Annals of African Medicine

ORIGINAL ARTICLE
Year
: 2012  |  Volume : 11  |  Issue : 2  |  Page : 70--74

Commercial kidney transplantation: Trends, outcomes and challenges-A single-centre experience


Bappa Adamu1, Mustafa Ahmed2, Raees F Mushtaq2, Fuad Alshaebi2,  
1 Department of Medicine, Nephrology Unit, Aminu Kano Teaching Hospital, Kano, Nigeria
2 Department of Medicine, King Fahad Medical city, Saudi Arabia

Correspondence Address:
Bappa Adamu
Nephrology Unit, Department of Medicine, Aminu Kano Teaching Hospital, Kano
Nigeria

Abstract

Background/Objective: Many experts believe that commercial organ transplants continue unabated despite international efforts to curb them. The aim was to determine the trends, outcomes and challenges of commercial living unrelated renal transplants (LURT) as seen in our institution. Materials and Methods: A retrospective study of LURT patients on follow-up at our institution. The list of all LURT patients was obtained from our renal registry. Inclusion criteria for the study were 1) Presentation to our hospital within the first month post transplant; 2) Completion of one-year follow-up OR patient or allograft losses prior to completing one-year follow-up. SPSS 17.0 was used for data analysis. Results: Forty-five patients satisfied the entry criteria; 33 males and 12 females with age range 13-68 years, and mean ΁ SD of 40 + 15 years. The majority (28) of the transplants were carried out in Pakistan, the remaining in Egypt, Philippines, and China. There has been a steady decline in the number of new patients with commercial transplants over a four-year period. Complications encountered included infections in 19 (42.2%) patients, biopsy-proven acute rejections in nine patients (20%), surgical complications in 10 patients (22.2%), post-transplant diabetes in seven (15.6%), delayed graft function in one (2.2%), and chronic allograft nephropathy in one (2.2%) patient. Patient survival at one year was 97.8% and allograft survival was 88.9%. Conclusions: Commercial kidney transplant is on the decline as seen in our center, likely as a result of international efforts to curb it, as well as due to a parallel increase in renal transplants in the country. One-year patient and allograft survivals are good but there is a relatively high rate of infections.



How to cite this article:
Adamu B, Ahmed M, Mushtaq RF, Alshaebi F. Commercial kidney transplantation: Trends, outcomes and challenges-A single-centre experience.Ann Afr Med 2012;11:70-74


How to cite this URL:
Adamu B, Ahmed M, Mushtaq RF, Alshaebi F. Commercial kidney transplantation: Trends, outcomes and challenges-A single-centre experience. Ann Afr Med [serial online] 2012 [cited 2022 Oct 2 ];11:70-74
Available from: https://www.annalsafrmed.org/text.asp?2012/11/2/70/93527


Full Text

 Introduction



The waiting time for kidney transplants is continually increasing despite persistent efforts to increase the number of deceased and living related donor organs. Consequently, despite the ethical issues, many patients resort to commercial, living unrelated renal transplantation (LURT).

There have been efforts in the last few years internationally to curb commercial organ transplants. However, many experts believe that commercial organ transplants continue unabated.[1],[2] Conflicting data have been published regarding the outcomes and complications of LURT.[2]

The objectives of this study were to determine the trends, outcomes and challenges of LURT as seen in our institution over a four-year period (2006-2009).

 Materials and Methods



The list of all LURT patients was obtained from our renal registry data. Patients' case records were traced and relevant demographic and clinical information obtained. Inclusion criteria for the study were:

Presentation to our hospital for follow-up within the first month post transplant.

Completion of one-year follow up OR patient or allograft losses prior to completing one-year follow-up.

Extracted data was entered into computer-based statistical software (SPSS 17.0 for Windows) and analyzed.

Statistical analysis used

Quantitative data was summarized with ranges, means ± standard deviations. Qualitative data were presented as percentages.

 Results



Forty-five patients satisfied the entry criteria of the study; 33 males and 12 females with age range 13-68 years, and mean ± SD of 40 ± 15 years. All the patients had commercial LURT outside the kingdom. None of the LURTs were emotionally related transplants. The majority (28) of the transplants were carried out in Pakistan. The rest were carried out in Egypt (10), Philippines (6), and one in China [Figure 1]. There has been a consistent decline in the number of new patients with commercial transplants over a four-year period, from 2006 to 2009 [Figure 2].{Figure 1}{Figure 2}

Serum creatinine at presentation was 42-705 μmol/L with mean ±SD of 161± 149 μmol/L and at one year 67-425 μmol/L with mean ± SD of 122 ± 57 μmol/L. The majority of the patients had good graft function at one year with serum creatinine less than 132 μmol/L (1.5 mg/dl). Six patients (13.3%) had mild elevations of creatinine (140-185 μmol/L) but stable graft function. Only one patient had advanced chronic allograft nephropathy with creatinine of 425 μmol/L.

Thirty-seven (82.2%) patients were on cyclosporine, mycophenolate mofetil (MMF) and prednisolone immunosuppressant protocol, while eight (17.8%) were on tacrolimus, MMF and prednisolone protocol.

