The organization of Kidney Transplantation Services at Ramathibodi Hospital: fourteen years experience on waiting list, kidney donors and kidney transplantation.

The Kidney Transplantation Program at Ramathibodi Hospital was established in 1985. By the end of 1998, there were 1,614 patients on the cumulative waiting list. The first kidney transplantation (KT) was started in 1986 by using kidney from living-related donor (LD) while cadaveric KT (CD-KT) was started in 1987. A total of 528 KT were done, 278 cases (52.7%) were CD-KT and 250 cases (47.3%) were LD-KT. Six patients had two kidney transplants. 278 kidneys were donated from 189 cadaveric donors. Fifty cadaveric donors (26.4%) were from Ramathibodi Hospital while the rest were from other hospitals and the Organ Donation Center, Thai Red Cross Society. For LD, 233 out of 250 (93.2%) were from living-related, more than 50 per cent of these donors were from siblings. 17 spousal donors have been accepted for KT at Ramathibodi Hospital since 1997. Concerning the recipient pools, 522 patients (32.3%) were transplanted, 123 patients (7.6%) died without KT, 111 patients (6.9%) underwent KT at other hospitals, and 78 patients (4.8%) changed to waiting lists at other hospitals. The rest were lost to follow-up. At present, only 265 patients are still actively waiting (send serum every month). The number of KT and living donors has gradually increased, whereas, the number of cadaveric donors has decreased. However, cooperation with the "Organ Donation Center" has improved the number of cadaveric donation in the last two years. Sufficient organ donations and an active working team will provide a good kidney transplant service for the patients.

The urological complications of renal transplantation: an 11-year-experience at Ramathibodi Hospital.

From February 1986 to December 1996, renal transplantation was performed on 344 patients at Ramathibodi Hospital. The urological complications were retrospectively analyzed in 335 patients (338 renal transplants), 9 patients were lost to follow-up. There were 227 males and 108 females with age ranging from 15 to 62 years (mean age 40.28 years). There were 207 cadaveric and 131 living-related graft donors. The ureteroneocystostomy was performed either by modified Politano-Leadbetter (93 cases) or extravesical technique (245 cases). There were 23 cases of urological complications: ureterovesical anastomotic leakage 6, ureteric obstruction 6, vesicoureteric reflux 4, significant bleeding from ureterovesical anastomosis 3, renal infarction with fistulas 2, hydronephrosis due to blood clot retention and swelling of the anastomosis, requiring temporary double J stenting 2. The analysis was done by dividing the patients into 3 groups, the first and second groups consisted of 100 cases each and the third group consisted of 138 cases. The urological complications in the groups were 10 per cent, 9 per cent and 2.89 per cent respectively. There was a statistically significant difference between the first two groups combined and the third group in terms of complications (p < 0.025). The urological complications of living-related cases were 9 (6.87%), and of cadaveric cases were 14 (6.76%). There was no significant difference of the complications between living-related and cadaveric transplants (p < 0.05). The comparative results of the ureteric complications of the extravesical technique were significantly less than the modified Politano-Leadbetter technique (4.49% vs 10.75%), (p < 0.05). In conclusion, the extravesical technique of ureterovesical anastomosis was superior than the modified Leadbetter-Politano technique in terms of post-operative ureteral complications.

Increasing the chance to accept HLA-ABDR mismatched donor in kidney transplantation.

Two hundred and fifty-three kidney transplantations (KT) which included 68 (26.9%) living-related (L) and 185 (73.1%) cadaveric (C) KT with 0-6 HLA-ABDR mismatches (MM) were studied for the association of HLA-ABDR-MM specificities and the occurrence of graft rejection (GR). It was found that the incidence of acute and chronic rejection in CKT was significantly higher than that of LKT (42.1% vs 22.1%, p < 0.005). It was also observed that the number of ABDR-MM, AB-MM and BDR-MM which is important in GR were 2 times in CKT compared with LKT. The analysis revealed that HLA-A11, B16, B22, B35, B5, B17 and DR3 were good responders, whereas, HLA-A30, A2, B62, B18, B40, B44, B46 and DR10 were good stimulators for KT. GR were significantly increased with p < 0.01 and < 0.05, respectively. Specific HLA-MM specificities played a significant role in GR, i.e., some HLA-MM specificities were permissible, whereas, some were immunogenic. Careful selection of donor and recipient for KT by avoiding immunogenic HLA-MM and/or accepting permissible HLA-MM will improve graft survival and reduce the demand of kidney for retransplantation.

Crossmatching technique facilitating kidney transplantation.

Accelerated acute cellular rejection (AR) continues to be a serious problem in kidney transplantation (KT), suggesting that undetected presensitization may be encountered. The purpose of this study was to determine the most sensitive crossmatching (XM) technique to detect the preformed antibody (Ab) which may cause AR. One hundred and twenty two sera from 98 patients, on the waiting list for KT at Ramathibodi Hospital were XMed with 23 cadaveric splenic lymphocytes including 2 living related KT (LR-KT). The XM was performed by 3 different techniques namely, standard microlymphocytotoxicity test (standard NIH), antihuman globulin microlymphocytotoxicity test (AHG) and flow cytometric XM (FCXM). The XM results revealed that 8 out of 75 (10.7%) tests were negative by standard NIH, i.e., 5 tests were positive by AHG only and 1 test was positive by FCXM only and 2 tests were positive by both AHG and FCXM. In addition, the patients who had the AHG technique were not done, 5 out of 47 (10.7%) tests were also negative by standard NIH but were positive by FCXM. The sensitivity of the techniques was done by titrations of anti HLA-A2. It was found that FCXM was the most sensitive technique, followed by AHG and standard NIH, consecutively. In the retrospective study of LR-KT, case #1, the standard NIH for XM using pre-KT blood sample was negative while AHG and FCXM were strongly positive. The patient had AR at day 2 post-KT which confirmed by needle biopsy. The serum at day 11 and day 116 post-KT were tested again and were positive by the 3 techniques. Case #2, pre-KT blood sample showed negative T-XM by the 3 techniques while auto-B and B-XM were positive by standard NIH and AHG but negative by FCXM. This patient had rejection at day 16 after KT. The post-KT blood sample at day 30 showed positive auto T/B and T/B-XM by standard NIH and AHG whereas it was still negative by FCXM. It was also noted that Ab to donor B cell was better detected by standard NIH and AHG than FCXM. In conclusion, FCXM is more sensitive than standard NIH and AHG, however this technique is limited in detecting IgM T and B cell Ab. AHG technique can detect both IgG and IgM antidonor T and B cell Abs. In addition, AHG technique is more sensitive than standard NIH and does not require sophisticated equipment. AHG technique should be appropriate for routine XM, especially, in LR-KT and sensitized patients.