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Saudi Journal of Kidney Diseases and Transplantation
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RENAL DATA FROM THE ARAB WORLD  
Year : 2015  |  Volume : 26  |  Issue : 1  |  Page : 153-160
Eligibility for renal transplantation: A Moroccan interregional survey


1 Department of Nephrology, Hassan II University Hospital, Fez, Morocco
2 Department of Epidemiology, Medical Faculty, Fez, Morocco

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Date of Web Publication8-Jan-2015
 

   Abstract 

In the treatment of end-stage renal disease, kidney transplantation (KT) is the best and most cost-effective alternative with regard to both prognosis and quality of life. To identify the proportion and the characteristics of kidney transplant candidates who can be considered eligible, a total of 2066 hemodialysis patients were investigated as part of the ARTEMIS (Attitude toward Renal Transplantation and Eligibility among dialysis patients in a Moroccan Interregional Survey) study. We investigated all patients receiving hemodialysis in the 39 centers of four Moroccan departments. The mean age was 52.9 years and the mean duration of hemodialysis was 55.3 months. Fifty-eight percent of our patients were considered eligible for KT; 18.2% had an absolute contraindication and 23.8% had one or more relative contraindications. When compared with eligible patients (n = 1200) in the univariate analysis, those ineligible were significantly older (61 years vs. 51, P < 0.0001), had no residual diuresis (59.8% vs. 49.1%, P < 0.0001), were more often diabetic (25.1% vs. 11.9%, P < 0.0001) and hypertensive (54.5% vs. 45.8%, P < 0.0001), and their median dialysis duration was longer (61 months vs. 51, P < 0.0001). In the multivariate models, eligibility remained associated with young age, less term of dialysis and residual diuresis. Adequate control of cardiovascular risk factors before dialysis and early referral for transplantation might help to improve eligibility of the renal transplant candidates.

How to cite this article:
Kabbali N, Mikou S, El Bardai G, Najdi A, Ezziani M, Batta FZ, El Pardiya NT, El Fadil C, El Hassani A, Arrayhani M, Houssaini TS. Eligibility for renal transplantation: A Moroccan interregional survey. Saudi J Kidney Dis Transpl 2015;26:153-60

How to cite this URL:
Kabbali N, Mikou S, El Bardai G, Najdi A, Ezziani M, Batta FZ, El Pardiya NT, El Fadil C, El Hassani A, Arrayhani M, Houssaini TS. Eligibility for renal transplantation: A Moroccan interregional survey. Saudi J Kidney Dis Transpl [serial online] 2015 [cited 2021 Feb 28];26:153-60. Available from: https://www.sjkdt.org/text.asp?2015/26/1/153/148769

   Introduction Top


Kidney transplantation (KT) is the treatment of choice for most patients with end-stage renal disease. The transplant evaluation process requires a comprehensive assessment of each patient's medical, surgical and psychosocial histories. Selection of the suitable transplant candidate remains a challenge for transplant physicians, owing predominantly to the presence of complex medical issues in the potential candidates and non-standardized criteria for acceptance or rejection among transplant centers.

In Morocco, up to 2010, 10,632 patients were receiving hemodialysis (336 per million population), while the number of kidney transplantations performed since 1986 does not exceed 300 because of various obstacles that oppose it (social, economic, religious beliefs...).

The aim of this study was to determine hemodialysis patients who meet the eligibility criteria for KT according to the European recommendations. [1]


   Methods Top


"ARTEMIS" design

This is a substudy of the ARTEMIS study, a multicenter, cross-sectional study including all chronic hemodialysis patients from four regions among the 16 Moroccan administrative regions: Fez Boulemane, Meknes Tafilalt, Taza Al Hoceima - Taounat and the Oriental region [Figure 1]. These regions were chosen because they contain the population most likely to benefit from KT in the Hassan II University Hospital of Fez - Morocco (CHU Hassan II). The total population of these four regions according to the general census of the population in Morocco is 7,405,410 people (29.5% of the Moroccan population).
Figure 1: Geographical distribution of hemodialysis centers included in the study.

