Deceased donor renal transplantation: A single center experience

Deceased Donor Kidney Transplantation Outcomes at a Sri Lankan Center: A Comprehensive Single-Center Analysis

Background Chronic kidney disease (CKD) causes significant morbidity and mortality in patients and incurs a huge burden on healthcare expenses globally. Renal replacement therapy becomes imperative when patients reach end-stage renal disease. Kidney transplant is the best modality of choice for the majority of patients, and deceased donor kidney transplantation is the major contributor in the majority of countries. We present an outcome study in Sri Lanka for deceased donor kidney transplantation. Methodology This is an observational study conducted at the Nephrology Unit 1 at the National Hospital of Sri Lanka, Colombo, in patients who had undergone deceased donor kidney transplantation from July 2018 to mid-2020. We studied the outcomes of these patients for one year, including delayed graft function, acute rejection, infection, and mortality. Ethical clearance was obtained from the ethical review committee of the National Hospital of Sri Lanka, Colombo, and the University of Colombo. Results The study included 27 participants with a mean age of 55 ± 9.519 years. Diabetes mellitus (69.2%), hypertension (11.5%), chronic glomerulonephritis (7.7%), chronic pyelonephritis (7.7%), and obstructive uropathy (3.8%) were the etiological factors of CKD. Basiliximab was used as an induction agent, and a tacrolimus-based triple-drug regimen was used for maintenance in all patients. The mean cold ischemic time was 9 ± 3.861 hours. The majority (44%) of recipients had an O-positive blood group. At one year, the mean serum creatinine was 1.40 ± 0.686 mg/dL, and the mean estimated glomerular filtration rate was 62 ± 21.281 mL/minute/1.73 m². Delayed graft function occurred in 25.9% of the recipients, and 22.2% had acute transplant rejection. Postoperative infection was observed in 44.4% of recipients. One year after transplantation, 22% of the recipients died. Infection was the cause of death in 83% of recipients (five of six patients). The causes of death in the study sample were pneumonia (50%), including pneumocystis pneumonia (17%), myocardial infarction (17%), mucormycosis (16%), and other infections (17%). There was no significant association between outcomes at one year with age, gender, causes of CKD, or postoperative complications. Conclusions Our study found that the one-year survival rate following deceased donor kidney transplantation in Sri Lanka is relatively low, with infections being the leading cause of mortality. The high infection rate during the early post-transplant period underscores the need for enhanced infection prevention and control measures. Although we did not observe any significant association between the outcomes and the variables studied, it is important to note that the small sample size of our study may have influenced this finding. Future research with larger sample sizes may provide more insights into the factors influencing post-transplant outcomes in Sri Lanka.

Induction with rATG versus No-induction in Deceased Donor Renal Transplantation - A Retrospective Observational Study

Introduction

Deceased donor renal transplantation (DDRT) poses special immunological challenges; particularly in resource-poor scenarios. There is substantial evidence that rabbit antithymocyte globulin (rATG) is superior to interleukin-2 receptor blocker and placebo among patients at high immunological risk. However, due to the lack of randomized controlled trials, this remains controversial in DDRT maintained on tacrolimus/mycophenolic acid/steroids. Here, in this study, we compared the clinical outcomes of induction with rATG therapy to no-induction therapy.

Methods

The study was a single-center, retrospective cohort study. A total of 62 patients were divided into two groups, based on induction immunosuppression; induction with rATG (N = 25) and no-induction group (N = 37). Both groups received tacrolimus/mycophenolate mofetil sodium/prednisolone as maintenance immunosuppression. The main outcomes were incidence of acute rejection (AR) within the first year and graft survival at the end of 1 year.

Results

The AR at the end of 1-year was reported as 8% and 27% for the induction and no-induction groups (P = 0.07), respectively. A total of 15 patients died. Patient survival rates at 12 months were 83.8% (no-induction) and 64.0% (induction; P = 0.094). Death-censored graft survival rates, 12 months after transplantation, were similar in both treatment groups (83.7% vs. 83.5%, P = 0.972). The incidence of death with functioning graft was significantly high in the induction group (28% vs. 5.4%, P = 0.045).

Conclusion

The incidence of AR was less in patients who received rATG induction compared with patients who did not receive any form of induction. An added advantage of induction with ATG in terms of reduced incidence of AR must be weighed against high incidence of infection, death with functioning graft, and death.

