PREDICTORS OF EARLY AND DELAYED GRAFT FUNCTION IN LIVE AND CADAVERIC RENAL TRANSPLANTATION

Background: Kidney transplantation gives the best quality of life to chronic kidney disease patients and also increases longevity. Aim: Analysis of factors responsible for the early and delayed graft functioning in live and cadaver renal transplants Patients and Methods: It was a retrospective observational study. Donor and recipient age, sex, BMI, comorbid illness, and functioning status of the donor kidney, duration and severity of chronic kidney disease and associated bladder disorders were collected. Operative factors like perfusion time, cold ischemia time, blood pressure fall, need for blood transfusion, vasopressor support was recorded. Patients were divided into two groups based on early versus delayed graft function. Results: 27 cases of Live donor renal transplant and 23 cadaver transplants were included. The average age in live donor and cadaveric transplants was 43.5 ±7.6 years and 38.3 ±10.5 years, respectively. 24 Live Transplant Recipients had Early Graft function (89%). Seven Cadaveric Transplant Recipients had Early Graft function (31%) and 16 of them had Delayed Graft Function (69%). HLA Mismatch, Perioperative Hypotension and BMI of recipient had statistically significant relationship to Early Graft Function with p values of 0.02, 0.004 and 0.007, respectively. With p-value of 0.021 and of 0.046, respectively, perioperative hypotension and cold ischemic time in Cadaveric renal transplantation had statistically significant relationship to Early Graft Function. Conclusion: Live donor transplants have better early graft function. HLA Mismatch, Perioperative Hypotension, BMI of recipient and cold ischemic time in Cadaveric renal transplantation are the predictors of early graft function.


Introduction:
hronic Kidney disease (CKD) is one of the major cause of mortality and morbidity in the world today. Diabetes mellitus, Hypertension and Glomerulonephri s are the leading causes of chronic kidney disease 1 . The Kidney Disease Outcomes Quality Ini a ve (KDOQI) and the interna onal guideline group of Kidney Disease Improving Global Outcome (KDIGO) have defined chronic kidney disease as either kidney damage or decreased Glomerular filtra on rate (GFR) of less than 60ml/min/1.73m2 for at least 3 months 2 . Different op ons for Renal Replacement Therapy (RRT) include peritoneal dialysis (PD), intermi ent haemodialysis (IHD), sustained low-efficiency dialysis (SLED), extended daily dialysis (EDD) and con nuous renal replacement therapy (CRRT) and Renal transplanta on 3 . Out of these, kidney transplanta on C satihal, s., reddy, s. K., qazi, i. A., devraj, r., sss, d. Predictors of early and delayed graft function in live and cadaveric renal transplantation. Basrah Journal of Surgery, 2022; 29(1): 4-14. doi: 10.33762/bsurg.2022.135361.1029 5 gives the best quality of life and probably also increases longevity 4 . There are two main types of renal transplanta on; live renal transplanta on and cadaver renal transplanta on. in the past 45 years, the live donor kidney transplanta on program in India has evolved. It is currently the second largest program in numbers a er the USA 5 . The prevalence of end-stage renal disease which requires transplanta on in India is es mated to be between 151 and 232 per million popula on 6 . Approximately 220,000 people require kidney transplanta on in India. Against this, currently, approximately 7500 kidney transplanta ons are performed at 250 kidney transplant centres in India. Of these, 90% come from living donors and 10% from deceased donors. Transplanta on is an example of a mul -disciplinary team approach involving not only urologists and nephrologists but also anaesthe sts and pathologists working in concert to produce the best results for the pa ent 7 . Despite being done with good surgical exper se and proper nephrological management, some cases of renal transplant recipients do not achieve the long term expected gra func on. One of the factors predic ng the long term gra func oning is the evalua on of early gra func on one week a er transplant 8 . In our study, we analyzed various factors responsible for the early and delayed gra func oning of both live and cadaver renal transplants.

Pa ents And Methods:
It was a retrospec ve observa onal study conducted in our ins tute at the department of urology for 2 years. All the pa ents undergoing renal transplanta on during the study period were included in the study, except those pa ents who had undergone previously failed transplanta on. The study was conducted a er taking approval from the ins tu onal ethical commi ee. The data collected included Donor and Recipient age, sex, BMI, comorbid illness, blood group match, the func oning status of the donor kidney (renogram), dura on and severity of chronic kidney disease, and associated bladder(cystogram) disorders. Various opera ve factors like perfusion me, cold ischemia me, type of perfusion solu on, perfusion before versus a er bench dissec on, and anastomosis me were also noted. Some inadvertent factors like blood pressure fall, need for blood transfusion, and vasopressor support was recorded. In this study, we analyzed recipient factors which can cause delayed gra func oning and mainly the factors responsible from the urological standpoint were studied. Then the serum crea nine at the end of the first-week posttransplant and/or the need for dialysis were all recorded. Pa ents were divided into two groups (Group A & B) based on early versus delayed gra func on. The above data collected was analyzed. Chi-squared test was used to test the strength of associa on and a p-value of <0.05 was considered sta s cally significant. Sta s cal analysis was done using SPSS version 26.

RESULTS:
Fifty patients underwent renal transplantation which included 27 cases of Live related renal transplants and 23 cadaver transplant (Deceased Brain donor) cases. The demographic profile of the patients is shown in Table I.

Tables 1:Demographic Profile Of Donor And Receipt :
The average age of the live transplant donor was 43.5 years with a standard deviation (SD) of 7.

and Early Graft function in Live related Renal Transplantation
Most of the biopsies done in recipients (66%) with delayed graft function were found to have Acute tubular necrosis Table IV.    [21] the main cause of DGF was acute tubular necrosis (ATN) in 88% of cases, and acute rejection in 8% of cases. Similarly in a study by Y K Swami et al [14], ATN was observed in 50% of cases of DGF.
Conclusion: DGF in the immediate postoperative period necessitates the use of dialysis which adds a significant cost impact to patient management, also complicating posttransplant management as an outpatient. Thus, achieving early graft function is of paramount importance. Avoiding Perioperative Hypotension, optimizing the BMI of the recipient, and Decreasing Cold ischemia time in Cadaveric transplant will improve the early graft function in Live transplants. Cold ischemia time can be significantly reduced with good coordination between organ retrieval and transplant teams. Every effort should be made to minimize the effect of these factors to optimize the Early Graft function and improve the overall outcome of Renal transplantation.