Deceased Donor Program Research Articles

A Comparative Study of the Biliary Outcome in Roux-en-Y Hepaticojejunostomy versus Duct to Duct Biliary Anastomosis in Right Lobe Living Donor Liver Transplantation in Adults

Abstract Background Recently, liver transplantation settled to be a real breakthrough in surgery as the only curable treatment to deal with fatal liver diseases. Living donor liver transplantation (LDLT) is the only available option in Egypt owing to the inactive deceased donor program. Most of the patients indicated for LDLT do not have the luxury of having an ideal living donor although we have big families in Egypt. Surgeons of recipient’s operation should occupy refined surgical skills and experience to reduce the risk of complications. The incidence of biliary complications (BCs) ranges from 5.3% to 40.6%. Leaks occur in 0% to 21.9% while strictures occur in 3.7% to 25.3%. Duct-to-duct anastomosis (D2D) and hepaticojejunostomy (HJ) are the two most common techniques of bile duct anastomosis in LDLT. D2D is gaining popularity over HJ, because of shorter operative time, fewer septic complications, a better physiologic gastrointestinal function and rapid recovery beside easier endoscopic approach to the reconstructed biliary tract. Patients and Methods The current surgical methodology is a prospective study with nonrandomized convenient sampling that was conducted at Liver Transplantation Unit in Air Forces Specialized Hospital and Nasser Institute for Research and Treatment, Cairo, Egypt, between August 2019 to August 2021. During this study, 40 patients candidate for LDLT was divided into two groups according to type of biliary anastomosis, group A included 20 recipients who had stentless duct-to-duct biliary anastomosis compared to group B including 20 recipients underwent Roux-en-Y hepaticojejunostmy. Results A total of 40 recipients were divided into two equal groups according to biliary reocstruction into group A duct-to-duct biliary anastomosis, and group B Roux-en-Y hepaticojejunostmy. The incidence of biliary related complications was higher in group A reaching 30%, double that recorded in group B (15%, p = 0.262). Upon stratification of those complications, the incidence of biliary leakage was reversed being doubled in group B 10% versus 5% in group A (p = 0.553). After exclusion of seven mortalities (one in group A and 6 in group B) who did not complete the 6 months follow-up period necessary for complete observation of BAS, there was insignificant difference between the two groups. The overall mortality was 17.5% (7 out of 8 recipients), and all died from non-biliary complication related causes. The only recipient died from biliary sepsis following ERCP and stenting for BAS, was included in the results as he died after 5 months from the operation. In a trial to understand the relation between the biliary reconstruction and the complication rate (Table 8), we found that there was a higher frequency of complications in both 1x1 and 2x2 technique in group A (33% each). In contrast, all complication happened in group B was in 1x1 technique. In addition, we could not apply the statement that the higher the number of ducts the higher the rate of complications in the study as 2 ducts grafts represent 66.7% of complications in group A compared to 100% in single duct graft in group B. Conclusion BC is a bottleneck along the path of a successful LDLT as it is multifactorial making it impossible to specify a single predictable risk factor to avoid. The advantages of D2D over HJ; especially the beneficial use of ERCP in management of complications, are buffered by the higher incidence of biliary complication that is involved with D2D. Therefore, we think that surgeons should master both reconstruction techniques and weight the risk-and-benefit case by case.

Enhancing Kidney Transplant Outcomes: The Impact of Living Donor Programs.

The protocol for deceased donor kidney transplants has been standardised. The procedure for a living donor has peculiarities derived from the differences in the graft. When a living kidney donor program is implemented, changes occur in both the profile of the kidney transplant candidate and in the postoperative treatments. To discover whether a living donor program influences the functional outcomes of kidney grafts in a longstanding classical deceased donor kidney transplant program and to identify the factors associated with transplant outcomes. Retrospective observational multicentre study. Kidney transplant patients in two urology referral centres for renal transplant in Spain between 1994 and 2019. Groups: TV (living transplant): patients given kidney transplants from living donors (n = 150); TCpre11 (deceased transplant previous to 2011): patients given kidney transplants from deceased donors before the living donor program was implemented (n = 650); and TCpost11 (deceased transplant after 2011): patients given kidney transplants from deceased donors after the living donor program was implemented (n = 500). Mean age was 55.75 years (18-80 years), higher in TCpre11. There were 493 female patients (37.92%) and 1007 male patients (62.08%). Mean body mass index (BMI) was 26.69 kg/m2 (17.50-42.78 kg/m2), higher in TCpre11. Mean ischemia time was 17.97 h (6-29 h), higher in TCpost11. Median duration of urethral catheter: 8 days (6-98 days), higher in TCpost11. Median duration of double-J ureteral stent: 58 days (24-180 days), higher in TCpost11. Pretransplant UTIs: 17.77%, higher in TCpre11 (25.69%) than in TV (12%), higher in TV (12%) than TCpost11 (9.2%), and higher in TCpre11 (25.69%) than TCpost11 (9.2%). Acute renal rejection in 9.33% of TV, 14.77% of TCpre11, and 9.8% of TCpost11. Multivariate analysis: TCpost11 featured higher BMI, more smoking, and chronic renal failure progression time. Lower use of nonantibiotic prophylaxis to prevent recurrent urinary tract infections, increased duration of urethral catheters due to obstructive problems, and favoured deterioration of kidney function was observed in the deceased donor program. The living donor (LD) program had a strong influence on deceased donor transplants in the prelysis phase. Implementation of a LD program was associated with a decrease in the likelihood of acute rejection in TCpost11 and an increase in the tendency towards normal kidney function. Implementing living donor transplant programs affects functional outcomes in deceased donor transplants, reducing the probability of acute rejection and increasing the tendency towards normal kidney function. Preventing recurrent urinary tract infections with measures other than antibiotics, smoking cessation, delaying the removal of the double-J stent from the graft, and pre-emptive transplant (transplant prior to dialysis) are associated with improved renal function of the graft.

