Spousal

Comparison of Spousal With Other Donor Groups: Study of a Single Center J. Roozbeh, A.R. Mehdizadeh, M.A. Izadfar, A. Razmkon, H. Salahi, and S.-A. Malek-Hosseini ABSTRACT In coping with the shortage of living-related and cadaveric donor groups for renal transplantation, and in the fear of organ marketing, spousal donors are considered an invaluable potential source. Survival rates have been reported to be as high as even some related groups. This study evaluated 1039 renal transplantations up to 2003. Patient survival rates in different donor groups were determined using the Kaplan-Meier method. The 3-year patient survival rates were 93% for kidneys from 61 spouses; 92% for kidneys from 433 living-related donors; 91% for kidneys from 427 living-unrelated (excluding spouses) donors; and 90.5% for 118 cadaveric kidneys. Such results were consistent with many other reports which consistently showed that spousal donors were at least as good as living-related donors, representing a reliable source in cases of organ shortage. The high survival rate of spousal donors is probably related to their strong emotional support.

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HE SEVERE SHORTAGE of organs is one of the major barriers facing the issue of transplantation today. One of the proposals designated to overcome this serious problem is to increase the use of genetically unrelated living kidney donors.1– 4 Recent studies have shown that the survival rates of kidney transplantation among spouses are as high as even some related groups, despite poor HLA matching.5 Kidney donation by spouses has been ethically approved in many countries, but is prohibited by law in others.6,7 In Iran, kidney transplantation from spousal donors has been a part of living-unrelated kidney programs. In the Iran model of the living-unrelated donor renal transplant program, all renal transplant candidates are told of the advantages of living-related donors compared with living-unrelated donors. If the patient has no living-related donor, he or she is referred to the Dialysis and Transplant Patients Association (DTPA) to find a suitable living-unrelated donor. The objectives of this study were to evaluate the patient and graft survival rates in spousal combinations compared with the corresponding rates in living-related, living-unrelated, and cadaveric donor grafts in our center, as well as to compare the results of wife to husband and husband to wife kidney transplantation. MATERIALS AND METHODS Up to 2003, we performed 1039 renal transplantations. The KaplanMeier method was used to compare the survival rates of patients and grafts from 61 spouses, 433 living-related donors, 427 livingunrelated donors (excluding spouses), and 118 cadaveric donors. In 0041-1345/06/$–see front matter doi:10.1016/j.transproceed.2005.12.058 562

Iran, marriage between relatives (eg, cousins) is common; therefore, related spouses were excluded in this study. The minimum follow-up period was 12 months. The immunosuppressive protocol consisted of azathioprine, prednisolone, cyclosporine, and mycophenolate mofetil, which has been described previously.8 Overall patient and graft survival rates, patient and graft survival rates in wife to husband and husband to wife, and the causes of graft loss were studied. Patient and graft survival rates were compared with the corresponding rates in living-related, living-unrelated, and cadaveric transplantations. Graft loss was defined as patient death or return to chronic dialysis. The diagnosis of acute rejection was made by a clinical increase in serum blood urea nitrogen (BUN) and creatinine and confirmed by biopsy. In our center, the cold ischemia time was short (1–2 hours) and therefore not considered to be an important contributing factor.

RESULTS

Among the spouses, the donor-recipient relationships were wife to husband in 49 cases and husband to wife in 12 cases. The mean age was 36.4 ⫾ 12.5 years (range, 21–56 years). The 1- and 3-year patient survival rates were 97% and 93% in 61 spousal renal grafts; 96% and 92% in 433 livingFrom the Shiraz Transplant Research Center, Shiraz University of Medical Sciences (A.R.M., S.-A., M.-H.); and Shiraz Transplant Center, Nemazee Hospital (J.R., H.S., M.A.I., A.R.), Shiraz University of Medical Sciences, Shiraz, Iran. Address reprint requests to Ali Razmkon, MD, Shiraz Transplant Scientific Pole, Shiraz University of Medical Sciences (SUMS), Shiraz, Iran. E-mail: [email protected] © 2006 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710 Transplantation Proceedings, 38, 562–563 (2006)

SPOUSAL VERSUS OTHER DONOR GROUPS

related donor cases; 93% and 91% in 427 living-unrelated donor cases; 93% and 90.5% in 118 cadaveric donor cases; and finally 94% and 91.5% in all 1039 patients transplanted at our center. The 1- and 3-year graft survival rates were 91% and 86% in 61 spousal cases; 91% and 85% in living-related cases; 87% and 82% in living-unrelated cases; 88% and 84% in cadaveric donor cases; and finally 88% and 84% in all 1039 patients transplanted at our center. These results were similar to other reports which consistently showed no significant difference between patient and graft survival rates of spousal donor transplantations and the corresponding overall, living-related, and living-unrelated donor transplantation survival rates.1– 6 The patient survival rates at 1 and 3 years were 100% and 97% in 49 wife to husband and 100% and 95% in 12 husband to wife transplantations, respectively. Corresponding graft survival rates were 98% and 94%, and 96% and 93%, respectively. There was no significant difference if the wife had not been pregnant. Among spousal cases, six recipients died in the posttransplantation period because of renal failure and cytomegalovirus infection. In the posttransplantation period, there was one case of pancreatitis, two cases of hypertension, and six cases of acute rejection. DISCUSSION