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The official list of hemodialysis centers, both in the public and the private sectors, was obtained from the regional administration of the Ministry of Health in the four respective regions. All the responsible doctors of the hemodialysis centers were contacted to obtain their prior consent to participate in the study. We developed a questionnaire consisting of two parts:

The first part is for collection of data by the interrogation of patients and their physicians.

Verbal consent was obtained from the subjects.

The information collected was:

  • Demographic data: Age, sex, marital status, number of children, brothers and sisters, education level, occupation, socio-economic level and health coverage.
  • Hemodialysis-related data: Date of start of dialysis, number of sessions per week, vascular access, initial nephropathy, comorbidities, immunizing events and blood group.


The second part concerns data collections by interrogation of the patients on their awareness of KT, and the information collected was:

  • Desire to be transplanted and the main reason
  • Possible availability of a living related donor
  • Opinion on the cost of KT compared with hemodialysis
  • Knowledge of the position of Moroccan law and religious recommendations with regard to transplantation from living or deceased donors


The validation of the questionnaire for chronic hemodialysis patients of the Fez Hospital hemodialysis center carried out the internal administration.

After an informed consent, the questionnaire was administered by the centers' doctors responsible for hemodialysis or by the residents of the nephrology department of the CHU Hassan II of FEZ. After the administration of the questionnaire, additional information was systematically given to patients for the purpose of increasing their awareness regarding kidney transplantation.

Definitions

In our study, we considered the eligibility criteria for patients to be considered for KT as the following:

  • Age < 70 years
  • Low to moderate cardiovascular risk (depending on the 2000 EBPG) [1]
  • No viral hepatitis B or C
  • No HIV infection
  • No tuberculosis in the year preceding the KT
  • No neoplasia, hematological or any other causes for reduction of life expectancy to < 10 years
  • No mental retardation or serious psychiatric problem.



   Statistical Analysis Top


This study was carried out in collaboration with the Laboratory of Epidemiology of the Faculty of Medicine of Fez. The data were entered by a single investigator and then doubly validated.

We analyzed the data by statistical software (SPSS version 17.0). The qualitative variables were presented as percentages and the quantitative variables in the form of means with standard deviation or median. Means were compared using the t-test and percentages by the Chi-square test. The results were significant if P < 0.05. Univariate and multivariate analyses were subsequently used to identify the factors influencing the medical eligibility for KT on one hand and those expressing the wish to be transplanted on the other.


   Results Top


Patient characteristics

A total of 2066 patients undergoing dialysis in 39 hemodialysis centers (22 public and 17 private centers) were included in the study [Figure 2].
Figure 2: Distribution of the hemodialysis patients in the private and public centers of the four regions studied

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[Table 1] shows the characteristics of our patients. The mean age was 52.9 ± 16 years (range, 4-90 years), including 14 children and 155 patients aged over 75 years. The sex ratio (male/female) was 1.17. The average hemodialysis duration was 55.3 ± 58 months. The native kidney disease was diabetic nephropathy in 21.6% and hypertensive nephropathy in 17.2%. The prevalence of hepatitis B and C was 2.7% and 10.2%, respectively. Of the 39 centers, six centers were "hepatitis free."
Table 1: Demographic characteristics of the patients.

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Eligibility for KT

Among the 2066 hemodialysis patients, 58% were considered eligible for KT. Among the ineligible patients, 18.2% had an absolute contraindication and 23.8% had one or more relative contraindications [Figure 3]. In terms of immunizing events, ten patients have already received a kidney transplant, 82% of women had at least one pregnancy and 69.7% of patients had at least one transfusion episode. The distribution of blood grouping ABO/Rh is shown in [Figure 4].
Figure 3: Kidney transplantation eligibility.

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Figure 4: Distribution of blood groups of the patients.

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In the univariate analysis, we found that young age, short hemodialysis duration and persistence of residual diuresis are predictors for KT patient's eligibility. Nevertheless, diabetes mellitus and hypertension were significantly more frequent in the ineligible patients' group [Table 2]. In the multivariate analysis, independent factors of eligibility for KT were young age, short duration on hemodialysis and residual diuresis [Table 3].
Table 2: Characteristics of eligible and ineligible patients (univariate analysis).

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Table 3: Characteristics for ineligible patients and eligible ones (multivariate analysis).

