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Table of Contents
ORIGINAL ARTICLE
Year : 2021  |  Volume : 15  |  Issue : 4  |  Page : 338-342

First single-center five-way kidney exchange cycle in India


1 Department of Nephrology and Transplantation Sciences, Institute of Kidney Diseases and Research Center, Dr. HL Trivedi Institute of Transplantation Sciences, Ahmedabad, Gujarat, India
2 Department of Transplantation Surgery, Institute of Kidney Diseases and Research Center, Dr. HL Trivedi Institute of Transplantation Sciences, Ahmedabad, Gujarat, India
3 Department of Obstetrics and Gynecology, Institute of Kidney Diseases and Research Center, Dr. HL Trivedi Institute of Transplantation Sciences, Ahmedabad, Gujarat, India

Date of Submission02-Jul-2021
Date of Acceptance03-Nov-2021
Date of Web Publication30-Dec-2021

Correspondence Address:
Dr. Vivek B Kute
Departments of Nephrology and Transplantation Sciences, Institute of Kidney Diseases and Research Center, Dr. HL Trivedi Institute of Transplantation Sciences, Ahmedabad, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijot.ijot_69_21

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  Abstract 

Objective: The logistical issues, limited resources, and surgical capacity are the challenges to simultaneous kidney exchange transplant surgeries in India. We report the first single-center 5-way nonsimultaneous kidney exchange cycle from India without donor renege. The challenges and solutions for the same are discussed. Methods: Five donor–recipient pairs (DRPs) participated in 5-way kidney exchange cycle after permission of Institutional and Gujarat State Level Authorization Committee for organ transplantation. Four DRP were ABO-incompatible and the fifth was compatible. Results: Two DRP were operated on November 22 and three on November 23, 2018. One bridge donor wait time was 1 day. All five recipients were discharged on November 30, 2018, without any medical or surgical complication; normal kidney allograft function and donor renege. We have increased chain length gradually from 2-way (June 2000), 3-way (February 2013), 4-way (April 2016), 5-way (November 2018), 6-way (February 2019), and 10-way (January 2020) in 440 kidney exchange transplants at our institute. We have used compatible pairs in gradually increasing chain length from 2-way (May 2012), 3-way (August 2013), 4-way (July 2018), 5-way (November 2018), and 6-way (February 2019) to increase transplant for difficult to match pairs. Conclusions: To the best of our knowledge, this is the first single-center 5-way kidney exchange cycle from India. Increasing chain length has the potential to offer better quality of matching and transplants rates for difficult-to-match pairs in kidney exchange.

Keywords: Donor–recipient pairs, kidney exchange, living donor kidney transplantation


How to cite this article:
Kute VB, Meshram HS, Patel HV, Engineer D, Banerjee S, Chauhan S, Navadiya VV, Patel H, Gupta A, Rizvi J, Mishra VV. First single-center five-way kidney exchange cycle in India. Indian J Transplant 2021;15:338-42

How to cite this URL:
Kute VB, Meshram HS, Patel HV, Engineer D, Banerjee S, Chauhan S, Navadiya VV, Patel H, Gupta A, Rizvi J, Mishra VV. First single-center five-way kidney exchange cycle in India. Indian J Transplant [serial online] 2021 [cited 2022 Aug 10];15:338-42. Available from: https://www.ijtonline.in/text.asp?2021/15/4/338/334436




  Introduction Top


Majority of kidney transplantations in India are from living donors as there is the shortage of organs from deceased donors. Kidney exchange, ABO-incompatible transplantation, and desensitization protocols are the ways to expand the donor pool. Kidney exchange transplantation has the best long-term patient and graft survival. Kidney exchange transplantation is recently increased in developing countries such as India.[1],[2],[3],[4],[5],[6],[7],[8] In developed countries, nonsimultaneous kidney exchanges are common.[9],[10],[11],[12],[13],[14],[15],[16] The challenges in expanding kidney exchange in India are lack of awareness, legal, and logistical issues including the large surgical team required to carry out simultaneous transplant surgery. We report the first single-center 5-way nonsimultaneous kidney exchange cycle from India and discuss challenges and solutions for the same.


