RESUMO
OBJECTIVES: This study reports our experience of the first 4-way kidney exchange transplant combined with desensitization in India, which allows increased access to living-donor kidney transplant for sensitized patients. MATERIALS AND METHODS: Four-way kidney exchange transplant procedures were approved by the ethics committee of our institution and the Organ Transplantation Authorization Committee of state governments of India (as per the Transplantation of Human Organs Act of India). The protocols conformed to Declaration of Istanbul principles and the ethical guidelines of the 1975 Helsinki Declaration. Written informed consent was obtained from patients, donors, and their guardians. RESULTS: In April 2016, our transplant team completed simultaneous 4-way kidney exchange transplant procedures without any medical (rejection and infections) or surgical complications. Reasons for being included for kidney exchange transplant were ABO incom-patible (2 recipients) and sensitization (2 recipients). All 4 recipients had stable graft function with no proteinuria and donor-specific antibody at 11-month follow-up on standard triple immunosup-pression. Patient and graft survival rates were both 100%. CONCLUSIONS: To the best of our knowledge, this is the first single-center report of 4-way kidney exchange transplant combined with desensitization from India. This procedure has the potential to expand living-donor kidney transplant in disadvantaged groups (eg, sensitized patients). Recipients who are hard to match due to high panel reactive antibody and difficult to desensitize due to strong donor-specific antibodies can receive a transplant with a combination of kidney exchange and desensitization. Our study suggests that 4-way kidney exchange transplant can be performed in developing countries (India) similar to that shown in programs in developed countries with team work, kidney exchange registry, and counseling.
Assuntos
Incompatibilidade de Grupos Sanguíneos/tratamento farmacológico , Dessensibilização Imunológica/métodos , Doação Dirigida de Tecido , Rejeição de Enxerto/prevenção & controle , Acessibilidade aos Serviços de Saúde , Imunossupressores/administração & dosagem , Transplante de Rim/métodos , Doadores Vivos/provisão & distribuição , Sistema ABO de Grupos Sanguíneos/imunologia , Adulto , Incompatibilidade de Grupos Sanguíneos/imunologia , Feminino , Rejeição de Enxerto/imunologia , Sobrevivência de Enxerto , Humanos , Índia , Isoanticorpos/sangue , Isoanticorpos/imunologia , Masculino , Pessoa de Meia-Idade , Fatores de Tempo , Resultado do Tratamento , Adulto JovemRESUMO
According to the Indian chronic kidney disease registry, in 2010 only 2% of end stage kidney disease patients were managed with kidney transplantation, 37% were managed with dialysis and 61% were treated conservatively without renal replacement therapy. In countries like India, where a well-organized deceased donor kidney transplantation program is not available, living donor kidney transplantation is the major source of organs for kidney transplantation. The most common reason to decline a donor for directed living donation is ABO incompatibility, which eliminates up to one third of the potential living donor pool. Because access to transplantation with human leukocyte antigen (HLA)-desensitization protocols and ABO incompatible transplantation is very limited due to high costs and increased risk of infections from more intense immunosuppression, kidney paired donation (KPD) promises hope to a growing number of end stage kidney disease patients. KPD is a rapidly growing and cost-effective living donor kidney transplantation strategy for patients who are incompatible with their healthy, willing living donor. In principle, KPD is feasible for any centre that performs living donor kidney transplantation. In transplant centres with a large living donor kidney transplantation program KPD does not require extra infrastructure, decreases waiting time, avoids transplant tourism and prevents commercial trafficking. Although KPD is still underutilized in India, it has been performed more frequently in recent times. To substantially increase donor pool and transplant rates, transplant centres should work together towards a national KPD program and frame a uniform acceptable allocation policy.
Assuntos
Países em Desenvolvimento , Doação Dirigida de Tecido , Recursos em Saúde/organização & administração , Acessibilidade aos Serviços de Saúde/organização & administração , Disparidades em Assistência à Saúde , Falência Renal Crônica/cirurgia , Transplante de Rim , Doadores Vivos/provisão & distribuição , Avaliação de Processos e Resultados em Cuidados de Saúde/organização & administração , Análise Custo-Benefício , Países em Desenvolvimento/economia , Doação Dirigida de Tecido/economia , Doação Dirigida de Tecido/legislação & jurisprudência , Custos de Cuidados de Saúde , Política de Saúde , Recursos em Saúde/economia , Recursos em Saúde/legislação & jurisprudência , Acessibilidade aos Serviços de Saúde/economia , Acessibilidade aos Serviços de Saúde/legislação & jurisprudência , Disparidades em Assistência à Saúde/economia , Disparidades em Assistência à Saúde/legislação & jurisprudência , Histocompatibilidade , Humanos , Índia/epidemiologia , Falência Renal Crônica/diagnóstico , Falência Renal Crônica/economia , Falência Renal Crônica/epidemiologia , Transplante de Rim/efeitos adversos , Transplante de Rim/economia , Transplante de Rim/legislação & jurisprudência , Doadores Vivos/legislação & jurisprudência , Avaliação de Processos e Resultados em Cuidados de Saúde/economia , Avaliação de Processos e Resultados em Cuidados de Saúde/legislação & jurisprudência , Formulação de Políticas , Fatores de Tempo , Resultado do Tratamento , Listas de EsperaRESUMO
BACKGROUND: In India, there are a large number of end-stage renal disease (ESRD) patients waiting for renal transplantation (RT). Organ retrieval from brain dead deceased donor (DD) is getting increased attention as the waiting list for organ recipients far exceeds the organ donor pool. In our country, despite a large population, the number of brain dead donors undergoing organ donation is very less. DDRT is the possible solution to bridge the disparity between organ supply and demand. In India, the potential for DDRT is huge due to the high number of fatal road traffic accidents and this pool is yet to be tapped. PATIENTS AND METHODS: We report DDRT outcome in 294 patients (age: 36.5 ± 14.1 years; male:female, 200:94) between 2005 and 2012. All patients received single-dose rabbit-anti-thymocyte globulin for induction and steroids, calcineurin inhibitor, and mycophenolate mofetil/azathioprine for maintenance immunosuppression. RESULTS: Our retrospective study in 294 DDRT shows a fairly successful outcome. Over a mean follow-up of 3.93 years, patient and graft survival rates were 81.7% and 92.6%, respectively, with a median serum creatinine of 1.5 mg/dL. 20.7% had biopsy-proven acute rejection. CONCLUSION: Given the widespread organ shortage, DDRT has a potential to expand the donor pool and shorten the waiting list for RT, encouraging the use of this approach even in low-income countries. Aggressive donor management, increasing public awareness about the concept of organ donation, good communication between clinician and the family members, and a well-trained team of transplant coordinators can help in improving the number of organ donations.