The cost of kidney transplantation in Iran

BACKGROUND: Kidney transplantation has gained widespread popularity by improving the outcome of end-stage renal disease (ESRD) patients. However, this is a highly complicated and expensive procedure that puts much pressure on the health system in developing countries. We report the costs in Iran model of kidney transplantation. MATERIALS AND METHODS: We reviewed the regulations for kidney transplantation using Dialysis and Transplant Patients Association (DATPA) information, 2005. All data regarding the cost of transplantation procedure, immunosuppression, and the money given to donors were included. The cost of transplantation procedure was categorized into personnel, drugs, paraclinics, hospital bed, and other expenses. To achieve more comprehensive results, all costs were converted into US dollars (1 USD = 9000 Rials). RESULTS: The total cost of kidney transplantation procedure was $9224. Of this, 65.8% ($6076) was related to the immunosuppression therapy in the first year, 22.2% ($2048) to the transplantation procedure, and 12% ($1100) to organ procurement. The details of donor nephrectomy were as follows: personnel, $183; accommodations, $107; drugs, $39; paraclinics, $23; and other, $22. These values for kidney recipient were personnel, $331; drugs, $367; paraclinics, $278; accommodations, $475; and other, $222. CONCLUSION: Compared with other countries, the kidney transplantation cost is low in Iran. The health system also pays for all the expenses. These, along with full medical insurance coverage of kidney recipients, make kidney transplantation available for every patient, regardless of the socioeconomic status due to its low cost. It is expected that a higher number of transplantation candidates with a low socioeconomic status will select transplantation.     

Inadequate donor size in cadaver kidney transplantation

There have been conflicting reports that kidneys from small donors may be at increased risk for late graft failure if they are transplanted into large recipients. Data from the United States Renal Data System was used to study all first cadaver kidney transplantations performed during the years 1994 to 1999. Donor and recipient body surface area (BSA) combinations were included along with other patient and transplant characteristics in a Poisson analysis of factors associated with early (in the first 4 mo) and late (> or =4 mo) graft failure. The numbers of large (BSA >2.2 m(2)) and medium size (BSA 1.6 to 2.2 m(2)) recipients that received kidneys from small (BSA <1.6 m(2)) donors are less than expected (chi(2) = 118.09; P < 0.0001), suggesting that transplant centers may be refusing some kidneys on the basis of donor-recipient size differences. Large recipients who received kidneys from small donors made up 1.5% of the population and had a 43% (95% CI, 17 to 75%; P = 0.0004) increased risk of late graft failure compared with medium-size recipients who received kidneys from medium-size donors (53.4% of the population). Medium-size recipients who received kidneys from small donors made up 12.0% of the population and had a 16% (95% CI, 6 to 26%; P = 0.0012) increased risk of late graft failure. Disparities in recipient and donor size had similar adverse affects on mortality. Effects of recipient obesity (body mass index) and donor gender on late graft survival were no longer statistically significant after the effects of donor and recipient body size were taken into account. In conclusion, the relative size of the donor and recipient should possibly be taken into account when choosing kidneys for transplantation.     

Simultaneous cadaver pancreas-living donor kidney transplantation

BACKGROUND: The expansion of the donor pool achieved with living kidney donation (LKD) is particularly beneficial for diabetic patients, who have a worse prognosis during dialysis when compared to other kidney recipients. Simultaneous cadaver pancreas-living kidney transplantation (SPLKTx) merges the advantages of LKD with those of cadaver donation, and may be an attractive alternative to simultaneous pancreas kidney transplantation (SPKTx). METHODS: The outcomes of 18 SPLKTx were compared with those of 33 SPKTx. RESULTS: LKD expanded the donor pool from 33 to 51 (P =.004). Median wait time was shorter for SPLKTx (14 days) than for SPKTx (95 days) (P =.006). The risk for surgical complications was not increased by SPLKTx, as witnessed by relaparotomy rates (SPLKTx: 2/18, 11.1%; SPKTx: 2/33, 6.1%; P >.05). Hospital stay averaged 26.1 +/- 11.2 days for SPLKTx and 27.1 +/- 16.3 for SPKTx (P >.05) with equivalent 30-day readmission rates (SPLKTx: 5.5%; SPKTx: 6.1%); (P >.05). One acute kidney rejection occurred in SPLKTx (5.5%) as compared with four in SPKTx (12.1%); (P >.05). Equivalent rates for the pancreas were 5.5% (1/18) for SPLKTx and 3.0% (1/33) for SPKTx (P >.05). Two-year recipient survival rates were 100% for SPLKTx as compared with 96.9% for SPKTx. Equivalent figures for kidney and pancreas were 80.0% and 84.0% for SPLKTx and 96.9% and 96.9% for SPKTx. CONCLUSIONS: SPLKTx is a valuable alternative to SPKTx. Further development of SPLKTX relies on increased rates of living kidney donation.     

