Departments of Nephrology and 1 Surgery, All India Institute of Medical Sciences, New Delhi,India
Sir,
We read with interest the article by Mathieson PW et al. [1]. In this context we would like to share our experience regarding spousal renal transplants. Prior to 1995, at our centre only living related renal transplant was performed. In India, the Transplantation of Human Organs Act came into force in 1995. Its primary aim was to allow removal of cadaver organs for transplantation and to regulate living unrelated renal transplant. It allows for organ transplants between near relatives which include parents, siblings, children (over 18 years) and spouse. Although spouse is not genetically related, it is included in the near relatives for obvious reasons. Subsequent to the Act, the policy at our centre was modified and we started to accept spouse as donor in exceptional circumstances. We have to be very cautious to prevent exploitation of wives in our social context. We strictly follow the following criteria before accepting wife as donors viz. (i) absence of suitable parent or sibling donor, (ii) documentation of marriage having taken place prior to diagnosis of ESRD and (iii) assure ourselves that she has not been coerced in this decision by anyone by separately interviewing the wife, husband, her parents and in-laws.
From 1995 to 1998, we have performed 33 spousal transplants. Three transplants were from husband to wife and the rest from wife to husband. All patients received immunosuppression with prednisolone, azathioprine and cyclosporine. The immunosuppression protocol for spousal transplants is the same as living related transplants. We have lost four patients to follow-up. Follow-up ranges from 2 to 50 months with a mean follow-up of 13.3 months. There have been eight rejection episodes in 29 patients. Nine patients died 23 years postoperatively with normal renal functions, three patients due to septicaemia and six HBsAg positive patients due to hepatic failure. Nineteen patients are well with a mean serum creatinine of 1.2 mg%. One patient is in chronic rejection with serum creatinine of 2.1 mg%. No major complications occurred in donors. All donors remain well at follow-up.
Maintenance haemodialysis facilities are very limited in India. Cadaver donor programme is still in its infancy. Parents are often medically unfit to donate. The joint family system is gradually breaking down. Siblings are increasingly unwilling. In the absence of a suitable and willing first degree related donor, the wife who is the emotionally most attached comes forward. The fact that this is legally permissible has also contributed to increasing number of spousal (wife) transplants. However, before accepting wife as donor, we have to be extremely careful to satisfy ourselves that it is voluntary. In our circumstances, this is quite difficult. Often the wife does not have any other option, since her husband is the sole breadwinner of the family and she feels it is her duty to save him.
Our results are skewed, as out of a small number of 33 patients, four were lost to follow-up and nine patients died with normal functioning grafts. Of the remaining 20 patients, 19 have normal renal functions. Although the graft survival of spouse transplants is comparable to that of all other living donors with the exception of HLA identical siblings [2], considering our social circumstances, it is our policy to consider wife only if no other donor is available.
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