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   Discussion Top


In this study, we evaluated the eligibility for KT in hemodialysis centers of four Moroccan regions. We based this study on the recommendations of the "European Best Practice Guidelines for Renal Transplantation," [1] which are in line with the American and the Canadian guidelines. [2],[3] All of them specify that KT should be considered in any patient with chronic renal failure as long as the risks do not exceed the expected benefits and if there is no contraindication. Potential recipients of kidney transplants undergo an evaluation process in order to identify medical, social and psychological factors, which may preclude successful outcome. The selection criteria adapted by various transplant centers most likely evolves from prior collective experience. [4],[5] However, it seems reasonable to maintain a more stringent eligibility criteria to ensure reasonable success rates in those centers starting an activity for KT, especially with organs from living donors. The age limit for recipients of kidney transplants has steadily increased over the last three decades. In our study, the age limit chosen is 70 years. We based this on the average life expectancy in Morocco, which is 71.8 years according to the data from the High Commission for planning and also on data from the literature where most of the patients enrolled on the waiting list for KT were < 70 years. In fact, in a French multicenter study that evaluated the criteria for inclusion on the waiting list for KT; no patient older than 70 years was enrolled in the 549 patients studied. [6]

The incidence of ischemic heart disease (IHD) is higher in KT recipients compared with the general population. Patients with IHD before transplantation are at high risk to develop IHD events after transplantation. [7],[8] Cardiovascular screening is considered by most transplant centers as an essential component of the transplant evaluation process. A number of transplant centers recommend direct coronary angiography in high-risk patients. [9],[10],[11] Cardiovascular disease was found in 14.6% of our patients. It was most frequently heart failure or ischemic heart disease. In a study of 1725 hemodialysis patients, Bayat et al found that 38% of the patients had a cardiovascular disease that significantly limited their inclusion on the waiting list for KT. [12]

One of the primary purposes of the pre-transplant evaluation is to eliminate infections that may persist and become life-threatening after transplantation. [13] In our study, 211 patients were suffering from hepatitis C and 56 patients were suffering from hepatitis B. One hundred and twenty-two patients had a history of tuberculosis, which was active in 0.3% of the cases. Transplant recipients are at greater risk of developing both de novo and recurrent malignancy owing to the use of immunosuppressants. As the incidence of malignancy increases with the intensity and duration of immunosuppression, a history of immunosuppressive therapy for the native kidneys represents an added risk for post-transplant malignancy. [14]

Recent history of neoplasia was observed in 21 patients in our study. It was most often urological tumor for men and gynecological cancer for women.

Recurrence of glomerular disease is the third most common cause of graft loss after chronic allograft injury and death with a functioning graft. [15],[16],[17],[18] Membranoproliferative glomerulonephritis and IgA nephropathy was found in 2.9% of our patients. However, native kidney disease was unknown in almost half of the cases.

One striking finding from our cohort is the positive association between ineligibility and longer dialysis duration. While the workup of patients with multiple co-morbidities may take longer, it is well known that longer dialysis duration is a risk factor for cardiovascular disease and hence may in itself ultimately contribute to ineligibility.

The reasons for ineligibility have been reported in other studies. [6],[12],[19] Kianda et al found that 8% of kidney transplant candidates whose files were forwarded to the transplant center were considered ineligible and that cardiovascular complications of chronic kidney disease represent the principal reasons of ineligibility [Table 4]. [19]
Table 4: Comparison with the literature.

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In conclusion, access to KT can be improved by starting pre-transplant evaluation before the onset of dialysis while reducing immunizing events, especially transfusion. We hope that our study would encourage the Moroccan nephrology community to establish valuable check-up guidelines for early transplantation of patients afflicted with advanced chronic kidney disease.