Deceased Donor Renal Transplantation: A Single Center Experience

Introduction:

Deceased donor kidney transplant are still not common across India. This study was done to assess various measures taken at a single center level to increase organ donation rate and to analyse the outcomes of transplants performed from these donors.

Methods:

All deceased donor renal transplants performed from November 2011 to February 2017 were analysed for patient and death censored graft survival, rate of delayed graft function, rate of rejection and mortality. Kaplan Meir analysis for Survival Curves was used.

Results:

Organ donation rate at our center improved from one donation every alternate year in 2004 to a peak of 44 donations in 2017. Patient survival was 93.42%, 89.44%, 85.53%, and death censored graft survival was 94.07%, 88.21%, and 82.86% at 1, 2 and 3 years respectively. Mean duration of hemodialysis pre transplantation was 34.6 ± 27.43 months.

Conclusions:

This study has shown that steps taken at a single center level alone can also significantly improve organ donation rates. Employment of dedicated professionals including transplant surgeons and coordinators, developing a protocol-based approach for referral, and early counseling in triage along with regular audits can help to establish deceased donor program with acceptable outcomes elsewhere in the country.

Cadaveric renal transplantation: Our experience at a tertiary care centre in India

BACKGROUND

Renal transplantation in developing countries like India is largely live donor transplantation. Cadaveric transplantation comprises <2% of all transplants in India.

METHODS

Ninety-two cadaveric renal transplantations were included. Various donor and recipient characteristics were analysed along with graft and patient survival, using Kaplan-Meier method.

RESULTS

The mean age of the recipients was 35.5 ± 10.9 years while that of cadaver was 43.9 ± 17.0 years. Proportion of females among recipients was 47.8% while that of donors was 34.8%. The most common underlying pathology was chronic glomerulonephritis (44.6%). Antithymocyte globulin was used as induction in 84.8% of cases. Tacrolimus-based triple-drug regimen was most commonly used as maintenance (80.4%). The mean follow-up time was 39.02 ± 28.24 months. The most common cause of death was sepsis (47%). More than 50% deaths (9/17) occurred within first 3 years, while 61.5% of graft loss occurred 5 years after transplantation. The mean graft survival time was 81.6 months (95% confidence interval [CI]: 72.8-90.4). Cumulative proportion of graft survival was 91.6% at 3 years and 77.1% at 5 years. Although females have better mean graft survival time (91.6 vs 73.5 months), it was not a significant difference as shown by log-rank test (p value = 0.062). Pretransplant haemodialysis has no significant effect on graft loss, but patients on peritoneal dialysis have significantly higher odds of graft loss (odds: 4.86, p value < 0.05 [0.018]). The mean patient survival time was 99.5 months (95% CI: 84.0-114.9). Cumulative proportion of patient survival was 83.3% at 3 years and 70.8% at 5 years.

CONCLUSION

Graft and patient survival rate of cadaveric transplant at our centre was satisfactory. There is need to sensitise and augment the rate of cadaveric transplantation to increase the donor pool.

Impact of single centre kidney paired donation transplantation to increase donor pool in India: a cohort study

In a living donor kidney transplantation (LDKT) dominated transplant programme, kidney paired donation (KPD) may be a cost-effective and valid alternative strategy to increase LDKT in countries with limited resources where deceased donation kidney transplantation (DDKT) is in the initial stages. Here, we report our experience of 300 single-centre KPD transplantations to increase LDKT in India. Between January 2000 and July 2016, 3616 LDKT and 561 DDKT were performed at our transplantation centre, 300 (8.3%) using KPD. The reasons for joining KPD among transplanted patients were ABO incompatibility (n = 222), positive cross-match (n = 59) and better matching (n = 19). A total of 124 two-way (n = 248), 14 three-way (n = 42), one four-way (n = 4) and one six-way exchange (n = 6) yielded 300 KPD transplants. Death-censored graft and patient survival were 96% (n = 288) and 83.3% (n = 250), respectively. The mean serum creatinine was 1.3 mg/dl at a follow-up of 3 ± 3 years. We credit the success of our KPD programme to maintaining a registry of incompatible pairs, counselling on KPD, a high-volume LDKT programme and teamwork. KPD is legal, cost effective and rapidly growing for facilitating LDKT with incompatible donors. This study provides large-scale evidence for the expansion of single-centre LDKT via KPD when national programmes do not exist.