  Methods Top


All transplants were performed as per the Transplantation of Human Organs and Tissues Act, India. We also abided by the Declaration of Helsinki and Declaration of Istanbul principles. The study was reviewed by the appropriate ethics committee. The five donor–recipient pairs (DRPs) consented to participate in nonsimultaneous surgery after nonanonymous allocation and exchange of kidneys of similar quality. Robust immunological compatibility was documented by negative complement-dependent lymphocytotoxicity crossmatch, flow crossmatch, and Luminex single-antigen donor-specific antibody in all pairs. This has the potential to prevent unequal outcomes due to immune injury after transplant. They also underwent psychological evaluation during medical fitness by multidisciplinary transplant team. These DRP was domicile of five different states of India (Bihar, Gujarat, Uttar Pradesh, Maharashtra, and Rajasthan). We required 1-week time to take legal permission for transplantation. Four DRP needed to wait for 3 weeks due to pretransplant dialysis catheter-related infection in the fifth pair. No other better suitable DRP were available in our registry during the same timeline for the remaining four DRP. The multidisciplinary transplant team reconfirmed the transplant fitness of five DRP on November 21, 2018, and was admitted before starting 5-way cycle.

Transplant human organ act, India and kidney exchange

Transplant Human Organ Act, India (THOA) 2011 amendment gives legal permission for kidney exchange also called swap transplantation in India. However, transplant hospitals were required to take permission for kidney exchange transplantation from State Level Authorization Committee for organ transplant of other states when DRP was from other states. We usually required 1–3 months for taking such regulatory permission. This was the reason for prohibiting long cycle kidney exchange in our program when DRP was from other states. We have earlier reported 3-way, 4-way, and 6-way kidney exchange of pairs from different states where there was delay in taking legal permission from their different states as per THOA requirement. THOA 2014 amendment reported that hospital, district, and state can give permission for kidney exchange transplantation from near relatives when DRP is from different states. There is no need to take permission from all the states when DRP is from different states. The state of Gujarat adopted this amendment in 2018 giving the permission for this 5-way kidney exchange. Before the adoption of this amendment in November 2018, we used to take permission for kidney exchange from other states when pairs are from states other than Gujarat. The participation from DRP of other states increased in our center after implementing the THOA 2014 amendment leading to early transplants. Thereafter, we also performed 6-way and 10-way kidney exchange cycles in February 2019 and January 2020 of DRP from different states in India.

Transplantation in the digital era and role of social media platforms

Five DRP despite being from five different states came to our transplant center through information about kidney exchange from social media platforms. It can be as effective tool to promote organ donation and expand living donor transplantation in countries with limited resources for transplantation. Increasing the use of social media among transplant professionals may provide an opportunity to deliver high-quality information to patients.[17]

Telemedicine: An enabler of health-care access and affordability in India

It was challenging to provide in-person healthcare for these 5DRP, particularly given the large geographical distances and limited resources during the COVID-19 pandemic scenario. Telemedicine increased timely access to appropriate monitoring including faster access and access to services that may not otherwise be available.[18] It has also reduced financial costs associated with travel. It also reduces the inconvenience to DRP and caregivers and social factors. Telemedicine has played a particularly important role for regular, routine checkups, or continuous monitoring.

Statistical analysis

Statistical analysis was performed using the Statistical Package for Social Science (SPSS) version 17.0 (SPSS Inc., Chicago, IL).

Patient consent

The patient consent has been taken for participation in the study and for publication of clinical details and images. Patients understand that the names and initials would not be published, and all standard protocols will be followed to conceal their identity.

Ethics statement

Ethical approval for this study was obtained from IKDRC-ITS Ethics Committee Number IKDRC-ITS EC/App/01 Oct 20/04. All transplants were performed as per Transplant human organ act, India. We also abided by the Declaration of Helsinki and Declaration of Istanbul principles.


  Results Top


At our institute, 4558 living donor kidney transplants (LDKTs) and 920 deceased donor kidney transplantations were performed between January 2000 and March 2020, 440 (9.6%) using kidney paired exchanges. There were 164 two-way (n = 328), 23 three-way (n = 69), 4 four-way (n = 16), 1 five-way (n = 5), 2 six-way (n = 12), and 1 ten-way kidney exchange (n = 10). With increasing experience, the chain length was gradually increased from 2-way (June 2000), 3-way (February 2013), 4-way (April 2016), 5-way (November 2018), 6-way (February 2019), and 10-way (January 2020) kidney exchange. We have successfully performed 38 and 67 nonsimultaneous single-center kidney exchange transplants between August 2015–December 2018 and August 2015–March 2020 without donor renege.