Conflict of interest: None

 
   References Top

1.
European Best Practice Guidelines for Renal Transplantation. Nephrol Dial Transplant 2000;15 (Suppl 7):3-38.  Back to cited text no. 1
    
2.
Kasiske1 BL, Cangro CB, Hariharan S, et al. The evaluation of renal transplant candidates: Clinical Practice Guidelines for the American Society of Transplantation. Am J Transplant 2001;1 Suppl 2:5-95.  Back to cited text no. 2
    
3.
Knoll G, Cockfield S, Blydt-Hansen T, et al. Canadian Society of Transplantation: Consensus guidelines on eligibility for kidney transplantation. CMAJ 2005;173:1181-4.  Back to cited text no. 3
    
4.
Jassal SV, Krahn MD, Naglie G, et al. Kidney transplantation in the elderly: A decision analysis. J Am Soc Nephrol 2003;14:187-96.  Back to cited text no. 4
    
5.
Frassetto L, Tan-Tam C, Stock P. Renal transplantation in patients with HIV. Nat Rev Nephrol 2009;5:582-9.  Back to cited text no. 5
    
6.
Villar E, Rabilloud M, Berthoux F, Vialtel P, Labeeuw M, Pouteil-Noble C. A multicentre study of Registration on renal transplantation waiting list of the elderly and patients with type 2 diabetes. Nephrol Dial Transplant 2004;19:207-14.  Back to cited text no. 6
    
7.
Gill JS, Ma I, Landsberg D, Johnson N, Levin A. Cardiovascular events and investigation in patients who are awaiting cadaveric kidney transplantation. J Am Soc Nephrol 2005;16:808-16.  Back to cited text no. 7
    
8.
Lentine KL, Schnitzler MA, Brennan DC, et al. Cardiac evaluation before kidney transplantation: A practice patterns analysis in Medicare-insured dialysis patients. Clin J Am Soc Nephrol 2008;3:1115-24.  Back to cited text no. 8
    
9.
Abbud-Filho M, Adams PL, Alberu J, et al. A report of the Lisbon Conference on the care of the kidney transplant recipient. Transplantation 2007;83:S1-22.  Back to cited text no. 9
    
10.
Patel AD, Abo-Auda WS, Davis JM, et al. Prognostic value of myocardial perfusion imaging in predicting outcome after renal transplantation. Am J Cardiol 2003;92:146-51.  Back to cited text no. 10
    
11.
Lentine KL, Hurst FP, Jindal RM, et al. Cardiovascular risk assessment among potential kidney transplant candidates: Approaches and controversies. Am J Kidney Dis 2009;55:152-67.  Back to cited text no. 11
    
12.
Bayat S, Frimat L, Thilly N, Loos C, Briançon S, Kessler M. Medical and non-medical determinants of access to renal transplant waiting list in a French community-based network of care. Nephrol Dial Transplant 2006;21:2900-7.  Back to cited text no. 12
    
13.
Peraldi MN, Rieu P. What test are necessary before registration on the kidney transplant waiting list? Néphrol Thér 2009;5 Suppl 4: S301-8.  Back to cited text no. 13
    
14.
Danovitch GM. Guidelines on the firing-line. Am J Transplant 2003;3:514-5.  Back to cited text no. 14
    
15.
Colgert WA, Appel GB, Hariharan S. Recurrent glomerulonephritis after renal transplantation: An unsolved problem. Clin J Am Soc Nephrol 2008; 3:800-7.  Back to cited text no. 15
    
16.
Kidney Disease Improving Global Outcomes (KDIGO) Transplant Work Group. KDIGO clinical practice guideline for the care of kidney transplant recipients. Am J Transplant 2009;9 Suppl 3:S1-157.  Back to cited text no. 16
    
17.
Fairhead T, Knoll G. Recurrent glomerular disease after kidney transplantation. Curr Opin Nephrol Hypertens 2010;19:578-85.  Back to cited text no. 17
    
18.
Schachter M, Monahan M, Radhakrishnan J, et al. Recurrent focal segmental glomerulosclerosis in the renal allograft: Single center experience in the era of modern immunosuppression. J Am Soc Nephrol 2007;74:173-81.  Back to cited text no. 18
    
19.
Kianda MN, Wissing KM, Broeders NE, et al. Ineligibility for renal transplantation: Prevalence, causes and survival in a consecutive cohort of 445 patients. Clin Transplant 2011;25:576-83.  Back to cited text no. 19
    

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Correspondence Address:
Nadia Kabbali
Department of Nephrology, Hassan II University Hospital, Fez
Morocco
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DOI: 10.4103/1319-2442.148769

PMID: 25579741

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