Kidney transplantation in patients travelling from the UK to India or Pakistan

Rob Higgins, Nick West, Simon Fletcher, Andy Stein, For Lam and Habib Kashi

Renal Transplant Unit University Hospitals of Coventry and Warwickshire Walsgrave Hospital Coventry UK Email: robert.higgins{at}uhcw.nhs.uk

Sir,

There is a shortage of kidneys for cadaver transplantation in the UK, and an allocation policy that disadvantages Indo-Asian subjects [1]. This has led some patients to travel abroad for transplantation. Previous reports of this practice indicate high complication and graft failure rates [25].

Since 1996, nine patients from our transplant list have travelled overseas for transplantation. One went to China, and no more has been heard. Five went to India and three to Pakistan. One patient received two transplants, giving nine transplants in eight patients. The outcomes in the first year after transplantation are shown in Table 1Go, compared with the outcomes of 30 living donor transplants performed in our unit between 1996 and 2001.


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Table 1.  Living-related transplants and first year of follow-up

 
There were two deaths and a graft failure in the India and Pakistan group, compared with one death and one graft failure in Coventry, UK (68% survival rate in India and Pakistan, 92% in Coventry). Serious complications occurred more frequently in patients transplanted in India and Pakistan than in Coventry, eight complications in six patients and 11 complications in 28 patients, respectively (Table 1Go). Serious complications were defined as contracting hepatitis B or C, or requiring readmission to hospital other than for diagnosis and management of suspected rejection. One patient died of infection in India, although the details of causation (bacterial, fungal or malaria) are not known to us. The patients transplanted in Coventry and Asia were not fully comparable. However, there were high-risk patients in both groups. Two patients who went to India were suspended from our transplant list for medical reasons. In Coventry, one patient had a previous heart–lung transplant and two transplants were performed urgently in patients judged to have a low chance of survival on dialysis (widespread vascular thrombosis and another with repeated critical care admissions for septicaemia).

Induction immunosuppression was tacrolimus based in two cases and cyclosporin based in four others from India and Pakistan. Two cases had anti-interleukin 2 receptor monoclonal antibody treatment. In Coventry, 16 patients received cyclosporin-based immunosuppression and 14 tacrolimus-based immunosuppression. There was no difference in the incidence of acute rejection between groups. The outcomes for the overseas donors could not be fully assessed. One donor had a horseshoe kidney with four arteries. The whole organ was removed, split into two parts, and then one part transplanted back into the donor. One recipient had a transplant biopsy performed in the UK that showed a glomerulonephritis, most likely of donor origin.

These patients were discouraged from travelling by their UK clinicians. This was because complications after transplantation were anticipated, and because none of these transplants was demonstrably compatible with the 1989 Human Organ Transplant Act.

In summary, living transplantation in patients travelling to India or Pakistan showed a high complication rate. The use of modern immunosuppressive agents such as tacrolimus and anti-interleukin 2 receptor monoclonal antibodies did not appear to be protective against poor practice, namely poor selection of both donors and recipients, and the development of serious infectious complications such as viral hepatitis.

Conflict of interest statement. None declared.

Acknowledgments

We would like to thank clinical colleagues from Heartlands Hospital, Birmingham, UK, for permission to report on patients under their care.

References

  1. Higgins RM, West N, Edmunds ME et al. Effect of a strict HLA matching policy on distribution of cadaveric kidney transplants to Indo-Asian and white European recipients: regional study. Br Med J 1997; 315:1354–1355[Free Full Text]
  2. Odum J, Rylance PB, Jackson MA. From Wolverhampton to Bombay. Lancet 1994; 343:734
  3. Ivanovski N, Stojkovski L, Cakalaroski K, Masin G, Djikova S, Polenakovic M. Renal transplantation from paid, unrelated donors in India—it is not only unethical, it is also medically unsafe. Nephrol Dial Transplant 1997; 12:2028–2029
  4. The Living Non-Related Renal Transplant Study Group. Commercially motivated renal transplantation: results in 540 patients transplanted in India. Clin Transplant 1997; 11:536–544[ISI][Medline]
  5. Sever M, Kazanciolu R, Yildiz A et al. Outcome of living unrelated (commercial) renal transplantation. Kidney Int 2001; 60:1477–1483[CrossRef][ISI][Medline]