Road To Deceased Donor Transplantation in Egypt.

In Egypt, there is presently a growing need to have a deceased donor transplant program. Egypt conducted its first kidney transplant from a living donor in 1976 and a first partial liver transplant in 2001. Since 2009, the Egyptian Health Authorities Combat Transplant Tourism in concordance with ethics codes and the Declaration of Istanbul Custodian Group has been in place. The Egyptian Transplantation Law of 2011 mentions that organs could be procured from deceased donors based on a will and on family consent. This law has had many critics, including religious authorities who have stressed that organs cannot be taken from a person with brain death because, in their view, life ends with death of all organs. Many intensivists disagree over the definition of death. In addition, the media has communicated contradicting and sometimes misleading health care information. Mummification is rooted in pharos practice and linked to religious beliefs. The ancient Egyptians believed that, by burying the deceased with their organs, they may rejoin with them in the afterlife. Since 2019, the transplant community in Egypt has started collaborations with international transplant organizations and campaigns with doctors and celebrities to donate their organs after death, which have stressed that a deceased donor program could help against end-stage organ mortality. In November 2022, after communications with politicians, President Abdelfattah El Sisi directed the government to establish a regional center for organ transplantation, which aimed to be the biggest in the Middle East and North Africa region. The new center will be part of a new medical city that would replace Nasser Medical Institution in Cairo, Egypt. The Ministry of Health issued an official form to be signed by a person before his death, accepting use of organs, to give hope and support to other patients in need.

Organ Donation in Syria.

The first living donor kidney transplant in Syria was performed 44 years ago; by the end of 2022, 6265 renal transplants had been performed in Syria. Kidney, bone marrow, cornea, and stem cells are the only organs or tissues that can be transplanted in Syria. Although 3 heart transplants from deceased donors were performed in the late 1980s, cardiac transplant activities have since discontinued. In 2003, national Syrian legislation was enacted authorizing the use of organs from living unrelated and deceased donors. This important law was preceded by another big stride: the acceptance by the higher Islamic religious authorities in Syria in 2001 of the principle of procurement of organs from deceased donors, provided that consent is given by a first- or second-degree relative. After the law was enacted, kidney transplant rates increased from 7 per million population in 2002 to 17 per million population in 2007. Kidney transplants performed abroad for Syrian patients declined from 25% in 2002 to <2% in 2007. Rates plateaued through 2010, before the political crisis started in 2011. Forty-four years after the first successful kidney transplant in Syria, patients needing an organ transplant rely on living donors only. Moreover, 20 years after the law authorizing use of organs from deceased donors, a program is still not in place in Syria. The war, limited resources, and lack of public awareness about the importance of organ donation and transplant appear to be factors inhibiting initiation of a deceased donor program in Syria. A concerted and ongoing education campaign is needed to increase awareness of organ donation, change negative public attitudes, and gain societal acceptance. Every effort must be made to initiate a deceased donor program to lessen the burden on living donors and to enable national self-sufficiency in organs for transplant.

Deceased donor availability for uterus transplantation in Australia.

