Preemptive living donor kidney transplantation: Access, fate, and review of the status in Egypt

Table 1 A comparison of the demographic and clinical characteristics of the patients with preemptive access to kidney transplantation and those with conventional access to kidney transplantation, n (%)

Variables	PAKT, n = 32	CAKT, n = 272	P value
Age in yr, mean ± SD (range)	31.7 ± 13 (13-60)	32.1 ± 11.5 (12-66)	0.677
Sex
Men	22 (68.8)	213 (78.3)	0.263
Women	10 (31.2)	59 (21.7)
Primary kidney disease
Glomerulonephritis	3 (9.4)	8 (2.9)	< 0.001
Hereditary disease	3 (9.4)	6 (2.2)
Obstructive uropathy	4 (12.5)	8 (2.9)
Systemic disease	4 (12.5)	14 (5.2)
Urolithiasis	3 (9.4)	7 (2.6)
Unknown	15 (46.9)	229 (84.2)
Number of potential donors1
Patients presented without donors	8 (25)	36 (13.2)	0.088
With one donor	17 (53.1)	187 (68.8)
With two donors	4 (12.5)	40 (14.7)
With three donors	3 (9.4)	9 (3.3)
Donor evaluation	24	236
Patients with evaluated donors	20	194
With accepted donor(s)	10 (50)	89 (45.9)	0.232
With one donor excluded	7 (35)	75 (38.7)
With two donors excluded	0 (0)	15 (7.7)
With three donors excluded	1 (5)	2 (1)
With excluded and accepted donors	2 (10)	13 (6.7)
Number of not evaluated donors per patient	6	56
One donor	3 (50)	51 (91.1)	0.024
Two donors	3 (50)	4 (7.1)
Three donors	0 (0)	1 (1.8)
Order of the accepted donor	12	102
First	10 (83.3)	87 (85.3)	0.634
Second	1 (8.3)	11 (10.8)
Third	1 (8.3)	4 (3.9)
Accepted donor age (yr), mean ± SD (range)	38.1 ± 9 (25-53)	40.6 ± 10.4 (21-60)	0.39
Patient-donor relatedness degree
First	5 (41.7)	55 (53.9)	0.234
Second	5 (41.7)	40 (39.2)
Third	1 (8.3)	6 (5.9)
Unrelated	1 (8.3)	1 (1)
Sex of accepted donors
Women	7 (58.3)	66 (64.7)	0.754
Men	5 (41.7)	36 (35.3)
Accepted donor commitment
Donated	4 (33.3)	55 (53.9)	0.171
Regressed	1 (8.3)	16 (15.7)
Released	7 (58.3)	31 (30.4)
Number of excluded donors per patient
One donor	7 (77.8)	84 (80)	0.262
Two donors	1 (11.1)	19 (18.1)
Three donors	1 (11.1)	2 (1.9)
Main causes of donor exclusion
Medical causes	1 (10)	51 (51.5)	0.027
Immunologic mismatch	7 (70)	34 (34.3)
Combined medical and immunologic	2 (20)	14 (14.1)
Main causes of donor release	5	28
Financial causes	0 (0)	3 (10.7)	0.235
Patient death	0 (0)	3 (10.7)
Patient non-candidacy	0 (0)	10 (35.7)
Patient regression	5 (100)	12 (42.9)
Achievement of kidney transplantation
Failed	25 (78.1)	191 (70.2)	0.568
Transplanted in our center	4 (12.5)	55 (20.2)
Transplanted in another center	3 (9.4)	26 (9.6)
Cause of non-achievement of transplantation in our center	28	191
Donor exclusion	8 (28.6)	88 (40.6)	0.035
Donor regression	1 (3.6)	16 (7.4)
Donor unavailability	7 (25)	37 (17.1)
Financial causes	1 (3.6)	13 (5.6)
Patient non-candidacy	0 (0)	25 (11.5)
Patient death	0 (0)	5 (2.6)
Patient regression	11 (39.3)	33 (15.2)
Fate of recipients who failed to have transplantation in our center
Death	0 (0)	13 (6)	0.213
On hemodialysis	24 (85.7)	147 (67.7)
Transplantation in another center	3 (10.7)	26 (12)
Unknown	1 (3.6)	31 (14.3)

¹The headings of the donor evaluation and non-evaluation may include overlapping numbers due to different outcomes of the evaluation of multiple donors, resulting in non-complementary values relative to the total number of patients in both groups.

CAKT: Conventional access to kidney transplantation; PAKT: Preemptive access to kidney transplantation; SD: Standard deviation.

