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Table of Contents
CASE REPORT
Year : 2020  |  Volume : 14  |  Issue : 4  |  Page : 338-342

Case report of swap kidney transplantation in Chhattisgarh – Challenges and solution


1 Department of Nephrology, Ramkrishna Care Hospital, Raipur, Chhattisgarh, India
2 Department of Urology, Ramkrishna Care Hospital, Raipur, Chhattisgarh, India
3 Department of Nephrology and Transplantation, IKDRC, Dr. H L Trivedi Institute of Transplantation Sciences, Civil Hospital Campus, Ahmedabad, Gujarat, India
4 Department of Urology, Lotus Hospital and Advance Urology Center, Raipur, Chhattisgarh, India
5 Department of Urology, DKS Super Speciality Hospital, Raipur, Chhattisgarh, India
6 Department of Anesthesia, Ramkrishna Care Hospital, Raipur, Chhattisgarh, India

Date of Submission08-Jul-2020
Date of Acceptance04-Oct-2020
Date of Web Publication30-Dec-2020

Correspondence Address:
Dr. Prawash Kumar Chowdhary
Department of Nephrology, Ramkrishna Care Hospital, Raipur - 492 001, Chhattisgarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijot.ijot_74_20

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  Abstract 


Kidney Transplantation is the best as well as the most cost-effective mode of renal replacement therapy for end end-stage renal disease patients with better survival and quality of life compared to dialysis. In the absence of a deceased donor programme in Chhattisgarh, Kidney paired donation (KPD) may provide an important strategy for easing the crisis in organ availability. In KPD, the incompatibility problems with two donor– recipient pairs can be solved by exchanging donors. We report our first successful KPD transplantation done by our institute in Chhattisgarh. Out of two, one had acute graft dysfunction which gets recovered after stopping tacrolimus and converting to sirolimus. Both the donors had a smooth hospital course and were discharged on the 5th postoperative day. They are in follow- up with us with good graft function (serum creatinine 1.2 mg/dl and 0.8 mg/dl). In the era of organ shortage, KPD provides hope to the growing number of patients suffering from end-stage renal disease in Chhattisgarh which will promote renal transplantation in our state.

Keywords: Graft outcome, Kidney paired Donation, Swap kidney Transplant


How to cite this article:
Chowdhary PK, Kale SA, Parashar A, Kute V, Sharma A, Agrawal S, Trivedi S, Khatkhedkar S. Case report of swap kidney transplantation in Chhattisgarh – Challenges and solution. Indian J Transplant 2020;14:338-42

How to cite this URL:
Chowdhary PK, Kale SA, Parashar A, Kute V, Sharma A, Agrawal S, Trivedi S, Khatkhedkar S. Case report of swap kidney transplantation in Chhattisgarh – Challenges and solution. Indian J Transplant [serial online] 2020 [cited 2021 Jan 22];14:338-42. Available from: https://www.ijtonline.in/text.asp?2020/14/4/338/305435




  Introduction Top


Chhattisgarh became an independent state separated from Madhya Pradesh in November 2000. The approximate population of the state is about 2.5 crores. About 33% of the population lives in tribal areas. After its separation, it emerges as one of the fastest growing states in the country and showcases a formidable growth story in terms of its medical and health-care sector. Basic health-care provisions are available across most districts in the state. Twenty years down the line, there has been significant, and in many cases absolutely remarkable, progress in Chhattisgarh regarding the management of both communicable and noncommunicable diseases.

Chronic kidney disease (CKD) is one of the noncommunicable diseases leading to high morbidity and mortality. The prevalence of CKD in India is 17.2%.[1] No study has been done in Chhattisgarh to find the actual burden of CKD in the state. Its management imposes a substantial financial burden on both health-care systems and patients and their households. The Government of Chhattisgarh has started various schemes (Sanjeevani Sahayata Kosh in 2001, Rashtriya Swasthya Bima Yojana in 2009, Ayushman Bharat in 2018, and recently, Khubchand Baghel Swasthya Sahayata Yojana) for support of people living in Chhattisgarh and to promote kidney disease management program. The government started supporting the kidney transplantation program through these schemes.