Uterus transplantation is an emerging treatment option for uterine factor infertility. Most uterus transplantation research programs use living donors, although this comes with considerable surgical and psychological risks and not all women desiring uterus transplantation will have an available living donor. A deceased donor program eliminates donor risks; however, the availability of deceased uterus donors is currently unknown in Australia. To establish the feasibility of a deceased donor uterus transplantation program in Australia and consider expanded inclusion criteria for this model. A retrospective review of the New South Wales (NSW) Organ and Tissue Donation Service database was undertaken to identify potential deceased uterus donors, with comparison to the broad deceased donor inclusion criteria from three international uterus transplantation trials including female, brain-dead, multi-organ donation, no major abdominal surgery, and <60 years of age. Between January 1, 2018, and December 31, 2022, 648 deceased donors were available in NSW. Of these, 43% (279/648) were female and 67% of the women (187/279) were also multi-organ donors. When the brain-dead donor-only and age criteria (<60 years) were applied, a total of 107 deceased donors met the available criteria for uterus transplantation, with an average of 21 deceased donors per year in NSW. There appears to be adequate deceased donor organ availability to establish a deceased uterus transplantation program in NSW, Australia. Should interest in uterus transplantation increase, including criteria such as older and nulliparous donors could increase organ availability for a uterus transplantation program.

A Plant Pathogen in a Human Host! A Case Report and a Review of Literature

In this case report, we present a renal transplant recipient who developed an infection due to a plant pathogen – Pantoea agglomerans. This pathogen is a rare organism with no case reports in a renal transplant recipient from India so far. A 50-year-old renal transplant recipient presented with fever for 20 days associated with productive cough and upper back pain. She had received her graft kidney 8 months earlier in a deceased donor program in her local state. In the immediate postoperative period, she had one episode of a mixed rejection, which required a course of antithymocyte globulin and plasmapheresis. On examination, tenderness was noted in her upper back over the cervical and thoracic vertebrae. Her computed tomography scan showed a collection over the cervical vertebrae and consolidation in the lung. Blood culture grew P. agglomerans. P. agglomerans is a rare plant pathogen usually occurring after trauma involving organic debris being deposited within the body. Spontaneously occurring infection is seen only in special situations such as immunocompromised states, malignancy, or excessive antacid use. It has been known to cause lung infections, bone and joint infections, and fever with systemic signs. Spontaneously occurring infections like in this patient are very rare with a handful of case reports worldwide. In an immunocompromised host, a multitude of infections can occur. This case report highlights the importance of removing unnecessary medication from our transplant recipients and optimizing immunosuppression while pursuing the underlying microbiologic cause of infection aggressively.

348.6: The Impact of Living-Unrelated Transplant on Establishing Deceased-Donor Liver Program in Syria

Liver transplant is the criterion standard for patients with end-stage liver disease. Yet there is no liver transplant in Syria. Traveling abroad for a liver transplant is a luxury few Syrians can afford. There is currently an on-going debate whether to start a liver transplant program using living or deceased donors. In 2003, a new law was enacted, authorizing the use of organs from volunteer strangers and deceased donors. Despite the positive aspects of this law (allowing unrelated donors to increase the number of transplants in the country); the negative aspects also were obvious. The poor used the law to sell their organs to the rich, and thismodel is in violation of the Istanbul Declaration. To better document transplant communities’ perceptions on organ donation, an e-mail survey was sent to a nationally representative sample of physicians (n = 115) that showed that 58% of respondents did not support the start of livertransplant from live donors, as they fear a considerable risk for the donor and the recipient. Seventy-one percent of respondents believe that unrelated kidney donation has contributed totarnishing the reputation of transplant, and 56% believe that a deceased-donor program can run in parallel with unrelated organ donations. The interest in deceased-donor program has been affected negatively by the systematic approach of using poor persons as the source of theorgan. This lack of interest has affected starting a liver program that relies on deceased donors; especially the need for kidneys is more than livers. Health authorities in Syria were inclined to initiate a liver transplant program from live donors, despite the risks of serious morbidities and mortality. In conclusion then, paid kidney donation in actual effect is actually a hindrance to establishing a deceased-donor liver program.

P10.01: How Did the War Affect Organ Transplantation in Syria?

Since 2011, the Syrian conflict has destroyed much of the country’s infrastructure. The deteriorating humanitarian situation has involved health workers and facilities. In 2010, before the war, 385 kidney transplants were performed in Syria. This number declined to 154 in 2013 (60% less) before increasing to 251 transplants in 2018, which is still 35% less than the number of transplants performed before the war. In addition, the number of operational kidney transplant centers has decreased from 8 in 2010, distributed over 3 cities, to only 4 in 2013, all located in Damascus, which increased to 6 centers in 2019. Interestingly, with regard to type of living donor, the percentage of unrelated kidney donors has decreased by 20% for unclear reasons. Another alarming statistic is that more than 50% of kidney transplant physicians and surgeons are no longer practicing transplant medicine in their centers, either because they have left the country or because their centers had become nonoperational. Since the war, free and timely provision of immunosuppressive drugs for all patients in all provinces has been a leading challenge for health authorities and transplant patients. This difficulty has led to adverse medical consequences for patients. A project to initiate liver transplant came to a halt because of complex reasons but mainly because foreign trainers could not visit Syria. Although the autologous bone marrow transplant program had slowed until recently, it has become more active, involving both autologous and allogeneic transplants. The deceased-donor program is still not available in Syria; the war has just reinforced the many reasons that prevented the start of this program before the conflict. The commitment of transplant teams despite these large challenges continues to be extraordinary. The Syrian conflict has affected all aspects of organ transplant, paralyzing new projects and negatively affecting existing programs.