Table 2 Detailed characteristics and fate of patients with preemptive access to kidney transplantation, n = 32

Case Number	Age in yr	Sex	No. of Potential donors relatedness	Primary kidney disease	Serum creatinine in mg/dL	Stage of CKD, eGFR as mL/min/ 1.73 m2	PLDKT receipt	Cause of cancelled PLDKT	Fate of the patient
Case 1	48	Male	3 (Wife, Sister, daughter)	Unknown	8.5	5 (7)	None	Donor exclusion	On HD for 20 m then CLDKT in our center
Case 2	25	Male	1 (Mother)	CMU	5.5	5 (14)	None	Donor exclusion	On HD for 62 m
Case 3	28	Male	3 (Brothers)	Unknown	8.2	5 (8)	None	Patient regression	On HD for 74 m
Case 4	59	Female	2 (Sons)	Diabetic nephropathy	5.4	5 (11)	None	Patient regression	On HD 75 m
Case 5	47	Male	2 (Unrelated)	ADPCKD	4.8	5 (14)	Yes	NA	Living with a functioning graft for 68 m
Case 6	26	Male	1 (Brother)	Urolithiasis	7.8	5 (9)	None	Patient regression	On HD then lost to follow up
Case 7	27	Male	1 (Aunt)	Unknown	6.9	5 (10)	None	Patient regression	On HD then CLDKT in another center
Case 8	38	Male	1 (Unrelated)	ADPCKD	7.4	5 (9)	None	Donor exclusion	On HD for 34 m
Case 9	22	Female	None	Unknown	4.8	5 (12)	None	Donor unavailability	On HD for 33 m
Case 10	19	Female	None	Unknown	3.5	4 (19)	None	Donor unavailability	On HD for 24 m
Case 11	24	Male	None	GN	4.4	4 (18)	None	Donor unavailability	On HD then lost to follow-up
Case 12	13	Male	1 (Mother)	Congenital VURD	4.6	4 (18)	Yes	NA	Died from COVID-19 complications
Case 13	14	Male	1 (Mother)	PUV	5.3	4 (16)	None	Donor exclusion	On HD then CLDKT in another center
Case 14	23	Male	1 (Mother)	Urolithiasis	5.1	5 (15)	None	Patient regression	On HD for 18 m
Case 15	34	Female	1 (Sister)	Unknown	8.6	5 (8)	None	Donor regression	On HD for 6 m before death
Case 16	52	Male	1 (Brother)	ADPCKD	6.2	5 (10)	None	Donor exclusion	On HD for 28 m
Case 17	19	Male	None	VURD	3.2	4 (28)	None	Donor unavailability	On HD 24 m
Case 18	36	Male	1 (Sister)	Hypertensive nephropathy	6.8	5 (10)	None	Patient regression	On HD for 26 m
Case 19	34	Male	3 (Unrelated)	ADPCKD	7.5	5 (9)	None	Donor exclusion	On HD for 27 m
Case 20	34	Male	2 (Brother, Sister)	Diabetic nephropathy	8.4	5 (8)	None	Patient regression	On HD for 28 m
Case 21	15	Male	1 (Mother)	Unknown	5.4	5 (15)	None	Donor exclusion	On HD for 6 m then lost to follow-up
Case 22	44	Male	1 (Brother)	Urolithiasis	6.7	5 (10)	None	Patient regression	On HD for 8 m then lost to follow-up
Case 23	40	Female	1 (Cousin)	Unknown	6.7	5 (7)	None	Donor regression	Unknown
Case 24	44	Male	1 (Brother)	Hyperuricemia	5.6	5 (12)	None	Donor exclusion	On HD for 13 m
Case 25	19	Male	1 (Mother)	Congenital VURD	4.7	4 (17)	Yes	NA	Living with a functioning graft for 12 m
Case 26	23	Female	1 (Mother)	Unknown	6.3	5 (12)	None	Patient regression	On HD for 18 m
Case 27	60	Male	None	Unknown	5.6	5 (11)	None	Donor unavailability	On HD then CLDKT in another center
Case 28	29	Male	1 (Sister)	GN	3.9	4 (19)	None	Donor exclusion	On HD 8 m
Case 29	25	Female	1 (Brother)	Unknown	9.8	5 (7)	None	Patient regression	On HD for 6 m
Case 30	47	Female	None	Unknown	6.4	5 (12)	None	Patient regression	On HD for 16 m
Case 31	25	Male	None	FSGS	4.5	4 (18)	None	Donor unavailability	On HD for 5 m
Case 32	21	Female	None	Unknown	4.2	4 (18)	None	Donor unavailability	On HD for 3 m

ADPCKD: Autosomal dominant polycystic kidney disease; CKD: Chronic kidney disease; CLDKT: Conventional living donor kidney transplantation; CMU: Congenital megaureter; COVID-19: Coronavirus disease 2019; eGFR: Estimated glomerular filtration rate; FSGS: Focal segmental glomerulosclerosis; GN: Glomerulonephritis; HD: Hemodialysis; N/A: Not applicable; PLDKT: Preemptive living donor kidney transplantation; PUV: Posterior urethral valve; VURD: Vesicoureteral reflux disease.