Immunological relevance of CREG matching in cadaver kidney transplantation

BACKGROUND: On the basis of cross-reactive antibodies that react with different human leukocyte antigens (HLA) with shared epitopes, HLA-A and -B antigens can be assigned to cross-reactive groups (CREG). In the context of renal transplantation, it has been reported that matching for CREG results in improved graft outcome and reduces the requirement for rejection treatment. Because CREG matching also improves the equity of kidney distribution to ethnic minorities, a CREG-based cadaver kidney allocation policy was introduced in the United States a few years ago. METHODS: The authors reexamined the immunologic relevance of matching according to CREG using the data of the international Collaborative Transplant Study. A total of 91,917 patients who received a first cadaver kidney transplant between 1991 and 2002 formed the basis of this analysis. RESULTS: The authors found that the underlying impact of matching for HLA antigens accounts entirely for the observed positive effect of CREG matching. For patients with a particular HLA antigen match grade, matching for CREG had no advantageous effect on graft outcome or rejection treatment. An immunologic basis for CREG matching could thus not be found in this large analysis of cadaver kidney transplants. CONCLUSIONS: The findings indicate that CREG matching for kidney allocation is conceptually flawed from an immunologic viewpoint.     

The cadaver kidney transplantation programme of Milano. Immunological report.

A retrospective investigation was carried out to evaluate the infuence of HLA (A, B) matching, blood transfusions, and preexistence of lymphocytotoxic antibodies on the outcome of the cadaver kidney graft: only non-NIH standard antibodies were considered, since patients with NIH standard antibodies do not undergo transplantation in the programme of Milano. It was found that (1) about one-half the patients with transplants had antibodies in their pretransplant serum. The preexistence of antibodies directed against B lymphocytes had an unfavourable effect on the graft survival; (2) the graft did particularly well in the nonimmunized patients who had been previously transfused; the graft survival was about 80% at 3 years in these patients; and (3) the HLA (A, B) match influenced the graft survival only in patients with antibodies.     

Repeat cadaver kidney transplantation using cyclosporine A immunosuppression

Repeat cadaver kidney transplantation using azathioprine immunosuppression carried a higher risk of graft loss than primary transplants. We analyzed the results of repeat cadaver kidney grafting with cyclosporine A immunosuppression. A total of 33 cyclosporine A-treated patients received the second kidney transplant at varying intervals after failure of the first transplant. Graft survival at 1 year was 66 per cent. A concurrent group of 189 cyclosporine A-treated first cadaver kidney recipients had a 1-year graft survival rate of 75 per cent, although this better result was not statistically significant (p greater than or equal to 0.25). A historical group of 31 azathioprine-treated second graft recipients had a significantly worse 1-year graft survival rate of 45 per cent compared to the cyclosporine A second graft group (p less than 0.1). Patient age, sex, early first graft loss, interval between transplants and the presence of panel reactive antibodies were not factors in predicting second graft outcome. A complete DR mismatch appeared to worsen the second transplant survival. These findings indicate that early graft survival of cyclosporine A-treated repeat cadaveric transplants is acceptable and is better than azathioprine-treated first or second grafts.     

Multivariate analysis of risk factors in cadaver donor kidney transplantation

Data collected prospectively on 3811 kidney transplants performed between June 1977 and July 1982 with follow-up to July 1984 by the 42 member institutions of the South-Eastern Organ Procurement foundation were analyzed to identify factors associated with graft and patient outcome in patients not receiving cyclosporine. Multivariate Cox regression analysis was used to examine the association and relative risk of 24 variables with three actuarial outcomes: overall graft failure, irreversible rejection, and patient death. Factors having no suggested association with any outcome included: recipient sex, history of pregnancy, blood group, and time on dialysis; organ preservation method, time and source; donor race; crossmatch test sensitivity; and annual center transplant rate. In decreasing order of relative risk, the factors most significantly associated with irreversible rejection were: loss of two or more prior grafts, low HLA-A,B match, lack of pretransplant blood transfusion, high (greater than 60%) pretransplant sensitization to leukocyte (HLA) antigens, and delayed graft function. Splenectomy, insulin-dependent diabetes, and antilymphocyte serum therapy provided the greatest risk of patient death. Factors such as recipient age, race, and native nephrectomy had suggested associations with outcome. By adding each center as a separate covariate in the analysis, other center-dependent factors were quantitated and found in some cases to have a highly significant association with graft and patient outcome. These results provide a basis for evaluating the potential risk of graft loss or patient death for those prospective cadaver kidney transplant recipients not being considered for cyclosporine therapy.     

