Recent management of Renal Transplantation in a Developing

Country like Bangladesh

Islam M S, R Alam, , R Alam,

H Rahman, HU RashidH Rahman, HU Rashid

Department of Nephrology, Department of Nephrology,

BSMMU, Dhaka, BangladeshBSMMU, Dhaka, Bangladesh

BackgroundBackground

Renal Tx is the treatment of choice for most patients with end stage renal diseases (ESRD).

Despite marked improvements in short-term renal allograft function and survival with newer immunosuppressive drugs, still renal graft loses continue to be a constant problem. (Ref. Transplantation 64:2004.)

Both immunological & non-immunological factors have been identified as an important risk factor to develop chronic graft loss.

Background Background (Contd.)(Contd.)

Cardiovascular complications specially HTN Cardiovascular complications specially HTN has been to be an independent non-has been to be an independent non-immunological risk factor for graft loss as immunological risk factor for graft loss as well as morbidity & mortality in transplanted well as morbidity & mortality in transplanted recipient. recipient. (Ref.Nephrol Dial transplant 10: (Ref.Nephrol Dial transplant 10: 1995 & Kidney Int.47:1995).1995 & Kidney Int.47:1995).

In our Country, renal Transplantation In our Country, renal Transplantation started since 1988 at started since 1988 at the then IPGMR now in the then IPGMR now in BSMMUBSMMU..

Only live related Tx. facilities are available at present, Only live related Tx. facilities are available at present, though caderveric Tx law has been passed by the though caderveric Tx law has been passed by the Govt. in 1999 but still not implemented due to lack of Govt. in 1999 but still not implemented due to lack of infrastructure for cadeveric Tx.infrastructure for cadeveric Tx.

Donor scarcity is a major factor to increase number Donor scarcity is a major factor to increase number of Tx. though huge number of ESRD patients are on of Tx. though huge number of ESRD patients are on MHD & waiting for Tx.MHD & waiting for Tx.

However no published data were available for those However no published data were available for those patients transplanted in our centre patients transplanted in our centre

BackgroundBackground ( (Contd.)Contd.)

In these study we are trying to:In these study we are trying to:

(1) Post Tx evaluation of the recipient.(1) Post Tx evaluation of the recipient.

(2) To see the complication of the post(2) To see the complication of the post Tx. patient.Tx. patient.

(3) To observe the survival rate of the (3) To observe the survival rate of the Tx. patient.Tx. patient.

Materials & Methods:Materials & Methods:

Duration of Study: 1995 – 2005Duration of Study: 1995 – 2005

Total No. of Tx.: 214Total No. of Tx.: 214

No. of Patient survival = 138 (64.48%)No. of Patient survival = 138 (64.48%)

Total No. of Death = 57 (26.63%)Total No. of Death = 57 (26.63%)Total No. of graft dysfunction put on Total No. of graft dysfunction put on

dialysis:19(8.87%)dialysis:19(8.87%)

Use of Immno suppressive protocol Use of Immno suppressive protocol in our centre:in our centre:

Initial use of immuno suppressive:Initial use of immuno suppressive: Cyclosporine 6mg/kgCyclosporine 6mg/kg MMF 1000mg/dayMMF 1000mg/day Prednisolon .5mg/kgPrednisolon .5mg/kg

NB: - Cyclosporin dose may be adjustable NB: - Cyclosporin dose may be adjustable according to Caccording to C22 level level

- No induction therapy given in any patient- No induction therapy given in any patient

After one year (maintenance dose)After one year (maintenance dose)

Azathiopurin 2mg/kgAzathiopurin 2mg/kg Prednisolon 7.5 to 10 mg/dayPrednisolon 7.5 to 10 mg/day

NB: Periodic check-up blood count, renal NB: Periodic check-up blood count, renal

function.function.

RESULTS:RESULTS:Year wise distribution of Tx.Year wise distribution of Tx.

