Spousal renal transplants: implications in developing countries
Article Outline
Until 1994 it was a policy at our institute to include only the following categories of living related donors in the kidney transplantation program: parents, siblings, children; and first cousins, uncles, and aunts. Spouses were excluded as we strongly felt that in the prevailing socioeconomic condition, wives could be coerced into becoming donors. The Transplantation of Human Organs Act (THOA) was passed with a view to legalize cadaver transplantation and to regulate transplant-related activities in India. This Act allows spousal donors in addition to parents, sibling, and children. All other donors are considered unrelated and need to be authorized by a committee. Following the Act we started accepting wives as donors after carefully ruling out coercion to be a donor. The aim of this study was to examine the change in the pattern of living donors following this Act and also their outcome.
Patients and methods
We analyzed the records of all kidney transplants who had living donors between 1994 and 2001. The immunosuppression regimen included cyclosporine, prednisolone, and azathioprine. The dosage was the same in spousal transplants as other patients who received organs from related donors. All data were entered into MS- Excel and analyzed using the statistical package WS-Stata. Survival analysis was performed to estimate graft survival.
Results
There were 73 spousal renal transplants. Except for four cases, all spousal donors were wives. From 1994 the percentage of spouses among living donors increased rapidly until 1998 thereafter it stabilized at 20% (Fig 1).
Fig 1.
Percentage distribution of living kidney donors.
Four patients were lost to follow-up. One patient experienced hyperacute rejection leading to graft nephrectomy. The rate of acute rejection was the same (42%) among recipients of related versus spousal renal allografts. Two patients died in the early postoperative period due to septicemia with graft failure. Four patients developed chronic rejection and three subsequently died due to septicemia. Nineteen of 24 patients died with a normally functioning allograft due to pneumonia, or sepsis with hepatic coma in patients with chronic hepatitis. The graft survival at 1 year was 73%, at 3 years was 66% and at 5 years-was 51%. The corresponding graft survival in all the patients transplanted at our center was 86.6%, 71%, and 56%.1
Discussion
The worldwide shortage of organs available for transplantation has led to the use of living unrelated kidney donors. This group represents the fastest growing donor source in the United States and provides excellent results.2 Unfortunately in India organ commerce had been prevalent in many centers bringing unrelated organ transplantation into disrepute.3 Thankfully the THOA has been by and large successful in curbing this menace. Unfortunately cousins, uncles and aunts cannot now be routinely considered, as they too have to be cleared by the authorization committee, leading to a loss of a valuable donor pool.
Gjertson et al felt that encouraging spouses to donate would be an effective way of reducing the waiting time for renal transplants,2 an approach that may not be entirely appropriate in developing countries.4 At our center we exercise caution before accepting wives as donors. We insist initially on evaluating parents and siblings. Only in the absence of a suitable parent or sibling do we start the evaluation of a wife, provided we are convinced that she has not been coerced to making the decision. Although we encourage husbands to come forward, few agree. In spite of these measures, spousal (mainly wife) donors now account for one fifth of our living donor pool, reflecting the changing Indian society. The joint family system is gradually breaking down and nuclear families are now increasingly common. Siblings are often unwilling to donate due to intrafamilial pressures leading to progressive reduction in their contribution. Parents may be medically unfit to donate. Under such circumstances the wife may not have any other option. The transplantation team has to tread very carefully in such a scenario while accepting the wife as a donor.
Our experience with spousal transplants up to 1998 has been published previously.5 The current study includes all spousal transplants until 2001. Since 19 of 24 patients died with a functioning graft, the graft survival has been adversely affected despite the use of the same immunosuppression regimen in these patients as in recipients with related living donors.
References
PII: S0041-1345(02)03852-6
doi:10.1016/S0041-1345(02)03852-6
© 2003 Elsevier Science Inc. All rights reserved.
