Clinical Profiles and Outcomes of Kidney Transplant Recipients in Kenyatta National Hospital: a Retrospective Analysis Between 2010 and 2019

Abstract

Study Background Kidney transplant confers a significant survival advantage over long-term dialysis but overall survival is lower than age-matched controls in the general population. Negative long-term outcomes of kidney transplantation still occur even with the improved access to healthcare, medication and diagnostics. This study sought to establish the recipient clinical profiles, status of allografts after transplant and their relationships over a 10 year period. Objective The primary objective was to establish the clinical profiles and outcomes of kidney allograft recipients and their relationships. Secondary objectives were to establish any relationships of haemodialysis vintage, human leukocyte antigens (HLA( -A, -B and –DRB1 matches, medication used, morbidities before and after transplant with allograft outcomes. Study design and site This was a retrospective chart file review study on kidney transplant recipients at the KNH from 2010 to 2019. Participants and Methods Single-centre, retrospective cohort study involving 125 adult living related donor kidney transplants (LRDKTs) performed between January 2010 and December 2019. Files of recipients above the age of 18 years who had the kidney transplant done at the Kenyatta National Hospital (KNH) and were on follow up in the transplant clinic were included in the analysis. The data collected included the recipients’ and donors’ demographics, recipient clinical data including morbidities before and after transplant, HLA-A, -B, -DRB1 match, ABO blood grouping, medication used for induction and clinical status and survival of the recipients and allografts at the time of the last documented medical review. This data was collected from existing file records and entered into a study proforma. Results Donors were young with a mean age of 35.8±8.4 years, predominantly male at 55.2% and 84% were first degree relatives to the recipients. Donors were predominantly blood group O at 69.6% with blood group AB being the lowest recorded at 1.6%. Recipients were young with a mean age of 39.4±11.9 years and predominantly male at 72.8%. The average body mass index (BMI) among the recipients was 21.5±3.3kg/m2. Recipients xv were mostly blood group O at 60% and blood group A being 20%. Comorbid conditions documented among the recipients prior to transplant were hypertension (86.4%), diabetes (22.4%), obstructive uropathy (2.4%), chronic glomerulonephritis (37.6%) and autoimmune diseases (0.8%). The HLA matches were 11.2% at zero match, 10.4% at one match, 18.4% at two match, 23.2% at three match, 12.0% at four match, 2.4% at five match and 11.2 were haploidentical. Immunosuppresant agents used pre transplant included basiliximab in 50(40%) of recipients, tacrolimus in 32.8% and cyclosporine in 67.2% with solumedrol and prednisone used in all recipients. Post-transplant any change in calcineurin inhibitor was noted in 13(10.4%) and any change of antimetabolite was noted in 10(8%) of recipients. Post-transplant comorbid conditions included hypertension in 86.4%, diabetes of new onset after transplant in 14.4%, infections including tuberculosis noted in 11(8.8%)and cytomegalovirus disease in 15(12.0%). Acute dysfunction including acute rejection noted in 37.6, Kaposi sarcoma was documented in 3.2% of recipients and cardiovascular conditions (stroke in 1.6% and myocardial infarction in 2.4%). The estimated glomerular filtration rate (eGFR) improved from the moment of transplant and settled at the sixth month at a mean of 62.4 ml/min/1.73m2. Allograft survival and recipient survival was 90.4% at the end of the first year, at the fifth year allograft survival was 64%and the ten year allograft survival was 37.2% respectively. Among the conditions that were associated with poor allograft survival included allograft dysfunction and tuberculosis. The use of basiliximab used in recipients who had an HLA match of less than 50% was associated with a similar survival in comparison to the recipients who did not receive it as part of their treatment while the use of cyclosporine as part of induction had better allograft survival. Conclusion Donors and recipients were young and predominantly male with first degree relationships and were within normal BMI limits. The recipient age, haemodialysis vintage, HLA match, pre and post-transplant comorbidity, infections and malignancy state did not impact allograft survival. There was a trend for male sex having a better allograft survival but it was not significant. The use of immunosuppressant medication impacted positively on allograft survival and reinforces the need for these medications on a long term basis. Cyclosporine was found not to be inferior on allograft survival when compared to tacrolimus. The limitation of this study was being a single centre retrospective study with limitation on retrieval of medical records that could have led to a sampling bias. It is our recommendation that the use of basiliximab be supported in kidney transplant recipients with less than 50% match as it has allograft survival similar to recipients who do not receive it due to better HLA match. We also xvi recommend that this LRKDT program is a viable treatment modality with improving allograft survival so the modality should be encouraged and supported.