233.12: Commercial Kidney Transplantation: Sociodemographic and Clinical Characteristics

Background: Transplantation is the renal replacement therapy of choice for patients with end-stage kidney disease. In addition to the survival benefit and better life quality, it confers an economic advantage to the health care system. Although condemned by the international community, transplant tourism and commercial transplantation are still evident. The disparity between organ supply and demand finds an outlet whenever the regulations are less strict. Objectives: To describe the sociodemographic and clinical characteristics of patients who received a commercial transplant and address the causes to seek commercial transplantation. Methods: A questionnaire-based survey was done from September 2021 to December 2021 at the outpatient clinic of the Nephrology and Renal Transplantation Center, Baghdad. In Iraq, renal transplantation is a live donor, blood group compatible program. A central team should approve all donors to ascertain noncommercial conduct. As per Iraqi legislation, renal transplantation services and maintenance immunosuppression are provided free of charge at governmental hospitals. Commercial transplantation is defined as the state of paying a donor at a non-governmental unit. The questionnaire included 15 questions distributed to patients who received transplants at non-governmental units inside Iraq or sought a transplant outside the country. It provided demographic and clinical data and assessed the reason for performing a paid donation. Laboratory data were retrieved from patients records. Results: Seventy-eight patients accepted to participate in the study. The majority (66/85%) were male, and the study group’s mean age was (43.3 + 10.8 years). Fifty-four (69.2%) patients were below the college education level, and 47% were unemployed. The cause for ESRD was unknown in 51%. All donors were live unrelated, and five patients (6.41 %) had their transplants outside Iraq. The duration of the hospital stay was 5-14 days. The time since transplantation was 1 to 5 years. The reported complications at 1-year post-transplantation were: rejection (15%), wound infection (2.5%), CMV infection (1%), and recurrent disease (1%). The mean serum creatinine at one year was 1.27 + 0.52 mg/dl. At five years, 14 patients (17.94%) had a diagnosis of chronic allograft dysfunction. The leading reason for seeking commercial transplantation was the unavailability of the biologically related or unrelated altruistic donor in 74% of the study participants. The average cost was around 30,000-40,000 US$ exceeding the nearly free transplantation services at governmental units. Conclusion: Unavailability of live related or altruistic donors was the leading cause for seeking commercial transplantation in this sample of Iraqi renal transplant recipients. For a live donor transplant, the early graft function was acceptable. Commercial transplantation adds a lot of financial burden to patients and their families. This emphasizes improving transplantation services and implementing a deceased donor program.

413.4: The Beginning of the End for Living Unrelated Donation Kidney Transplantations in the Middle East: The Shiraz Transplant Center Experience

Background: The Middle East is a region with much controversy and limitations regarding deceased organ transplantations. In this report we describe our unique experience with the establishment of our deceased donor organ donation program for Central and Southern Iran. Methods: During the initial phases in the 70s and 80s, only living related kidney transplantations were allowed in Iran. However, this policy was not continued and was expanded due to severe shortage of hemodialysis facilities and an urgent need to increase the number of kidney transplantations. Accordingly, some centers in Tehran started unrelated kidney transplantation with the support of the government that offered bonuses to persuade unrelated donors. It should be mentioned that, during this time, permission for deceased organ donation was not yet obtained in Iran. The main focus of the Shiraz Transplant Center was to develop a deceased donation program from the beginning. During three decades this center was able to expand its deceased donation program to a degree that in 2008 it completely replaced all its unrelated kidney donations by deceased donations. Prior to 2008, most transplantations were related living and deceased donations, and only in cases where a patient was on the wait list for more than one year and a compatible donor was not found, they were only allowed to have living unrelated donations. The deceased program in the STC has since expanded and has aimed to stop unrelated living donations to achieve some goals which include: to abide by ethical guidelines in organ donations/transplantation such as the declaration of Istanbul, and to finally change the dominant practice of unrelated living donations within the Middle East. These efforts have resulted in an increase of deceased donations in Iran from 1.6 in 2004 to 14.34 per million population in 2019, and in some areas this has reached to as high as 50. Results: Up to March 2021, in the STC, overall 5389 kidney transplantations have been performed. Figure 1 shows the trend in kidney transplantation in the STC. Conclusion: Living unrelated donations are still an ongoing issue in the Middle East region. Our center, has implemented a wide deceased donor program and as a result has been able to completely stop unrelated living kidney transplantations. The deceased donor organ donation program should further be expanded within Iran and other countries in the region and continuous campaigns should be held up against any type of unethical issues such as living unrelated transplantations to meet with international standards.