The Government of Chhattisgarh has established the Chhattisgarh state authorization committee to promote kidney transplantation. After its separation from Madhya Pradesh, the renal transplantation program was first started in Modern Medical Institute, Raipur, by Dr. Sanjeev Anant Kale and team. The first renal transplantation was done on March 7, 2004. At present, four centers in Raipur (Ramkrishna Care Hospital, Narayana Hrudayalaya Modern Medical Institute, Balaji Super Speciality Hospital, and Shri Narayan Hospital) and one center in Bilaspur (Apollo Hospital) are doing renal transplantation. Lack of immunology and renal histopathology facility in the state makes renal transplantation difficult. Even drug (tacrolimus, cyclosporine, and sirolimus) level measurement is done outside the state. All these difficulties make renal transplantation challenging in the state of Chhattisgarh. However, there is a continuous imbalance between the number of recipients on the waiting list and the number of donors. Due to lack of ABO-compatible donors, most of the CKD patients on dialysis are not able to undergo kidney transplantation. ABO-incompatible renal transplantation is more costly and had high risk of poor graft survival in comparison to ABO compatible renal transplantation, but recent studies show equal outcomes.[2] In Chhattisgarh, the deceased donor program is not yet started.

Kidney paired donation (KPD) increases access to living-donor grafts,[3],[4] by enabling incompatible living donor–recipient pairs to be matched with other pairs leading to acceptable kidney transplantation for each recipient. It is practiced widely throughout the world, but its use is infrequent because of the complexity of donor issues, a lack of awareness about the exchange method, and logistic barriers. In a donor exchange program, criteria for both ABO incompatible and incompatible for crossmatch-positive donor–recipient pairs are taken. In our state, the cadaver transplantation program is not yet started. Hence, to increase the donor pool, we started a kidney paired donor exchange program in our institute. We maintained a KPD register in our institute and allocation is being done manually.

Here, we share our experience with the first KPD performed by us in our state, Chhattisgarh. It took near about 8 months to get the ideal KPD donor after registration in our center. We describe two donor–recipient pairs that were ABO incompatible and had no other suitable donors in the family.


  Case Report Top


Both the potential donors and recipients were informed about the risk and benefit of KPD before initiating evaluation. The pedigree chart of both donor and recipient pairs is shown in [Figure 1]. The ABO titer of Pair 1 was 1:512 and the other was 1:1026. They were explained regarding the pros and cons of ABO-incompatible kidney transplantation. They were very poor, could not afford for ABO-incompatible kidney transplantation. So chosen for KPD, as outcomes are better in KPD as described in the Indian Society of Organ Transplantation KPD guidelines. One of the patients had comorbidities (diabetes mellitus and Parkinsonism disease). They were explained regarding unequal outcomes because of patient-related comorbidities, although we exchange kidney of similar quality. They agreed for it. Hence, the patients decided to go for KPD. Both the pairs of recipients and donors were allowed to meet each other before and after allocation and after transplantation. They were allowed to exchange their medical reports and clarify any doubts regarding this. The time taken from the allocation of KPE to get legal permission was 5 months and from legal permission to transplantation was 1 month. Permission for KPD was taken from the Chhattisgarh State Authorization Committee. There was a delay in getting permission from the state authorization committee as it was a new subject of KPD for the state.
Figure 1: The pedigree chart of both donor and recipient pairs

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Both donor and recipient pairs were from the same district (Bilaspur) of Chhattisgarh. [Table 1] describes the pretransplant characteristics along with the immunological and crossmatch status of recipient and donor pairs.
Table 1: The pretransplant characteristics along with immunological and crossmatch status of the recipient and donor pairs

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Donors were subjected to a diethylenetriaminepentaacetic acid renal scan before transplantation and displayed satisfactory glomerular filtration rate (>40 mL/min on each side). Recipients were cytomegalovirus (CMV) immunoglobulin G positive. The donors were swapped with the recipients, as shown in [Figure 2]. Renal transplantation was done as per the declaration of the Istanbul castudary group and Human Organ Transplantation Act.
Figure 2: Donor and recipient swap

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Kidney transplantation

Both the pairs were taken to the operation theater on the same day. Due to the unavailability of two transplant teams at a time, we induced one pair at a time and the second donor was induced before the extubation of the first recipient, to avoid refusal of consent by the second donor. All donors had single renal artery and single renal vein on the left side and underwent open donor nephrectomy.