Complications encountered are summarized in [Table 1]. Infections were the commonest complications, confirmed in 19 (42.20%) patients, four of them with multiple infections. The infections include urinary tract infection (UTI) in nine (20%) patients, cytomegalovirus (CMV) in six (13.3%) patients, wound infections in four patients (8.8%), genital herpes in one patient (2.2%) and chickenpox in one patient (2.2%). Isolates of UTI included Escherichia coli in five patients (four of the isolates were extended spectrum beta lactamase (ESBL) producing), Klebsiella pneumonia (ESBL-producing) in two patients, Enterococcus in two patients, and Acinetobacter baumani in one patient. Three of the patients with E. coli UTI had associated bloodstream infections with the same organism. Isolates from the wound infection included Pseudomonas auriginosa in three patients, Staphylococcus aureus in one patient and Mycobacterium fortuitum in one patient. Post-transplant diabetes mellitus occurred in seven patients (15.6%). Nine patients (20%) had biopsy-proven acute rejections which responded to pulse steroids except one patient who lost the graft due to severe vascular rejection. One patient had delayed graft function and one had biopsy-proven chronic allograft nephropathy (CAN). {Table 1}

Surgical complications occurred in 10 patients (22.2%) as summarized in [Table 1].

Patient survival at one year was 97.8% while allograft survival was 88.9%. The five graft losses were due to one case each of death with a functioning graft, allograft artery thrombosis, renal allograft infarction, severe renal artery stenosis and severe vascular rejection.

 Discussion



Currently, the Kingdom of Saudi Arabia (KSA) has the highest rate of living renal transplants in the world with a reported rate of 32 procedures per million population.[3] However, there are concerns that a significant number of these transplants are commercial transplants carried out abroad.[4]

The World Health Organization (WHO), the Transplant Society as well as the governments of many countries have taken several steps to curb the menace of commercial transplant tourism. Notable is the recent Istanbul declaration.[5] Despite these steps, some experts believe that commercial transplants have continued unabated.[1],[2] However, data from the Saudi Centre for Organ Transplant (SCOT) suggest that commercial transplants have been on the decline in the country since 2007, with the number of living transplants carried out outside the country falling by about 50% from 700 in 2005 to 382 in 2008.[6] The result from our centre also agrees with this. The decline in commercial transplants may be partly explained by the passage of the Pakistani transplant ordinance in 2007, which is believed to have led to a near halt of commercial kidney transplants in that country.[7] Another contributory factor to the decline in commercial transplants outside KSA may be the parallel increase in both living and deceased kidney transplantations within the country,[6] which may have led to a reduced inclination of patients to source for commercial organs abroad. The majority of our patients were transplanted in Pakistan in contrast to the study by Al-wakeel et al., in which the majority of the patients were transplanted in India.[8] This change most likely occurred as the Indian government prohibited commercial transplants in the 1990s,[9] shifting transplant tourism to Pakistan where the transplant ordinance was not passed till 2007.[7]

There had been conflicting reports of the outcome of commercial transplants worldwide. A recent systematic review of 27 publications from several countries revealed that although some studies report good outcomes of LURT, the majority report poor outcomes.[2]

The results from our center show a good one-year patient survival (97.8%) which is comparable to the one-year survival of living related renal transplants in the KSA (98.4%).[10] The one-year mortality rate in our study (2.2%) is much lower than the mortality rate of 12.7% in the first six months in hemodialysis patients reported by Mohamed in 2005.[11] One-year allograft survival of our patients is also good (88.9%) but relatively inferior to that of LRT in KSA (96.7%).[10] One limitation of this study is that only one-year outcome was reported since our transplant clinic became active in 2006, and no patient had reached five years post transplant at the end of this study period. However, we envisage that five-year graft survival may ultimately be good in our patients considering the fact that renal function was good in most patients at one year with serum creatinine less that 132 μmol/L (1.5 mg/dl). Serum creatinine less that 132 μmol/L has been shown to be a predictor of long-term allograft survival.[12]

Infection rate at one year was relatively high (42.2%) with UTI as the commonest infection, which is in keeping with the known fact that UTI is the commonest infection in renal transplant patients.[13] Infections in our patients included potentially life-threatening infections such as Pseudomonas, Acinetobacter, and ESBL-producing organisms. Infection with ESBL organisms is increasingly recognized in renal transplant patients, accounting for both morbidity and mortality.[14] Although no mortality was encountered with the ESBL infections in our patients, they accounted for significant morbidity as the patients had to be admitted for administration of meropenem, with one patient requiring several admissions due to relapse. There were several other medical and surgical complications encountered as summarized in [Table 1].

There have been seven publications on commercial transplants from KSA over the last two decades involving 782 patients as summarized in [Table 2].[8],[15],[16],[17],[18],[19],[20] All the studies, apart from two, reported good allograft and patient survival, though with significant incidences of serious infections.

However, even if recipient outcomes are good and ethical issues are set aside, commercial transplants should not be condoned because of studies showing poor outcomes in the donors of commercial transplants.[9],[21] It is hoped that as transplant activities increase steadily in KSA, commercial transplants abroad will ultimately cease.{Table 2}

We conclude that commercial kidney transplant is on the decline as seen in our center, likely as a result of international efforts to curb it, as well as due to a parallel increase in kidney transplants in KSA. One-year patient and allograft survivals are good but there is a relatively high rate of infections including ESBL organisms.

 Acknowledgment



We wish to acknowledge the invaluable assistance of Zharifa Lipae in collating the data from our transplant register.

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