The worldwide shortage of organs available for transplantation has led to the use of living-unrelated kidney donors.9 –11 The waiting list for renal transplantation is growing by 20% annually, even in countries that have solved the problem of obtaining cadaveric organs long ago.12 Each year thousands of patients die while awaiting a renal transplant. To solve this problem, we recommend the Iran model of living-unrelated donor program. Adopted in 1988, this model permits compensated and controlled livingunrelated donor renal transplantation. It has eliminated the renal transplant waiting list in Iran. At the end of 2002, among the 14,288 renal transplantations performed, 78% were from living-unrelated donors. More than 50% of the living-unrelated kidney donors have been from the poor socioeconomic class of Iran. Terasaki and colleagues reported that although HLA compatibility determined outcome within any of the subgroups studied, totally mismatched or poorly matched organs from living-unrelated donors functioned as well as kidneys from matched cadaveric donors or haploidentical living-related donors in first transplantations.1,6 Compared with cadaveric donors, livingunrelated donors are free of general and kidney diseases. In addition, the recipients of kidneys from spousal donors may comply better with the immunosuppressive drugs and other treatments.6 Although the HLA matching is better with a cadaveric graft than with a spousal graft13,14 or a graft from another living-unrelated donor, the survival rates of unre-

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lated donors was almost 10% greater than that of cadaveric donors in our experience. We believe that this difference is related to the quality of the kidney. Kidneys from livingunrelated donors are certainly healthier compared with cadaveric ones. Kidney donation was more frequent from wife to husband in our center, similar to studies from other centers. There was no significant difference between graft survival rates in wife to husband and husband to wife kidney transplantations in accordance with previous patient studies.1,7 The high survival rate of spousal donors is probably related to the strong emotional support between them. In this type of donation, the couples are even together in the operating room, and further postoperative compliance will be ensured as both the recipient and the donor live together. Intercourse and pregnancy may also contribute to better spousal results by the way of prior antigenic presentation and possible desensitization. REFERENCES 1. Terasaki PI, Cecka JM, Gjerston DW, et al: High survival rates of kidney transplants from spousal and living unrelated donors. N Engl J Med 333:333, 1995 2. Spital A: Evolution of attitudes at U.S. transplant centers toward kidney donation by friends and altruistic strangers. Transplantation 69:1728, 2000 3. Haberal M, Gulay H, Tokyay R, et al: Living unrelated donor kidney transplantation between spouses. World J Surg 16:1183, 1992 4. Kikuchi K, Narumia Y, Hama K, et al: Kidney transplantation from spousal donors. Transplant Proc 32:1817, 2000 5. Mathieson PW, Jolliffe D, Jolliffe R, et al: The spouse as a kidney donor: ethically sound? Nephrol Dial Transplant 14:46, 1999 6. Soulillou JP: Kidney transplantation from spousal donors. N Engl J Med 333:379, 1995 7. Salahi H, Ghahramani N, Malek-Hosseini SA, et al: Religious sanctions regarding cadaveric organ transplantation in Iran. Transplant Proc 30:769, 1998 8. Ahmad E, Malekhosseini SA, Salahi H: Experience with 300 renal transplants in Shiraz, Iran. Transplant Proc 27:2767, 1995 9. Bhowmik D, Dash SC, Guleria S, et al: Spousal renal transplants: implications in developing countries. Transplant Proc 35:26, 2003 10. Jirasiritham S, Sumethkul V, Mavichak V, et al: Spouse donor kidney transplantation in Thailand. Transplant Proc 32:1600, 2002 11. Emiroglu R, Yagmurdura MC, Karakayali H, et al: Results with living-donor kidney transplants from spouses: 14 years of experience at our center. Transplant Proc 34:2060, 2002 12. Haberal M, Karakayali H, Moray G, et al: Results of living-unrelated donor kidney transplantation at our center. Transplant Proc 31:3124, 1995 13. Tang S, Lui SL, Lo CY, et al: Spousal renal donor transplantation in Chinese subjects: a 10 year experience from a single centre. Nephrol Dial Transplant 19:203, 2004 14. Pretagostini R, Rossi M, Lappelli M, et al: Survival in kidney transplantation from living donors: a single-center experience. Transplant Proc 36:467, 2004