YearYear No. of TxNo. of Tx No. of DeathNo. of Death No. of Graft dysfunction put on HDNo. of Graft dysfunction put on HD

19951995 77 22 --

19961996 2020 88 22

19971997 99 22 11

19981998 1212 33 11

19991999 1616 33 22

20002000 2929 88 33

20012001 2323 55 22

20022002 3333 88 2220032003 2626 88 44

20042004 1515 44 11

20052005 2424 44 11

Causes of DeathCauses of Death

Graft failure = 12 (21.15%)Graft failure = 12 (21.15%) Infections = 28 (49.12%)Infections = 28 (49.12%) MI = 8 (14.13%)MI = 8 (14.13%) CVD = 7 (12.28%)CVD = 7 (12.28%) Unexplained = 2(3.51%)Unexplained = 2(3.51%)

No. of Study Recipient : 115No. of Study Recipient : 115

Male: 86Male: 86Female: 29Female: 29Mean age : 31.52 ±11 (18-48 yrs)Mean age : 31.52 ±11 (18-48 yrs)Primary causes of ESRD:-Primary causes of ESRD:-

GN = 73 (63.48%)GN = 73 (63.48%) HTN = 28 (24.35%)HTN = 28 (24.35%) CPN = 10 (8.69%)CPN = 10 (8.69%) DN = 2 (1.74%)DN = 2 (1.74%)

Unknown = 2 (1.74Unknown = 2 (1.74%)%)

Relation with donor:Relation with donor:

Mother = 37 (32.17%)Mother = 37 (32.17%)

Brother = 33 (28.70%)Brother = 33 (28.70%)

Sister = 18 (15.65%)Sister = 18 (15.65%)

Father = 15 (13.14%)Father = 15 (13.14%)

Spouse = 3 (2.61%)Spouse = 3 (2.61%) Uncle = 2 (1.73%)Uncle = 2 (1.73%)

Post Tx. evaluation of the RecipientPost Tx. evaluation of the Recipient

HTN = 83 (72.17%)HTN = 83 (72.17%)Acute Graft dysfunction = 42 (36.52%) – Acute Graft dysfunction = 42 (36.52%) –

recovered recovered Chest Infection = 32 (27%)Chest Infection = 32 (27%)Post Tx. proteinuria = 29 (25.22%)Post Tx. proteinuria = 29 (25.22%)Chr. Graft dysfunction = 29 (25.22%)Chr. Graft dysfunction = 29 (25.22%)DM = 22 (19.13%)DM = 22 (19.13%)UTI = 25 (21.74%)UTI = 25 (21.74%)CMV = 18 (15.65%)CMV = 18 (15.65%)CVD = 9 (7.83%)CVD = 9 (7.83%)Cyst in Tx. Kidney = 7. (6.18%)Cyst in Tx. Kidney = 7. (6.18%)

Post Tx. Survival Rate in our centrePost Tx. Survival Rate in our centre

1 year1 year = 85%= 85%3 year3 year = 75%= 75%5 year5 year = 65%= 65%7 year7 year = 55%= 55%10 year10 year = 50%= 50%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

1 yr 3 yr 5 yr 7 yr 10 yr

Fig: Tx. Patient Survival Rate

Tx. On January,2000

Tx. on July, 2003

Tx on Oct.,2005 (Mother is Donor)

Summary:Summary:

(1)(1) Renal Tx is the best form of treatment in Renal Tx is the best form of treatment in selective ESRD patients. selective ESRD patients.

(2)(2) But number of Tx is inadequate as But number of Tx is inadequate as compared to number of ESRD in each yearcompared to number of ESRD in each year

(3)(3) At present live related Tx is being done at At present live related Tx is being done at BSMMU, Kidney Foundation,NIKDU & BSMMU, Kidney Foundation,NIKDU & BIRDEM in our country.BIRDEM in our country.

(4)(4) Mothers are the commonest source of Mothers are the commonest source of donor.donor.

(5)(5) 1 year patient survival rate is about 85%, 5 1 year patient survival rate is about 85%, 5 year about 65% & 10 year 50%.year about 65% & 10 year 50%.

(6)(6) Infection is the major cause of death in post Infection is the major cause of death in post transplant patients.transplant patients.

Conclusion:Conclusion: Only 1–2% of ESRD patients are getting opportunity Only 1–2% of ESRD patients are getting opportunity

for Tx.for Tx.

Quality of life is better after successful Tx. Quality of life is better after successful Tx.

Can be use these immunosuppression in developing Can be use these immunosuppression in developing countrycountry

To increase number of Tx. needed - To increase number of Tx. needed - - Awareness of Renal disease & Tx. - Awareness of Renal disease & Tx. - To over come the donor scarcity - To over come the donor scarcity - Increase number of Tx. centre- Increase number of Tx. centre..

Both Govt. and private sector should come forward Both Govt. and private sector should come forward to over come the obstacles.to over come the obstacles.