Saudi Journal of Kidney Diseases and Transplantation

RENAL DATA FROM THE ARAB WORLD
Year
: 2007  |  Volume : 18  |  Issue : 2  |  Page : 265--269

Adult-to-Adult Living Related Donor Renal Transplantation in Yemen: The First Experience


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

Correspondence Address:
Ibrahiem H El-Nono
Director of Urology and Nephrology Center, Al-Thawra Modern General Hospital, Sana«SQ»a University, Sana«SQ»a
Yemen

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«SQ»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.



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;18:265-269


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 Aug 14 ];18:265-269
Available from: https://www.sjkdt.org/text.asp?2007/18/2/265/32324


Full Text

 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.

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