Kidney Transplantation in Low- to Middle-Income Countries: Outcomes and Lessons Learned from Armenia

BACKGROUND Treatment of end-stage renal disease constitutes a heavy financial burden, especially in developing countries. Maintaining a kidney transplantation program is an extremely complex task in countries with limited resources. It often requires expertise and support from developed countries. Living donor kidney transplantations (LDKT) have been performed regularly in the Republic of Armenia since 2002. The purpose of this article is to review the history and outcomes of kidney transplantation in Armenia. MATERIAL AND METHODS A chart review was performed retrospectively on all patients who had undergone LDKT in Armenia. The key personnel involved in the development and operation of the unique kidney transplant program in the country were interviewed for a comprehensive review of the history and challenges of transplantation. RESULTS There were 172 LDKT (4 re-transplantations) performed between 2002 and 2019. The mean age of recipients was 35.9±13.4 years (range 7.1-65.7): 116 (67.4%) were male and 12 (6.9%) were children (<18 years). Seventy-four patients (43%) had peri- (n=5) and postoperative (n=69), mostly mild, surgical complications. Delayed graft function occurred in 17 (9.9%) patients, requiring hemodialysis in 16, and 6 patients stayed HD-dependant. Sixty-nine patients (40.1%) had at least 1 episode of acute rejection, with 26 (15.1%) having more than 1. Late complications were mostly infectious (n=49) or malignant processes (n=13). Follow-up studies showed that out of 172 patients, 126 had functioning grafts, 17 died with functioning grafts, 3 were lost to follow-up, and 26 lost grafts. Graft survival at 1, 3, 5, and 10 years, non-censored for death, after LDKT was 96.4% (CI 93.6-99.2), 93.7% (CI 89.9-97.5), 90.5% (CI 85.7-95.3), and 75.3% (CI 66.9-83.7), respectively. CONCLUSIONS Findings from this study suggest that a renal transplant program with acceptable outcomes can be successfully introduced in countries with limited resources.

Native kidney biopsies in Armenian and Swiss children: high prevalence of amyloidosis in Yerevan and of IgA nephropathy in Zurich

The spectrum of pathology in native kidney biopsies varies considerably between different countries. Based on similar biopsy policy and joint workup, biopsy data of native kidneys of children in Yerevan (Armenia) and Zurich (Switzerland) were compared over a period of two decades (1993-2002 and 2003-2012). A total of 487 renal biopsies in Yerevan (EVN), n = 253; median age 11.2 years (range 0.8-18; 56 % males) and in Zurich (ZRH), n = 234; median age 8.7 years (range 0.1-18; 61 % males) were analyzed. Biopsies from EVN were locally analyzed by light microscopy (LM) and sent to ZRH for electron microscopy (EM) and immunohistochemistry. Biopsies from ZRH were evaluated by LM, EM, and immunofluorescence. The significant difference concerns the high frequency of amyloidosis in EVN (25.4 % in the first and 19.4 % in the second decade vs. 0 % in ZRH) and of IgA nephropathy in ZRH (30.2 % in the first and 26.1 % in the second decade vs. 8.1 in EVN). Certain forms of glomerulonephritis (membranoproliferative type I and membranous) and primary focal segmental glomerulosclerosis tended to be more frequent in EVN than in ZRH. Amyloid nephropathy due to familial Mediterranean fever is still highly frequent in Armenia with a slight decrease in the second decade. In Switzerland, the most common finding was IgA nephropathy.