Immunosuppressive therapy constituted induction with methylprednisolone (500 mg, 250 mg, and 250 mg in Recipient 1 and 500 mg, 250 mg, and 125 mg in Recipient 2) for 3 days and rabbit-antithymocyte globulin (1.5 mg/kg two doses) along with calcineurin inhibitor-based triple immunosuppression (tacrolimus, enteric-coated mycophenolate, and prednisolone) for maintenance therapy. Patients received prophylaxis against CMV, fungal, and Pneumocystis jiroveci pneumonia infection.

Postoperative course

Recipient 1

Had posttransplant brisk diuresis with rapid normalization of serum creatinine. Permcath was removed on the 7th postoperative day. After normalization of blood sugar, he was discharged on 9th postoperative day with serum creatinine of 1.1 mg/dl. On discharge, his maintenance immunosuppressants were tacrolimus (2.5 mg twice a day), enteric-coated mycophenolate (720 mg twice a day), and prednisolone (20 mg once a day).

Recipient 2

Had posttransplant brisk diuresis. On 3rd postoperative day, his serum creatinine was 1.4 mg/dl. On the 4th postoperative day, had a rapid drop of urine output. Urgent Doppler ultrasonography was performed, and results showed normal diameter, color flow, and spectral waveform of the main renal artery. Perfusion of the transplanted kidney appeared normal. The renal vein was reported to be patent. The resistive index of the transplant kidney was 0.7. He had blood pressure of 160/80 mmHg and mild tremors were present. Tacrolimus was stopped. Three doses of methylprednisolone 500 mg each on 3 consecutive days were given. Graft biopsy was done and donor-specific antibodies (DSA) and tacrolimus trough levels were sent. On 6th postoperative day, his urine output started improving and serum creatinine also showed a downward trend. The tacrolimus trough level was 3.3 ug/l. On 7th postoperative day, we received a graft biopsy report which showed patchy areas of severe acute tubular injury with focal areas of interstitial hemorrhage, suggestive of acute humoral rejection (Banff scores: i0, ti1, t0, v1, mm0, g2, cg0, ci0, ct1, cv0, ah1, and ptc2). Stains for C4d were negative along peritubular capillaries [Figure 3]. Tacrolimus was restarted. Urine output again dropped. On the 9th postoperative day, the DSA report came which was negative. Tacrolimus was stopped and sirolimus was started. Following which he had brisk diuresis and a rapid drop in serum creatinine. He was discharged on the 16th postoperative day with urine output of more than 5 L and serum creatinine of 0.8 mg/dl. His maintenance immunosuppressant was sirolimus (2 mg once a day), enteric-coated mycophenolate (360 mg thrice a day), and prednisolone (20 mg once a day).
Figure 3: Biopsy of the transplant kidney of recipient 2

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Pretransplant, surgical, and outcome data are being described in [Table 2].
Table 2: Pretransplant, surgical, and outcome data are being described

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Both the donors had smooth hospital course and were discharged on the 5th postoperative day.

Both the pairs were allowed to meet each other after transplantation to see the outcome. After the transplant, they remained to be good friends because of KPD.

In the postoperative follow-up, recipient 1 developed diarrhea which was managed after converting from enteric-coated mycophenolate to azathioprine. Recipient 2 had leukopenia which was managed after adjusting the dose of sirolimus and enteric-coated mycophenolate. They are in follow-up with us with good graft function (serum creatinine 1.2 mg/dl and 0.8 mg/dl).


  Discussion Top


Living kidney donation offers superior outcomes and is the most readily expandable source of kidneys for transplant. The two greatest barriers to improving living-donation rates are ABO incompatibility and human leukocyte antigen sensitization. The methods of KPD offer a relatively low-cost option for overcoming the incompatibility barrier. It is feasible, successful, and if applied to larger donor pools, capable of expanding access to renal transplants.[4],[5],[6]

KPD can be carried out by any center that performs live donor renal transplantation. The success of KPD is greatly dependent on the size of the pool and composition.

