The Effect Of Pretransplant Liver Function On The Short Term Outcome Of Renal Transplanta In Patients With Chronic Renal Faliure:

Ramadan Fouad Arafa

Liver disease is one of the leading causes of death in long-term survivorsafter kidney transplantation. Chronic liver disease is a frequent complicationaffecting about 15 % of renal allograft recipients. Infection by hepatitis B and Cviruses is the predominant cause of hepatic dysfunction in these patients.Hepatic cirrhosis and clinically active hepatitis due to HBV and HCV infectionclearly contraindicate kidney transplantation. More controversial is the attitudeto be adopted towards candidates with clinically quiescent chronic HBV orHCV. It was proved by many authors that schistosomiasis does not affect shortas well as long-term outcome of kidney transplantation.In an attempt to study the impact of pretransplant liver dysfunction andetiology of liver disease on the short-term outcome of renal transplantation, weprospectively followed up 75-end stage renal disease patients on regularhemodialysis and arranged for living donor kidney transplantation at MansouraUrology and Nephrology Center from the pre- to post-transplant period.The patients were classified into two main groups:Group (1): twenty-five patients with healthy liver considered a control groupGroup (2): fifty patients with abnormal liver function of different etiologies.So, they were subclassified into:Subgroup (a): patients with HCV antibodies and I or HCV RNA positive(28 patients); (i) Treated by interferon (before transplantation): 16 patientsand (ii) Non-treated by interferon: 12 patientsSubgroup (b): patients with mixed HCV and HBV infection (5 patients).Subgroup (d: patients with mixed HCV and schistosoma! infection (8patients).Subgroup (d): patients with Schistosomiasis (9 patients)We noticed high sustained response to IFN in HCV viremic haemodialysispatients (68.2 %) which is much better than non-uremic HCV positive patientsand only one patient turned HCV RNA positive after renal transplantation. Also,we found that HCV patients treated by IFN as well as pure schistosomal renalallograft recipients had excellent graft function during the period of follow upand significantly better than other groups. Moreover, number of rejectionepisodes was nearly equal to the control group.Also, we found that HCV (not treated by lFN) showed non-significantelevation of serum creatinine especially during the first 8 months after kidneytransplantation. However, after that, serum creatinine DROPped and was nonsignificantlydifferent from the control group.The mixed HCV and HBV infection group showed significant pretransplantimpaired liver function in comparison to control group. After kidneytransplantation, serum creatinine was non-significantly higher than controlgroup especially during the first year after transplantation. Moreover, thenumber of rejection episodes was non-significantly higher than control group.Unfortunately, mixed HCV and schistosomiasis group had bad results.Only 2S % did not experience rejection, 2S % experienced 2 episodes and 50 %experienced more than 3 rejection episodes during their follow up period. Theirserum creatinine ranged from 1-12 mg / dl (mean 2.S mg / dl) versus 0.6-3.4 mg/ dl (mean 1.24 mg /dl) in control group. Also, their serum creatinine reached itspeak in the 7th month (4.94 versus 1.5 mg /dl). Moreover, number of rejectionepisodes was nearly double that of control group (2.38 versus 1.24) but it wasnon-significant due to high standard deviation.None of our patients developed fulminant hepatitis or chronic liverdisease.In summary, our presented data confirmed that IFN is highly effective inmanagement of pretransplant HCV infection which may contribute to betterpost-transplant graft function. Neighther HCV nor schistosomiasis affect theshort term out come either of the patients or of the graft survival after kidneytransplantation. Mixed HCV and HBV may cause more susceptibility to earlypost-transplant graft impairment and more rejection episodes. Also, mixed HCYand schistosomiasis was associated with post-transplant graft impairment. So, itcarries a high risk to patients as well as graft survival after kidneytransplantation.We conclude that problems occurring in renal transplant recipients must bediagnosed as early as possible to avoid either irreversible rejection or a rapidlyfatal outcome: the management of these patients appears to be one of the mostimportant factors for the long term success of an allograft. Such managementmust be performed by a well-trained clinical and laboratory consultants. Onemust keep in mind that an otherwise benign disease can be rapidly lethal in atransplant recipientAgain, we conclude that pre-transplant treatment of HCY in chronic renalfailure patients by interferon is highly effective in management of pretransplantHCY infection which may contribute to better post-transplant graft function.Also, patients with mixed HCY and Schistosomal infection are liable to badpost-transplant results either in the patient or the graft survival.We recommend IFN therapy for HCY RNA positive haemodialysispatients and caution must be taken in renal transplantation to patients withmixed HCY and Schistosomiasis. Further studies are needed to complete thiswork, to detect the possible pathogenesis of impaired graft survival in mixedHCY and schistosomiasis patients and postulation of new regimens ofimmunosuppression therapy suitable to these patients as well as closemonitoring of graft function after kidney transplantation.