Expanding the living related donor pool in renal transplantation: use of marginal donors
Article Outline
The availability of donors is a major limiting factor in living related renal transplant programs. Cadaveric renal transplantation is almost nonexistent in India, because of social and ethical problems as well as financial constraints. Among the 80,000 patients added per year to the pool with end-stage renal disease, only 4% receive a renal transplant.
This disparity compels the acceptance of marginal donors to partially meet the need for renal replacement. Marginal donors are defined as those who are not ideal in terms of age or who have some form of benign renal or nonrenal disease.
Materials and methods
We retrospectively reviewed the records of the 1011 living related transplants performed from July 1988 to December 2001. Eighty-two donors were older than 60 years and 104 had associated renal or nonrenal anomalies or disease (Table 1). All recipients received triple immunosuppression with cyclosporine, azathioprine, and prednisolone.
Table 1. Marginal Donors
| Marginal Donors | No. |
|---|---|
| Elderly donors | 82 |
| Renal anomaly and disease | |
| Low GFR | 10 |
| Renal artery stenosis | 4 |
| Renal stone | 6 |
| Ureteric stone | 2 |
| Renal cyst | 27 |
| Ectopic kidney | 2 |
| Angiomyolipoma | 2 |
| Double ureter | 1 |
| Nonrenal disease | |
| Severe kyphoscoliosis | 3 |
| Mild hypertension | 12 |
| Gallstones | 15 |
| Ovarian cyst | 5 |
| Breast fibroadenoma | 1 |
| BPH | 4 |
| Multinodular goiter | 1 |
| Difficult intubation | 1 |
| Pulmonary tuberculosis | 8 |
| Total | 186 |
Ten donors had a low GFR with cumulative rates of less than 45 mL/min. Grafts with renal cysts were evaluated to rule out malignancy, including frozen section biopsy before kidney removal. Cysts were unroofed, the cavity filled with oxidized regenerated cellulose, and the margins were sutured. Six donors had a solitary, small (<1 cm) pelvic calculus in the ipsilateral kidney with a normal opposite kidney and normal metabolic profile. In one of them the stone was removed by a small pyelotomy after graft harvest. The other patients underwent postoperative lithotripsy in the prone position. Two donors had a small nonobstructing stone in the ureter, which was removed from the cut end of the ureter after kidney retrieval.
Four donors had unilateral renal artery stenosis. All of them were normotensive with normal renal function. The renal artery was divided beyond the stenosis and anastomosed end-to-end to the internal iliac artery. One donor had an ectopic malrotated kidney with four arteries and three veins. The upper polar artery was anastomosed end to end to the internal iliac artery. The middle two arteries were fashion in to a common stump, which was anastomosed end to side to the external iliac artery. The lower polar artery was anastomosed to the inferior epigastric artery. The two smaller veins were tied and the largest vein anastomosed to the external iliac vein. We had another donor with a pelvic kidney and a GFR of 20 mL/min, which was transplanted successfully.
The 12 hypertensive donors on a single antihypertensive medications were also accepted. For patients with gall stones the right kidney was chosen as all of them underwent simultaneous cholecystectomy. One donor with a common bile duct stone underwent simultaneous choledocholithotomy and T-tube insertion.
Upon follow-up all donors underwent clinical evaluation, blood pressure measurements, and laboratory tests including hemogram, blood urea nitrogen, serum creatinine, and urine analysis at postoperative months 1, 3, and 6 and yearly thereafter. Donors with benign diseases were evaluated for recurrence. Recipient records were reviewed for the number of rejections, serum creatinine at last follow-up, and graft survival. Complications and morbidity were also analyzed to assess the safety of using such donors.
Results
We utilized 82 elderly donors with a mean age of 62.7 ± 3.4 years and a male-to-female ratio of 1.2:1. Total follow-up ranged from 0.3 to 7.4 years (mean 3.26 ± 0.6 years). Actuarial 2- and 5-year graft survivals were 96% and 74%, respectively. Twenty-six patients (31.7%) experienced acute rejection episodes during the first 3 months.
Among the donors 10 had a mean global GFR of 43.5 and a mean single kidney rate of 22.4 mL/min. The mean increase in GFR in the recipients was 15.2 mL/min. Recipients of grafts with cysts have shown no recurrence upon follow-up ultrasound. Recipients of kidneys with renal artery stenosis were doing well with a mean follow-up of 3.1 years. Donors of these kidneys have not needed antihypertensives to date. In the two donors with angiomyolipoma, the diagnosis was confirmed by intraoperative frozen section biopsy and the lesion was enucleated. One of these two recipients died of viral encephalitis after 3 months posttransplantation. The other recipient is doing well at a follow-up of 14.2 months. One donor with a renal stone was emergently admitted for anuria 2 years after surgery. Investigations revealed a stone in the lower ureter, requiring emergency DJ stenting and subsequently ureteroscopic removal of the stone. There was no recurrence of stone disease in the other recipients or donors. Donors on antihypertensives and their respective recipients have not shown any change in antihypertensive medications to date. All donors with pulmonary tubeculosis were given INH, rifampicin, pyrazinamide, and ethambutol for 8 weeks before surgery. Intravenous urography in all of them was normal and three consecutive samples of morning urine were negative for acid-fast bacilli. All of their respective recipients were given INH prophylaxis for 1 year in the posttransplant period, and none has shown evidence of tuberculosis after a follow-up of 26 ± 4 months. A 47-year-old donor had a difficult intubation needing tracheostomy. He had no postoperative morbidity.
Among the donors one died in a road traffic accident, and one committed suicide 6 months postoperatively when the recipient lost the graft due to acute rejection. One elderly donor died of severe pulmonary infection after 3 years of surgery.
Discussion
Elderly donors have not been widely accepted due to age-related changes in glomeruli and vulnerability to ATN. Kostakis et al reported no significant difference in the graft survival of organs from donors younger versus older than 60 years.1 Our study showed a 5-year graft survival of 76%. The presence of a calculus did not affect the outcome of the kidney graft.2 The likelihood of recurrence is minimal in cases of solitary, <1 cm, asymptomatic stones with a normal metabolic profile.3 In our study only one donor had a recurrent stone in the ureter, which needed ureteroscopic removal. There was no recurrence in the recipients or the rest of the donors. The presence of mild atherosclerosis or fibromuscular dysplasia does not preclude donation.4 Our donors with unilateral renal artery stenosis without any evidence of hypetension or atherosclerosis are doing well after the kidney was removed by resecting the artery beyond the stenosis. An ectopic kidney may be accepted; however, the possibility of multiple vessels should be considered. Accepting hypertensive donors is controversial. Long-term follow-up with a large number of cases is needed to give a definite conclusion. Donors with benign diseases in our series had the additional advantage of undergoing treatment for the same simultaneously. Figure 1
Fig 1.
Serum creatinine at last follow-up in recipients of grafts from elderly donors.
Conclusions
Refusal of marginal donors would have promoted unrelated transplantation or forced lifelong dialysis in 18.2% of our patients. Healthy donors should not be rejected on the basis of age or the presence of renal or nonrenal anomalies, if they can be treated without compromising the donor or recipient safety.
References
PII: S0041-1345(02)03890-3
doi:10.1016/S0041-1345(02)03890-3
© 2003 Elsevier Science Inc. All rights reserved.
