Outcome of living-related donor renal allografts in hepatitis C antibody-positive recipients

Renal transplantation in developing countries

Healthcare in developing countries less funded than developed nations (0.8 to 4% vs. 10 to 15%, respectively), and must contend against approximately 1/3 of the population living below the poverty line ($1US/day), poor literacy (58% males/29% females), and less access to potable water and basic sanitation. Cultural and societal constraints combine with these economic obstacles to translate into poor transplantation activity. Donor shortage is a universal problem. Paid donation comprises 50% of all transplants in Pakistan. Post-transplant infections are a major problem in developing countries, with 15% developing tuberculosis, 30% cytomegalovirus, and nearly 50% bacterial infections. The solutions to these problems may seem simplistic: alleviate poverty, educate the general population, and expand the transplant programs in public sector hospitals where commerce is less likely to play a major role. The SIUT model of funding in a community-government partnership has increased the number of transplantations and patient and organ survival substantially. Over the last 15 years, it has operated by complete financial transparency, public audit and accountability. The scheme has proven effective and currently 110 transplants/year are performed, with free after care and immunosuppressive drugs. Confidence has been built in the community, with strong donations of money, equipment and medicines. We believe this model could be sustained in other developing nations.

Posttransplant infections in the tropical countries

Over half of all renal transplant recipients in the tropical countries develop a serious infection at some point in the posttransplant period and 20% to 40% of them succumb to these infections. Many of these infections are endemic to the region. A multitude of factors including unhygienic conditions, hot and humid climate, late presentation, lack of knowledge about the spectrum of organisms in these areas, scanty diagnostic techniques, and high cost of lifesaving antimicrobial agents contribute to this dismal outcome. Tuberculosis is observed in 10% to 15% of transplant recipients. Pleuropulmonary disease is most frequent, but the commonly employed tests are seldom helpful in the diagnosis. Bronchoalveolar lavage is very sensitive in early detection of this infection and allows timely institution of specific therapy. Hepatitis virus infections are generally acquired before transplant, and viral replication is accelerated under the effect of immunosuppressive therapy leading to chronic liver disease. Cytomegalovirus (CMV) disease has shown a fourfold increase after introduction of cyclosporine to the immunosuppressive regimes at our center. Coinfection with other bacteria or fungi is frequent in CMV-infected allograft recipients. Opportunistic fungal infections are seen in less than 10% of allograft recipients, but this figure is likely an underestimate. The frequently encountered fungal infections include Candida, Aspergillus, Cryptococcus, and Mucor. Fungal infections carried a high mortality of over 65% at our center. The protean manifestations of the opportunistic infections and nonavailability of sensitive diagnostic tests in most centers in the underdeveloped countries often delay the diagnosis and institution of therapy.