Yemen, where the resources are limited and medical services are not yet optimized, was not an easy task. In 1996, we decided to accept the challenge and overcome all the difficulties to achieve our mission. We started an experimental project for renal transplantation in dogs to have a well-trained team in transplant surgery. Two years later, we performed the first human renal transplanttation in our country.
We faced numerous problems in this endeavor; namely, the establishment of wellequipped laboratories especially for tissuetyping, immunological and histopathological testing supervised by well-trained personnel and established centers in the field of transplantation. Moreover, the availability of immunosuppressive drugs with their blood assay was not easy. Thus, on a step-by-step basis, we built our well-established transplant program over a six-year period during which a few sporadic cases were transplanted.
However, we gained experience over the last decade in post-transplant care since we followed more than 600 Yemeni kidney transplant recipients, who received their renal allograft abroad.
Mycophenolate mofetil, a potent immunosuppressive agent with less incidence of either acute or chronic rejection, [4],[5],[6] was the cornerstone of our immunosuppressive protocol. It was used in conjunction with steroids in the first eight cases, or later on with calcineurin inhibitors (cyclosporine or tacrolimus), the use of which began after availability of the blood assay in our country.
The incidence of acute rejection among our recipients was 19.3% and occurred in six of our patients; five of them were acute cellular rejection and the sixth was of the vascular type. Five cases responded well to high-dose steroid therapy, while the sixth case was steroid resistant and responded to ATG therapy.
In our series, three patients (9.6%) developed graft artery thrombosis and lost their grafts. In one patient, the process was secondary to atherosclerosis as the patient was an obese female and had type-2 diabetes mellitus. The other two cases developed renal artery thrombosis after initial good graft function for a period of five and fifteen days, respectively. The incidence of vascular complications among our recipients is higher in comparison to the reported incidence in the literature (0.5-8%).[7],[8],[9]
Urinary leakage occurred in three recipients (9.6%). Two cases did not require any active intervention, while in the third, surgical correction was necessary. Our incidence of urinary leak is comparable to the reported incidence in literature. [10],[11]
Wound related complications, either delayed healing or infection, were encountered in three recipients (9.6%). All were obese females and two were older than fifty years. Again, this is comparable with other reports. [12],[13]
It is of interest to note that the patient who experienced steroid resistant rejection and received ATG therapy, developed wound dehiscence, CMV infection, and ultimately cutaneous Kaposi's sarcoma. This patient died one-year post-transplant from a massive bilateral bronchopneumonia.
However, most of the complications occurred in the early period of our experience. In the last two years after establishment of the transplant program in our center, the incidence of complications decreased.
All patients in our study received renal allograft from living related donors and the patient and graft survival rates are comparable to other reports.[14]
| Acknowledgement | | |
The authors are deeply grateful to Prof. Mohammed Ahmed Ghoneim, pioneer of renal transplantation in the Arab world for his continuous, unlimited and generous support in the initiation and maintenance of the renal transplant program in Yemen.
Special thanks are conveyed to all members of the Urology and Nephrology Center in Mansoura, Egypt, who trained our transplant team in the different specialties.
| References | | |
| 1. | Shaheen FA., Souqiyyeh MZ, Al-Swailem AR. Saudi Center for Organ Transplantation, activities and achievements. Saudi J Kidney Dis Transpl 1995; 6;41-52.  |
| 2. | Samhan M, Al-Mousawi M, Hayati H, et al. Results in 158 consecutive cadaveric renal transplantations. Transplant Proc 2005;37; 2965-6. |
| 3. | Shaver MJ: In Anderoli TE, Carpenter CC, Griggs RC (Eds): Cecil Essential of Medicine: Chronic Renal Failure, 5th Edition Philadelphia: WB Sanders: 2002 p291. |
| 4. | Srinivas TR, Kaplan B, Schold JD, Meier-Kriesche H. The impact of mycophenolate mofetil on long-term outcomes in kidney transplantation. Transplantation 2005; 80 (15): S211-20. |
| 5. | Meier-Kreische H, Ojo AO, Arndorfer JA, et al.: Mycophenolate mofetil decreeases the risk for chronic renal allograft failure. Transplant Proc 2001; 33:1005-6. |
| 6. | Ojo AO, Meier-Kriesche HU, Hanson JA, et al. Mycophenolate mofetil reduces late renal allograft loss independent of acute rejection. Transplantation 2000; 69:2405-9. [PUBMED] [FULLTEXT] |
| 7. | Rouviere O, Berger P, Beziat C, et al. Acute thrombosis of renal transplant artery: graft salvage by means of intra arterial fibirnolysis. Transplantation 2002; 73:403-409. [PUBMED] [FULLTEXT] |
| 8. | Osman Y, Shokeir A, Ali-el Dein B, et al. Vascular complications after live donor renal transplantation: Study of risk factors and effects on graft and patient survival. J Urol 2003; 169:859-62. |
| 9. | Shokeir AA, Osman Y, Ali-el-Dien B, et al. Surgical complications in livedonor pediatric and adolescent renal transplantation: Study of risk factors. Pediatr Transplant 2005; 9:33-8. |
| 10. | Humar A, Matas AJ. Surgical complications after kidney transplantation. Semin Dial 2005; 18:505-10. [PUBMED] [FULLTEXT] |
| 11. | Mangus RS, Haag BW. Stented versus nonstented extravesical ureteroneocystostomy in renal transplantation: a metaanalysis. Am J Transplant 2004; 4:1889-96. [PUBMED] [FULLTEXT] |
| 12. | Hernandez D, Rufino M, Armas S, et al. Retrospective analysis of surgical complications following cadaveric kidney transplantation in the modern transplant era. Nephrol Dial Transplant 2006;21:2908-15. [PUBMED] [FULLTEXT] |
| 13. | Valente JF, Hricik D, Weigel K, et al. Comparison of sirolimus vs. mycophenolate mofetil on surgical complications and wound healing in adult kidney transplantation. Am J Transplant 2003; 3:1128-34. |
| 14. | Ghoneim MA, Bakr MA, Hassan N, et al. Live-donor renal transplantation at the Urology and Nephrology Center of Mansoura: 1976-1998. Clinical Transplants 2001, Cecka and Terasaki, Eds. UCLA Immunogenetics Center, Los Angeles, California. 167-178. |
Correspondence Address:
Ibrahiem H El-Nono
Director of Urology and Nephrology Center, Al-Thawra Modern General Hospital, Sana'a University, Sana'a
Yemen
 Source of Support: None, Conflict of Interest: None  | Check |
PMID: 17496409 
[Table - 1], [Table - 2] |
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