Steroid and calcineurin inhibitor-sparing protocols in kidney transplantation

Recent improvements in kidney transplantation have been driven largely by lower acute rejection rates attributed to better immunosuppressive agents. In an effort to reduce the long-term toxicities of immunosuppressant drugs, corticosteroid- and calcineurin inhibitor (CNI)-sparing immunosuppression protocols have become increasingly popular in managing kidney transplant recipients. Nevertheless, these strategies may increase the risk of acute and chronic allograft injury (CAI) that may worsen the fate of transplant recipients. This article focuses on steroid and CNI sparing protocols to elucidate their safety and efficacy in patients receiving a kidney transplant. Steroid avoidance protocols are rapidly and increasingly being used. Studies have shown that corticosteroids are not essential to achieve excellent short- and intermediate-term results. However, the role of steroid withdrawal is only marginally beneficial and very often benefit overstated. CNI-sparing strategies have been used to help maintain the balance between allograft survival and nephrotoxicity. Trials evaluating CNI minimization have shown reduced incidence of CAI and preservation of allograft function. CNI withdrawal within 3 to 12 months after kidney transplantation improved graft function despite increased risk of acute rejection. This approach may be feasible with adequate exposure and proper usage of mammalian target of rapamacin inhibitors. Late withdrawal or conversion did not show a clear benefit. Timing and degree of renal dysfunction are key determining factors. With regards to CNI avoidance, earlier trials, such as the Symphony study, did not support the use of a CNI-free regimen of low-dose sirolimus as initial immunosuppression. However, recent studies using costimulatory blockade-based immusouppression showed that CNI avoidance is possible. The best maintenance immunosuppressive with CNI- or steroid-sparing is a work in progress and awaits longer term follow-up. The availability of newer biologics for costimulatory blockade and new immunosuppressive agents with novel mechanisms of action have the potential of using CNI- and steroid-sparing protocols to minimize the incidence of CAI and improve long-term outcomes in kidney transplant recipients.     

Excellent clinical outcomes in primary kidney transplant recipients treated with steroid-free maintenance immunosuppression

Steroid-free maintenance immunosuppression is desirable to eliminate the side effects of chronic corticosteroid use. Complete steroid avoidance or rapid post-transplant steroid withdrawal has recently been used in renal transplant recipients with encouraging results. The present study evaluated the outcome of a steroid-free maintenance immunosuppressive protocol in kidney transplant recipients with at least one-yr follow up. Between April 2002 and October 2004, a total of 301 primary kidney transplant recipients received steroid-free maintenance immunosuppression. The regimen consisted of induction with thymogobulin and prednisone for the first five d. Patients were maintained on Sirolimus and Neoral. Neoral dose was adjusted to target C2 levels and the Sirolimus dose was adjusted to a target rapamycin trough level. All primary kidney transplants (n = 502) performed in the two yr (starting January 2000) prior to institution of the steroid-free regimen and thus maintained on a steroid-based immunosuppressive protocol were used for comparison. One-year patient and death censored graft survival were 93.1% and 98.1% for the steroid-free group vs. 95.2% and 95.2% for the comparator groups (p = ns). The incidence of biopsy-proven acute rejection was 4.9% in the steroid-free group vs. 9.4% in the comparator group (p < 0.01). Two (0.7%) of 301 patients in the steroid-free group lost their grafts because of acute rejection compared with nine (1.8%) patients in the comparator group (p < 0.05). At one-yr post-transplant the mean serum creatinine level was not different between the two groups. There were no significant differences in mean serum cholesterol and triglycerides levels as well as the percentage of patients on lipid lowering agents between the groups. White blood cell counts, daily doses of Neoral and weight gain were significantly lower in the steroid-free group vs. the comparator group. However, more patients in the steroid-free group required erythropoietin and iron therapy for anemia (p < 0.001). We conclude that excellent graft survival with a significantly lower incidence of acute rejection can be achieved using a steroid-free maintenance immunosuppressive protocol consisting of Neoral and Sirolimus.     

Race as a risk factor in cadaver kidney transplantation.

Recipients of 93 first-cadaver kidney transplants were studied for the effect of recipient and donor race on graft and patient survival. Both graft and patient survival were lower for black recipients than for whites. The difference was not explained by racial mismatch between donor and recipient. Black recipients had more rejection episodes and more instances of bacterial pneumonia. Pretransplant splenectomy reduced the likelihood of rejection episodes for black recipients and increased their rate of graft survival.