Objectives: End-stage renal disease is the complete failure of kidney function; kidney transplant offers the best survival advantage. We analyzed data from Al-Basheer Hospital’s newly established transplant program and present our kidney transplant results from the first year of operation.

Materials and Methods: Between April 2015 and June 2016, 20 kidney transplants were performed (19 living-related donors and 1 deceased donor). We assessed the demographic data, surgical techniques employed, complications, immunosuppressive drugs used, and graft and patient survival rates. The mean recipient age was 32.8 years. There were 10 male and 10 female patients. Two patients underwent preemptive trans­plant, and 18 were on hemodialysis. Preparation of the donor and recipient employed an established transplant protocol. Induction immunosuppression therapy was used in 13.65% of patients. The left kidney was used from all living donors, and the right kidney was harvested from the deceased donor. The total ischemia time in the living-donor grafts ranged from 30 to 53 minutes; in the deceased donor, the ischemia time was 90 minutes. Intraoperative Doppler ultraso­nography was used in most cases.

Results: There was no donor mortality, and no significant donor complications occurred, either intraoperatively or postoperatively. There was no recipient mortality, but there were complications in 6 patients. Intraoperative complications were reported in 2 patients: 1 with renal artery thrombosis and the other with external iliac artery dissection. Postoperative complications were reported in 4 patients: slow graft function in 1 patient with thrombotic thrombocytopenic purpura, 1 patient with acute cellular rejection treated with intravenous immunoglobulin, 1 patient with cytomegalovirus gastroenteritis, and 1 patient treated for varicella pneu­monitis. The follow-up ranged from 1 week to 13 months.

Conclusions: The first-year outcomes for our newly established transplant program at Al-Basheer Hospital are comparable to those of well-established programs.

Key words : Adult kidney transplant, Immunosuppression, Living donor, Surgical technique, Survival rate

Introduction

Kidney transplant is the best treatment option for patients with end-stage renal disease (ESRD), according to both quality-of-life and financial considerations.^1-3 Starting a transplant program is a major endeavor, more complex than starting a program for any other medical specialty. The clinicians who attempt to start a transplant program will experience excitement, frustration, and continuous rejection, with resistance coming from many different directions. Once achieved, however, the accom­plishment is very satisfying and rewarding, and the benefits experienced are tremendous. Our newly established transplant team is multinational and includes members trained in different health care institutions from all over the world.

Materials and Methods

Adult kidney transplant at Al-Basheer Hospital in Jordan
Between April 2015 and June 2016, 20 kidney transplants were performed at our center, using 19 living-related donors and 1 deceased donor. The mean recipient age was 32.8 years. There were 10 male patients and 10 female patients. The primary renal diseases in the recipients are listed in Table 1. Two patients underwent preemptive transplant, and 18 patients were on hemodialysis prior to transplant.

Figure 1 depicts the familial relations of the living donors. The exclusion criteria for living-organ donation were the presence of cancer, renal disease, glucose intolerance, major cardiac or cerebrovascular disease not amenable to surgical correction, liver disease, alcoholism, severe pulmonary disease, and a positive crossmatch. The recipient histories were analyzed for demographic data, the underlying cause of ESRD, and the type and duration of dialysis. We performed donor and recipient preparations using an established transplant protocol, which is provided in Table 2. The study was approved by the Ethical Review Committee of the Institute. All of the protocols conformed with the ethical guidelines of the 1975 Helsinki Declaration. Written informed consent was obtained from all patients.

Surgical technique
Transplant surgeries were usually performed on Saturdays because of the very busy operating room schedule at our hospital. We used 2 adjacent rooms with well-trained nursing and anesthesia staff. The donor team consisted of 2 urologists and 2 transplant surgeons, while the recipient team consisted of a vascular surgeon, a transplant surgeon, and a urologist. The left kidney was used in all 19 living donors; the organ was obtained using open nephrectomy technique and removed through a left subcostal incision. The right kidney was harvested from the 1 deceased donor. In 6 patients, we performed 2 arterial anastomoses, and in 2 patients, we performed 2 venous anastomoses. All kidneys were transplanted into the right iliac fossa of the recipient, except for 1 patient whose graft was placed in the left iliac fossa. The total ischemia time in the living-donor grafts ranged from 30 to 53 minutes; in the deceased-donor graft, the ischemia time was 90 minutes. Intraoperative Doppler ultrasonography was used in most cases. We routinely used double-J ureteric stents, removing them 6 weeks post­transplant. A Foley catheter was retained for 5 to 7 days.

Immunosuppression
Induction therapy was used in 13 patients (65%), depending on the results of human leukocyte antigen matching. These patients received basiliximab and methylprednisolone. For maintenance immuno­suppression, patients received triple therapy: cyclos­porine (monitoring the 2-hour postdose level), mycophenolic acid, and prednisone.

Results

Follow-up ranged from 1 week to 13 months. Both patient and graft survival rates were 100%, with good graft function in all patients.

Complications
There was no donor mortality, and no significant donor complications occurred, either intraoperatively or postoperatively. There was no recipient mortality, although there were 6 reported complications. Two patients had intraoperative complications: a patient with renal artery thrombosis was treated immediately with surgical thrombectomy and reanastomosis; the other patient had an external iliac artery dissection that was treated using a polytetrafluoroethylene iliofemoral bypass graft. There were postoperative complications in 4 patients: slow graft function in 1 patient with thrombotic thrombocytopenic purpura was treated with intravenous immunoglobulin and plasmapheresis; a second patient had acute cellular rejection treated with intravenous immunoglobulin; a third had cytomegalovirus gastroenteritis treated with ganciclovir; the fourth developed varicella pneumonitis and was treated with acyclovir.

Discussion

In the first year of the newly established transplant program at Al-Basheer Hospital, we obtained outcomes comparable to those of well-established centers. The toll of ESRD is particularly seen in patients from developing countries; the main reasons are the rampant epidemic of diabetes mellitus in developing countries and their aging populations.^4,5 The demand for kidney transplant has grown inexorably as the number of patients with ESRD has escalated rapidly worldwide. Aggravating the already dire situation, there has been a decline in the number of deceased-donor kidney transplants being performed. The diabetes pandemic is threatening developing countries more than developed countries; it is estimated that within the next generation, the number of people with diabetes will increase by 88% in Latin America, 98% in Africa, and 91% in Asia, contrasted with 18% in Europe. By 2030, more than 80% of patients with diabetes will be from developing countries. Type 2 diabetes mellitus has now overtaken glomerulonephritis as the major cause of end-stage kidney failure worldwide, in both the developed and developing worlds.⁶ Living-related donor grafts have a 10% to 12% better survival rate at 1 year and a significantly higher probability of function thereafter.⁷ Almost all transplant units continue to recommend living-donor renal transplant if suitable individuals volunteer to donate their organs.^8,9

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