The demographics and outcome of 5-way kidney exchange cycle are shown in [Table 1], [Table 2], [Table 3], [Table 4].
Table 1: Demographic characteristics of recipients

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Table 2: Demographic characteristics of donor

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Table 3: HLA of recipient and donor

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Table 4: Surgical details and outcome

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Four DRP were ABO incompatible. Fifth was compatible pair who was ultimately benefitted by 50% better human leukocyte antigen (HLA) matching at the A, B, and DR (B1, B3, B4, B5, and DQ1) loci with donor of similar age (40 years). Waiting time for compatible pair was 2 weeks to allocate better-matched donor. Baseline ABO titers were ≥1:512 for ABO-incompatible pairs and our transplant center usually do not perform ABO-incompatible transplants for such high ABO titers and economic contains was other additional limiting factor. All the donors underwent laparoscopic donor nephrectomy. Two pairs were operated on November 22 and three pairs on November 23, 2018 [Figure 1]. One bridge donor wait time was 1 day. All five recipients were discharged on the same day (November 30, 2018) without any medical (biopsy-proven rejection and slow/delayed graft function) or surgical (bleeding, lymphocele, and vascular thrombosis) complications with normal kidney allograft function and donor renege. One diabetic patient died at 6 months after transplant with functioning kidney allograft due to dental infection leading to sepsis. The graft survival was 100% at the last follow-up in March 2021, with mean serum creatinine of 1 mg/dl. DRP continues to meet each other as friends before and after surgery. The donor survival is 100% without any adverse effect of donation at 18-month follow-up. Unfortunately, all the recipients were males and all the donors were females. This is not related to kidney exchange but is common to overall LDKT scenarios in India. The various socioeconomic and cultural reasons contribute to this gender disparity.
Figure 1: Five-way kidney exchange cycle using one bridge donor

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  Discussion Top


This is the first report of a single-center 5-way nonsimultaneous kidney exchange cycle from India. The bridge donor wait time was only 1 day, and the medical fitness and willingness of pairs were double-checked before starting nonsimultaneous kidney exchange cycle. The nonanonymous allocation increases trust in DRP and Hospital team. Cowan et al. reported low donor to renege rate of 1.5%. Our study supports that donor renege is more hypothetical than real-world problem in carefully selected cohort.

The nonsimultaneous extended altruistic donor chain and modified sequence asynchronous transplant chain and deceased donor initiated kidney exchange chain are other strategies to expand the donor pool in kidney exchange. The altruistic or deceased donor can be used to repair broken chain due to donor renege.

There is no published data on kidney exchange from Bihar, Uttar Pradesh, and Rajasthan. (Apex Swap Transplant Registry), Mumbai, Maharashtra, reported their experience of the first domino swap transplant in India in June 2013. Surgeries were performed simultaneously in three private hospitals of Mumbai (Bombay Hospital, Hinduja Hospital, and Hiranandani Hospital) on June 25, 2013. They reported that 24 months were required to complete the first domino swap transplant including long time which was required for legal permission from Rajasthan Transplant Authorization Committee.

The bridge donor is the person who is trusted to donate the kidney after his/her recipient has received the transplant. We have used one bridge donor (Donor 2) who donated kidney 1 day later on November 23, 2018, after her recipient has received the kidney on November 22, 2018.

The success of nonsimultaneous kidney exchange surgery depends on careful selection of DRP after counseling of risk and benefit of nonsimultaneous surgery, minimum bridge donor wait time, and DRP medical fitness reconfirmation before starting nonsimultaneous surgery. High-risk recipients such as diabetics with heart disease and highly sensitized recipients should be operated on first and should not be dependent on bridge donors. Mechanism to repair broken chain in case of donor renege should be in place.

