Live Donor Renal Transplantation in Sri Lanka

Gunawansa N, Cassim MRN,

Wijeyaratne SM.

LIVE DONOR RENAL TRANSPLANTATION

IN SRILANKA: FACTORS AFFECTING OVERALL OUTCOME

Kidney transplantation is the most effective therapy for ESRD Ojo, J Am Soc Neph, 2001;12:589

LIVE DONOR RENAL TRANSPLANTATION IN SRI LANKA: FACTORS AFFECTING OVERALL OUTCOME 1

Introduction

• Medium and long-term patient / graft survival statistics after Live Donor Renal Transplantation (LDRT) in Sri Lanka is largely unknown

• The overall outcome of LDRT depends on numerous patient, donor and graft related variables

• Early identification of above predictors will help in optimizing overall graft and patient outcomes


Methodology

• Prospective computerized database• July 2006 – November 2011• University Vascular and Transplant Unit, Colombo.• Inclusion – All consecutive LDRT• Exclusion – re-transplants, cadaveric


Methodology contd.

• All transplants performed as simultaneous donor and recipient operations

• relatively constant cold ischaemia time of <2 hours

• Standardized immunosuppression regime (MMF, prednisolone, cyclosporin/tacrolimus)

• Single dose monoclonal Ab induction for those with a HLA mismatch >50%

Graft failure = need for maintenance dialysis, re-transplantation or death due to graft non-function within 1 yr of transplantation** Weiss-Salz et al. Clin Transplant 2004: 18: 571–575


Factors Determining Overall Outcome

• Type of donor (cadaveric vs. living)• HLA Matching (related, unrelated) • Sensitization• Duration of pre-Tx dialysis• Recipient Age• Donor Age• Cold ischaemia time, warm ischaemia time• Acute rejection, chronic rejection• Primary renal pathology• CMV status


Variables analyzed

• Type of donor (cadaveric vs. living)• HLA Matching and sensitization• Duration of pre-Tx dialysis• Recipient Age• Donor Age• Cold ischemia time• Acute rejection, chronic rejection• Primary renal pathology• CMV status• Multivariate log regression


Results

• 415 consecutive LDRT • Complete follow-up data available – 397 (95%)• Mean follow-up – 36 (3-66) months. • Mean recipient age – 42 (17-72) years• Mean donor age – 39 (20-60) years


18 Lost to follow up 397 (95%) complete follow up data

32 (8%) Graft failures365 (92%) Graft survival

24 PGF 8 SGF

337 (85%) overall patient survival

5 re-transplanted19 dead

5 re-transplanted or 3 on waiting list

415 LDRT


Results contd.

• Graft survival - 365/397 (92%)• Graft Failures (GF); 32 (8%)

– 24 primary GF– 05 successfully re-transplanted, 19 dead– 08 secondary GF (Mean graft survival – 10 months)– 05 re-transplanted, 03 activated on waiting list

• Overall patient survival – 337/397 (85%)


Causes of death

• Sepsis – 48 (80%)• myocardial ischaemia – 4 (7%)• stroke – 4 (7%)• PE – 2 (3%)• Unknown – 2 (3%)

Sepsis MI Stroke PE Other


Kaplan- Meir Curve – Graft survival


Predictors of GF

Variable Univariate analysisP

Multivariate analysisOR (95%CI) P

Recipient age: >50y/<50y 0.63 0.06-5.13 0.627

Donor age: >40y/<40y 0.85 0.12-4.22 0.71

CMV infection: Y/N 0.11 0.86-15.07 0.09

HLA mismatch: >50%/<50% 0.04 1.74-6.64 0.07

Pre-Tx dialysis: <12 months/<12 months

0.03 1.17-13.54 0.06

Biopsy proven ac. Rejection: Y/N

0.01 1.35-10.23 0.014


Conclusions

• Our mid-term graft / patient survival figures match favorably with comparable settings elsewhere

• Pre-Tx dialysis for >1 year, HLA mismatch of >50% showed a positive correlation to outcome although not statistically significant

• Acute rejection within the first month was an independent predictors of poor outcome

• Care of primary GF is suboptimal - restricted access to HD, advanced immunosuppressant regimes and the lack of a cadaveric transplant program until now


Recommendations

• Earlier referral for transplant• Better HLA match wherever possible• Increasing the donor pool (regular deceased donor

program)• A better balance of saving the graft versus saving

the patient


Health & Medicine

Live Donor Renal Transplantation in Sri Lanka