Kute et al. published a study about the feasibilities and outcomes of seventy kidney swap transplants. One-, 5-, and 10-year survivals were 94.6%, 81%, and 81%, and graft survivals were 96.4%, 90.2%, and 90.2%. About 10% of patients were lost due to infections. These findings are very significant, helping to promote and encourage swap transplants.[7] In a study, involving 42 donors, the length of hospital stays of donors was within 4 days and 53% of donors returned to work in 4 weeks.[8] In our swap transplant, both the donors were discharged on 5th postoperative day, though they both underwent open donor nephrectomy.

Our second kidney transplant recipient had acute graft dysfunction. In the management of the case, a dilemma was there between the renal histopathology report which was suggestive of acute humoral rejection and the clinical course suggesting of tacrolimus toxicity, though the level was low (3.3 ug/L). The situation generally becomes embarrassing for the transplant team when out of two pairs of donor kidney exchange, only one of the paired kidney works. Lack of immunological and renal histopathological laboratory in the state, result in delay for obtaining report on time which makes the renal transplantation challenging in our state. Even, the drug level estimation is done outside the state. C4d and DSA negativity with the improvement of graft function without any significant measures for rejection with early use of sirolimus helped this patient are in favor of diagnosis of tacrolimus toxicity. Our patient graft function recovered after converting his tacrolimus to sirolimus. He was discharged with serum creatinine 0.8 mg/dl.

In our center, we do only live-related kidney transplantation as the cadaver program is not yet started. Now, we are doing only live-related kidney transplantation, which includes ABO-incompatible kidney transplantation and pediatric transplantation. This is our first swap transplant done by our institute in Chhattisgarh. The outcome of our live-related renal transplantation is comparable and as good as this swap transplant. Encouraged by the promising initial results and long-term good outcome, we are planning to expand this program. We also need to strengthen renal histopathology and immunology laboratory in our state to avoid management dilemmas because of delay in getting reports which may lead to poor outcomes.


  Conclusion Top


The successful swap transplant in our hospital has given ray to hope to life in our state of Chhattisgarh. The shortage of kidney donors can be partly overcome by a kidney paired exchange living-donor kidney transplant program, especially in emerging states like Chhattisgarh where deceased-donor programs are not yet started.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal the identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Varma PP. Prevalence of chronic kidney disease in India-where are we heading? Indian J Nephrol 2015;20:133-5.  Back to cited text no. 1
    
2.
Thukral S, Kumar D, Ray DS. Comparative analysis of ABO-incompatible Kidney transplantation with ABO-compatible transplantation: A single-center experience from eastern India. Saudi J Kidney Dis Transpl 2019;30:97-107.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Maggiore U, Oberbauer R, Pascual J, Viklicky O, Dudley C, Budde K, et al. Strategies to increase the donor pool and access to kidney transplantation: An international perspective. Nephrol Dial Transplant 2015;30:217-22.  Back to cited text no. 3
    
4.
Ferrari P, Woodroffe C, Christiansen FT. Paired kidney donations to expand the living donor pool: The Western Australian experience. Med J Aust 2009;190:700-3.  Back to cited text no. 4
    
5.
Modi P, Rizvi SJ, Pal B, Baradwaj R, Gupta S, ShahV, et al. Living donor paired-kidney exchange transplantation: A single institution experience. Indian J Urol 2010;26:511-4.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Ferrari P, Weimar W, Johnson RJ, Lim WH, Tinckam KJ. Kidney paired donation: Principles, protocols and programs. Nephrol Dial Transplant 2015;30:1276-85.  Back to cited text no. 6
    
7.
Kute VB, Gumber MR, Patel HV, Shah PR, Vanikar AV, Modi PR, et al. Outcome of kidney paired donation transplantation to increase donor pool and to prevent commercial transplantation: A single-center experience from a developing country. Int Urol Nephrol 2013;45:1171-8.  Back to cited text no. 7
    
8.
Peters TG, Repper SM, Jones KW, Walker GW, Vincent M, Hunter RD. Living kidney donation: Recovery and return to activities of daily living. Clin Transplant 2000;14:433-8.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2]



 

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