Why we planned longer chain over short chain

Increasing chain length has the potential to offer better quality of matching and transplants rates for difficult-to-match pairs. The quality of matching for donor age and HLA matching was inferior in the shorter cycle of 2- or 3-way, so we planned to perform longer 5-way cycle. As per THOA 2014 amendment, we were able to get permission from Hospital and State Level Authorization Committee for kidney transplants, and pairs were not required to bring legal permission from different states. This reduces pretransplant dialysis and waiting time preventing morbidity and mortality and chain collapse.

Why we planned nonsimultaneous single-center kidney exchange cycle

There is no national kidney exchange program in India. The multicenter kidney exchange practice is not common in India due to various reasons including logistics and lack of harmony in different transplant centers. There is only one report of multicenter simultaneous kidney exchange of five DRP in India.[8] We have successfully performed 33 nonsimultaneous single-center kidney exchange cycles from August 2015 onward without donor renege. This zero percent donor renege boosted our confidence for this 5-way nonsimultaneous single-center kidney exchange cycle.

What are keys to success in nonsimultaneous single-center kidney exchange cycle?

Anonymous allocation in the kidney exchange program is the standard practice in developed countries.[19] However, in developing countries like India, nonanonymous allocation is the standard of care. The nonanonymous allocation increases trust and transparency between DRP, transplant team, and administrative team. DRP could meet before and after transplant and share the medical reports and outcome. 90% of DRP preferred nonanonymous allocation over anonymous allocation.[2] The dedicated transplant team helps DRP at all levels (medical fitness, taking legal permission from the Government, arranging economic support from Government-sponsored schemes, and social support with rehabilitation of DRP). Hence, nonanonymous allocation was the principal determinant of our success.

Future plan

Deceased donor initiated nonsimultaneous kidney exchange chain is where standard criteria deceased donor can be allotted to difficult to match recipient such as highly sensitized patient who is unlikely to receive living donor kidney exchange. The easy-to-match pairs such as A patient with B donor or B patient with A donor or patient with O donor should be excluded from deceased donor initiated kidney exchange as they can get living donor kidney in short waiting time even in single-center program.

At present, THOA allows only near relatives for kidney exchange and does not allow the use of nondirected altruistic donors to initiate nonsimultaneous kidney exchange or repair broken chains in case of donor renege. We suggest amendment in THOA for use of altruistic donor to initiate nonsimultaneous kidney exchange or repair broken chains in case of donor renege. The limited surgical team for simultaneous surgery is the main limitation in India to perform longer chain in kidney exchange.


  Conclusions Top


To the best of our knowledge, this is the first single-center 5-way nonsimultaneous kidney exchange cycle from India. Increasing chain length has the potential to offer better quality of matching and transplants rates for difficult-to-match pairs.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Kute VB, Shah PS, Vanikar AV, Gumber MR, Patel HV, Engineer DP, et al. Increasing access to renal transplantation in India through our single-center kidney paired donation program: A model for the developing world to prevent commercial transplantation. Transpl Int 2014;27:1015-21.  Back to cited text no. 1
    
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Kute VB, Patel HV, Shah PR, Modi PR, Shah VR, Rizvi SJ, et al. Impact of single centre kidney paired donation transplantation to increase donor pool in India: A cohort study. Transpl Int 2017;30:679-88.  Back to cited text no. 2
    
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Kute VB, Patel HV, Shah PR, Modi PR, Shah VR, Rizvi SJ, et al. Seventy-seven kidney paired donation transplantations at a single transplant centre in India led to an increase in living donor kidney transplantations in 2015. Clin Kidney J 2017;10:709-14.  Back to cited text no. 3
    
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Kute VB, Patel HV, Shah PR, Modi PR, Shah VR, Trivedi HL. A potential solution to make the best use of a living donor-deceased donor list exchange. Am J Transplant 2016;16:3580.  Back to cited text no. 4
    
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Kute VB, Agarwal SK, Sahay M, Kumar A, Rathi M, Prasad N, et al. Kidney-paired donation to increase living donor kidney transplantation in India: Guidelines of Indian Society of Organ Transplantation-2017. Indian J Nephrol 2018;28:1-9.  Back to cited text no. 5
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Travasso C. Five patients benefit from India's first “domino” kidney swap. BMJ 2013;347:f4260.  Back to cited text no. 7
    
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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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