400.1: The “Global Kidney Exchange” Proposal Is Impractical And Not Financially Neutral

This paper argues that, notwithstanding some recent claims by moral philosophers, the proposed Global Kidney Exchange (GKE) should be rejected as impractical and not ethical, as it does not accord with the principles of intergovernmental bodies (such as the World Health Organization) and professional societies (such as The Transplantation Society and the Declaration of Istanbul), and would violate national laws that forbid organ trafficking and that require financial neutrality in organ donation. Under the proposal, a kidney patient in a high-income country (HIC) who is biologically incompatible with his or her donor would be matched with a prospective donor from a low/medium-income country (LMIC) who is willing to donate to a patient there who cannot get a transplant for lack of the necessary funding or facilities. The GKE would bring the LMIC pair to the HIC, coordinate the two transplant operations (LMIC donor to HIC recipient and vice versa), and fund a US$50,000 escrow account for follow-up care of the LMIC pair, including the recipient’s post-transplant immunosuppression. A normal “kidney swap” meets ethical and legal requirements because only organs are exchanged, whereas in the GKE an LMIC patient who can supply a donor who meets the GKE’s requirements will receive not only a kidney but substantial financial benefits. Since the exchange is not financially neutral, the Council of Europe has rejected the GKE as a form of “organ trafficking” and an exploitation of financial inequality.In response, recent defenders of the GKE have made several arguments. First among these is the claim that saving recipients’ lives outweighs all the objections raised to the program. This proves too much, as it would justify all organ sales (including from poorer to richer countries) if lives are saved. Nor can the GKE be defended on grounds of autonomy, when the terms are entirely set by the GKE; the preferences of the LMIC donor, who might prefer something else in exchange—perhaps something that might make the commercial nature of the transaction more apparent—are ignored. Besides being unethical, the proposal is impractical. Some patients from LMICs will respond to the possibility of an organ transplant by recruiting paid donors and disguising them as an altruistic friend or relative, a ruse that experience shows transplant programs in HIC often fail to detect. Moreover, the assumption that financial inducements will yield a net increase in organs is contradicted by experience: donation rates are much higher in countries such as Spain and the US than in countries where payments occur such as Iran and Saudi Arabia.Finally, the GKE does not provide, as the philosophers claim, “an eminently fair solution” to the inequities that face LMIC patients, who would be better served if HIC organizations helped LMICs develop appropriate programs to prevent and treat kidney failure, including deceased donor programs.

Pediatric transplantation: An international perspective

The international practice of transplant in the pediatric population is heterogenous. Global trends in pediatric transplant activity are increasing, with diffusion of transplant activities into developing and emerging economies. There have been impacts of the COVID-19 pandemic which have in the earlier part of the pandemic caused a decrease in the number of transplants. While deceased donor programs are well established in advanced economies, emerging and developing countries rely heavily on live donor programs. Prioritization of organs for children exists in different forms throughout the world. Pediatric transplantation as a sub-specialty is young but growing around the world with a need to train surgeons and physicians in this discipline. Outreach efforts with multi-national and multi-institutional partnerships have enabled resource poor countries to establish new transplant programs for children. Further international collaboration, good quality data collection and audit, prospective research and ongoing mentorship and education are needed to further improve outcomes of all children receiving solid organ transplants.

Pediatric Kidney Transplantation in the Middle East: Challenges and Solutions.

Pediatric kidney transplant is the best option for treating children with end-stage renal disease. Poor economics and paucity of renal replacement therapy and transplant facilities are the most important challenges of pediatric kidney transplantation in the Middle East. The aim of the study was to collect data on the rates of pediatric kidney transplant during a recent year from the Middle East countries. All well-known kidney transplant centers from the Middle East were contacted to answer specified questions related to adult and pediatric kidney transplant volume from both living and deceased donors that was performed in each country during a recent year (preferably 2021, or, if not available, 2020 or 2019). In the single recent year, 8772 kidney transplants were performed for adult and pediatric patients in Middle East countries, making a total kidney transplant rate per million populations per year of 10.9 (ranging from 1.2 in Yemen and Pakistan to 39.7 in Turkey). Of these, 1399 transplants were from deceased donors (rate of deceased donor kidney transplants of 15.9%, ranging from 0% in 10 countries to 64.2% in Iran). Of 8772 total kidney transplants, 746 were pediatric recipients (<18 years old), with 166 pediatric kidney transplants from deceased donors (percent of deceased donor pediatric kidney transplant of 22.2%, ranging from 0% in 11 countries to 100% in Tunisia). Average pediatric kidney transplant rate per million populations per year was 0.93 (ranging from <0.1 in Pakistan to 3.2 in Syria). Average pediatric kidney transplant share was about 8.5% of total kidney transplants (ranging from 3.2 in Iraq to 20% in Algeria). The deceased kidney transplant program is currently available in only 8 of the 18 Middle Eastern countries included in this study. However, a deceased program is active in some Middle East countries (ie, Iran, Turkey, Kingdom of Saudi Arabia, Kuwait, and United Arab Emirates). Of note, Turkey had the highest kidney transplant rate per million populations per year (39.7), Syria had the highest pediatric kidney transplant rate per million populations per year (3.2), and Iran had the highest deceased donor kidney transplant percent of the total kidney transplants (64.2%). In the Middle East, Iran alone performed 63.5% (888/1399) of all deceased donor kidney transplants and 63.9% (106/166) of all deceased donor pediatric kidney transplants. Algeria had the highest pediatric kidney transplant share of the total transplants (20%). Low health spending, poorly developed infrastructures, delayed referral of children with chronic kidney disease, comorbidities, lack of technical expertise, inadequate pediatric dialysis programs, extended dialysis time, organ shortage, commercial transplantation, and posttransplant infections are the main pre- and posttransplant challenges. The community-government partnership model from the Sindh Institute of Urology and Transplantation in Karachi Pakistan showed that pediatric renal replacement therapy and transplant can be successfully established in a developing country. Although pediatric kidney transplant is active in many parts of the Middle East, it is still inactive in others, mostly relying on living donors. The lack of deceased donor programs in most Middle Eastern countries is a main issue to be addressed to adequately responding to the increasing demand for organs.

Pediatric Versus Adult Kidney Transplant Activity in Arab Countries.

This study aimed to evaluate current activities of pediatric versus adult kidney transplant in the Arab world. A questionnaire was mailed to all kidney transplant centers in Arab countries to collect the most recent data on kidney transplant activity. There were 3309 kidney transplants performed over a single year, with a transplant rate of 9.5 per million population; 298 of these were pediatric kidney transplant procedures, with a rate of 0.87 per million population, which is much lower than that shown in developed countries where it ranges from 5 to 10 per million population. Of all kidney transplants, the pediatric share is 9%, a rate that is twice as high as that shown among European children. Kidney transplant programs in most Arab countries rely exclusively on living donors, as there is a severe shortage of deceased donors. Of all transplants (that is, combined adult and pediatric), 93.5% were from living donors. Deceased donor pediatric kidney transplant is only available in the Kingdom of Saudi Arabia, Tunisia, and Kuwait. In these 3 Arab countries, which have stable deceased donor transplant programs, deceased donor transplant procedures ranged from 14% to 31% of all transplants. Of the 212 adult and pediatric transplant procedures that were performed from deceased donors in the 8 countries that perform deceased donor transplant, only 29 were for pediatric recipients. Surprisingly, the share of pediatric kidney transplant procedures was not better in the countries with higher overall kidney transplant rate or in those where deceased donor transplant was available. In general, pediatric kidney transplant procedures are still inactive in most Arab countries and mostly relies on living donors. The lack of well-developed deceased donor programs is the main issue to be addressed.

POS-800 OUTCOMES OF DECEASED DONOR KIDNEY TRANSPLANTATION AT CHO RAY HOSPITAL, VIETNAM

Cho Ray Hospital (CRH) started the kidney transplantation from deceased donor program with donor after brain death (DBD) in 2008, and with donor after circulatory death (DCD) in 2015. The aim of the study was to evaluate the outcomes of the deceased donor program of Cho ray Hospital, Ho Chi Minh City (HCMC), over 12 years. Case series study, both DBD and DCD kidney transplantation at CRH from 2008 to 2020. Of 30 donors, we had 25 DBD, 5 DCD, 24 males. Median age of donors was 39 Yo. 5 donors were extended criteria donor (ECD). 15 donors had Kidney Donor Profile Index < 80%. Causes of donor death included 5 strokes, 25 head traumas. 7 kidneys from 4 DBD were procured outside HCMC, the longest distance was 1712 km. We proceeded 55 kidney transplants (46 pts from DBD and 9 pts from DCD). 4 DBD recipients (DBDR) had second kidney transplant, 1 DCD recipient (DCDR) had dual kidney transplant from an ECD. Median waiting time were 45 months for DCDRs and 39 months for DBDRs (p=0.005). Median HLA mismatches was 4 antigens. Mean cold ischemic time of DCDRs was higher than that of DBDRs (no statistic significant). DCDRs had higher rate of delayed graft function (DGF) than that of DBDRs (77.9% vs 19.5%). Surgical complications were 4 hematomas, 2 ureteral stenosis, 1 symptomatic lymphocele, 1 renal artery thrombosis. Both DCD and DBD recipients had similar graft function at discharge time. Our deceased donor transplant had graft survival of 98.2%, and 84.7% at 1 year, and 5 years and patient survival of 92.7% and 89.5% at 1 year, and 5 years. Acute rejection in the first year and later were 6/55 cases (10.9%) and 5/55 cases (9.1%), respectively. DCDRs had lower graft and patient survival than DBDRs. 5 pts died with graft functioning. The most common infections occurred post-transplant were cytomegalovirus (CMV) infection (19 pts), and polyoma (BK) virus infection (8 pts). Median onset time of CMV and BK infection was 5 months, and 16 months, respectively. Tabled 1AllDCDDBDPNumber of recipients (n)55946Age at kidney Tx (median)3744360.461Male (n)398310.188WIT (min)(median)1213.550.001SWIT (min) (median)3837380.617CIT (h)(median)7.7115.20.065DGF (n)16880.000PNF (n)110Length of stays (days) (median)1227100.095Serum creatinine at discharge (mg%) (median)1.31.71.30.807Induction therapy (n)• Â · IL-2inhibitor397320.836• Â · Leukocyte depletion14212Maintenance immunosuppressive therapy (n)• Â · Tac+MMF/MPA+Pred498410.983• Â · Cyc+MMF/MPA+Pred615Biopsy-proven AR (n)7160.874• Â · ACR5050.300• Â · AMR2110.190Non-biopsy proven AR4130.628Graft survival• Â · At 1-year98.2%88.9%100%0.086• Â · At 5-year84.7%71.1%87.8%Pts survival• Â · At 1-year92.7%66.7%97.8%0.002• Â · At 5-year89.5%66.7%94.2%Death with graft functioning (n)5230.210Death total (n)9360.132Causes of death (n)• Â · Sudden cardiacdeath1010.150• Â · Aortic aneurysmrupture101• Â · Sepsis due tobacteria523• Â · PCP110• Â · SARS-COVI-2101Infection post-transplant (n)• Â · CMV196130.027• Â · BK virus8350.080• Â · PCP6240.234• Â · Pulmonary TB5230.134 Open table in a new tab Deceased donor kidney transplantation at CRH showed feasible outcomes and has increased the chance of kidney transplantation to patients on waiting list.

POS-811 A RETROSPECTIVE STUDY TO ASSESS DROPOUT RATE AND ITS CAUSES IN LIVING DONOR TRANSPLANT PROGRAM IN INDIA

Kidney transplant programs in developing countries rely heavily on living donor programs. Though increasing, deceased donor programs are still in infancy due to resource constraints and social or cultural barriers against deceased organ donation. As the burden of end-stage kidney disease (ESKD) is rising, the waiting times for transplants in living donor kidney transplant programs in public sector hospitals are increasing. A significant proportion of patients who do register with provisionally eligible living kidney donors ultimately do not receive transplants. Therefore, we decided to explore the reasons for dropout from the living donor kidney transplant program at a large public sector hospital in India. The study was done at the Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India. At PGIMER, living kidney donors are provisionally registered in the program after ruling out kidney disease and its risk factors. Thereafter, the recipient-donor pairs are extensively evaluated. The priority is decided by the date of donor registration. Retrospectively, we looked at all the provisionally eligible recipient-donor pairs registered between 1stJanuary 2018 and 31stDecember 2019. Pairs who did not undergo a kidney transplant at our center were contacted and reasons for the same were noted. A total of 576 eligible recipient-donor pairs were registered between 2018 and 2019. 252 (43.8%) underwent a living donor kidney transplant at our center (figure 1). The median waiting period from the time of registration to the date of the transplant was 246 days (IQR 133 days). 130 (22.6%) pairs could not be reached despite repeated attempts. Out of the remaining 194 (33.7%), 33 underwent a kidney transplant with the same donor at a private center due to long delays at our center. In the remaining 161 pairs, reasons for not getting the transplant were as follows: 73 (12.7%) recipients died while they were waiting for the transplant, donors were detected to be medically or surgically unfit in 44 (7.6%) pairs at subsequent evaluation, 12 (2%) had a positive crossmatch and 15 (2.6%) recipients changed their mind and continued hemodialysis. Other reasons included poor finances, legal issues in approval of donor, and death of other kidney paired donation (KPD) recipients thereby leaving the first recipient without an eligible living donor. 56.2% of living kidney recipient-donor pairs dropped out of living donor kidney transplant program at a large public sector hospital in India. 22.5% could not be contacted while 5.7% went on to get the transplant at a private center. 12.7% died while waiting to get a slot for surgery. Despite the availability of living kidney donors, 36% (161/446) failed to get a transplant. It is likely that the outcomes would be at least similar in the group that could not be contacted. The data suggest an urgent need for upscaling living donor kidney transplant programs, laying the foundation for quality improvement (QI) initiatives to optimize resource utilization and hence, improve accessibility in living donor transplant programs.

RENAL TRANSPLANT RELATED ANAESTHESIA EXPERIENCE, CONSIDERATIONS AND PRACTICE OVERVIEW OF AFIU, RAWALPINDI

Objective: To describe our experience of renal transplant operations in our institute.&#x0D; Study Design: Prospective observational study.&#x0D; Place and Duration of Study: Department of Anaesthesiology, Armed Forces Institute of Urology, Rawalpindi, from Sep 2016 to Sep 2019.&#x0D; Methodology: A total of 170 living related renal transplants were included in this study. Soda bicarbonate was given intra operatively to recipients according to arterial blood gas results. Blood transfusion was done where indicated.&#x0D; Results: Out of 340 (100 %) patients, 170 (50%) were living related donors and 170 (50%) were transplant recipients General anesthesia was the technique of choice. Three (1.76%) recipients out of 170 were awaked from anesthesia and postponed. Five (2.94%) patients were reopened on the same evening and 2 (1.17%) patients had transplant nephrectomy over a period 1 month. Soda bicarbonate was given to 143 (84.1%) and blood transfusion in 4 (2.35%) transplant recipients where as one patient had anaphylaxis intra-operatively.&#x0D; Conclusion: Living related kidney transplant is the standard transplant procedure in our institute because of non-availability of cadaveric donor. It’s now time that deceased donor program be started in Pakistan due to increased cases of renal failure and decreased living donors.

Deceased Donor Renal Transplantation: A Single Center Experience.

Introduction:Deceased donor kidney transplant are still not common across India. This study was done to assess various measures taken at a single center level to increase organ donation rate and to analyse the outcomes of transplants performed from these donors.Methods:All deceased donor renal transplants performed from November 2011 to February 2017 were analysed for patient and death censored graft survival, rate of delayed graft function, rate of rejection and mortality. Kaplan Meir analysis for Survival Curves was used.Results:Organ donation rate at our center improved from one donation every alternate year in 2004 to a peak of 44 donations in 2017. Patient survival was 93.42%, 89.44%, 85.53%, and death censored graft survival was 94.07%, 88.21%, and 82.86% at 1, 2 and 3 years respectively. Mean duration of hemodialysis pre transplantation was 34.6 ± 27.43 months.Conclusions:This study has shown that steps taken at a single center level alone can also significantly improve organ donation rates. Employment of dedicated professionals including transplant surgeons and coordinators, developing a protocol-based approach for referral, and early counseling in triage along with regular audits can help to establish deceased donor program with acceptable outcomes elsewhere in the country.

Renal angiographic evaluation of prospective renal donors: Single-center data and outcome analysis from South India - A retrospective observational study

Introduction: In countries without a well-developed deceased donor program, living donors form the backbone of the renal replacement strategy. Computed tomography (CT) angiography forms an integral part of the predonation evaluation. The course, number, and morphometric evaluation of the renal vasculature provided by CT angiography help to identify which kidney to harvest and which kidney to exclude from the donation. The characteristics of the Indian renal donor are a rarely studied topic with only a few studies on the same to date. Methodology: This is an observational study done over a period of 3 years noting the clinical and morphometric characteristics of the renal donors from a database. Results: In this study, 57 prospective living renal donors were included. Most donors were women. The length of the renal artery and renal vein was shorter in this cohort than in previously known statistics. The diameter of the renal vessels was also smaller than previous data. The left side kidney was more commonly harvested compared to the right. Conclusion: Renal angiographic morphometric data among the Indian population were different from previously known statistics. Angiographic data correlated well with intraoperative findings in the majority of patients.

Immunosuppression after the diagnosis of renal allograft renal cell carcinoma in two transplant recipients: Case reports and review of the literature

Renal cell carcinoma (RCC) is a common solid malignancy among renal transplant recipients. While it commonly involves the native kidneys, renal allograft RCC is increasingly being reported in renal transplant recipients. Most often, renal allograft RCCs are locally confined and nephron-sparing interventions are successful treatments. Immunosuppression is typically reduced in transplant recipients who develop malignancies; however, there is no consensus on the same for transplant recipients with a diagnosis of RCC. We report two cases of renal allograft RCC who were successfully managed with ablative therapy and reduction of immunosuppression. However, both the patients developed irreversible graft dysfunction and are wait-listed in the deceased donor program for the second transplant. We highlight the deficiency of evidence and the need for further studies on the aspect of immunosuppression modification after the diagnosis of RCC in transplant recipients.