Table 3 A comparison of the variables affecting the achievement (n = 59) and non-achievement (n = 245) of kidney transplantation in our center, n (%)

Variables		Achievement, n = 59	Non-achievement, n = 245	P value
Age in yr, mean ± SD (range)		29 ± 9.9 (13-57)	32.8 ± 11.9 (12-66)	0.034
Sex
Male		56 (94.9)	179 (73.1)	< 0.001
Female		3 (5.1)	66 (26.9)
Dialysis status
Preemptive access		4 (6.8)	28 (11.4)	0.354
On regular dialysis		55 (93.2	217 (88.6)
Primary kidney disease
Unknown causes		41 (69.5)	202 (82.4)	0.008
Systemic diseases		3 (5.1)	18 (7.4)
Renal diseases		15 (25.4)	25 (10.2)
Number of potential donors per patient1
Donor unavailability		0 (0)	44 (18)	0.003
One donor		43 (72.9)	161 (65.7)
Two donors		13 (22)	31 (12.6)
Three donors		3 (5.1)	9 (3.7)
Outcome of donor evaluation1
Accepted		48 (81.4)	51 (32.9)	< 0.001
Excluded		0 (0)	100 (64.5)
Excluded and accepted		11 (18.6)	4 (2.6)
Number of not-evaluated donors per patient1
One donor		4 (100)	51 (86.4)	> 0.999
Two donors		0 (0)	7 (11.9)
Three donors		0 (0)	1 (1.7)
Chronological order of accepted donor1		n = 59	n = 55
First		48 (81.4)	49 (89.1)	0.596
Second		8 (13.6)	4 (7.3)
Third		3 (5.1)	2 (3.6)
Age of accepted donors, mean ± SD (range)		40.2 ± 10.9 (21-60)	40.5 ± 9.5 (26-58)	0.937
Degree of relatedness of accepted donors1
First		34 (57.6)	26 (47.3)	0.339
Second		20 (33.9)	25 (45.4)
Third		3 (5.1)	4 (7.3)
Unrelated		2 (3.4)	0 (0)
Sex of accepted donor1
Male		20 (33.9)	21 (38.2)	0.779
Female		39 (66.1)	34 (61.8)
Number of excluded donors per patient1		n = 11	n = 102
One donor		8 (72.7)	82 (80.4)	0.572
Two donors		3 (27.3)	17 (16.7)
Three donors		0 (0)	3 (2.9)
Main causes of donor exclusion1		n = 9	n = 100
Medical causes		5 (55.6)	47 (47)	0.462
Immunologic mismatches		2 (22.2)	39 (39)
Combined medical and immunologic causes		2 (22.2)	14 (14)

¹The values and percentages of the donors are not complementary to the total number of patients, because there were multiple donors for 56 patients who had overlapping outcomes of evaluation and fate.

SD: Standard deviation.

Table 4 Multivariate logistic regression analysis of the variables influencing the achievement of kidney transplantation in our center

Variables	Modality	Odds ratio	P value
Age	Younger vs older	0.97 (0.94-0.997)	0.031
Sex	Men vs women	0.14 (0.04-0.46)	0.001
Dialysis status	Preemptive vs on dialysis	0.31 (0.09-1.1)	0.065
Primary kidney disease	Known vs unknown	3.24 (1.5-6.9)	0.002
Number of potential donors	One vs multiple	0.81 (0.42–1.57)	0.529

Table 5 Preemptive living donor kidney transplantation in publications from Egypt

Ref.	Publishing place	Settings	Type	Aim	Scope relative to PLDKT	Target age group	Outcomes relative to ELDKT/ CLDKT	Number of patients; PLDKT/Total (Percentage of PLDKT)
El-Agroudy et al[12]	Transplantation	Mansoura University	Retrospective comparative	Compare outcomes of CLDKT & PLDKT	Specific	Mixed	Comparable, except in death with functioning graft was due to CVD in PLDKT vs respiratory infections in CLDKT	82/1279 (6.4%)
Bakr and Ghoneim[14]	Saudi J Kidney Dis Transpl	Mansoura University	Retrospective series	Present experience in KT	General	Mixed	Overall graft survival rates were 76% and 52% at five and 10-yr, respectively	82/1690 (4.9%)
El-Husseini et al[15]	Pediatr Nephrol	Mansoura University	Retrospective series	Evaluate outcomes of pediatric LDKT	General	Pediatrics	5-yr graft survival was 73.6%	51/216 (23%)
Mosaad et al[16]	Dial Transpl	Mansoura University	Retrospective series	Study LDKT survival in low-weight children	General	Pediatrics	PLDKT might provide better graft survival	9/63 (14.3%)
Saadi et al[13]	Egyptian J Int Med	Cairo University	Retrospective series	Identify KT Epidemiology in Cairo University hospitals	General	Mixed	Most of patients and donors were males, mostly as LDKT	14/282 (5%)
1Gadelkareem et al[9]	Afr J Urol	Assiut University	Prospective comparative	Compare short term outcomes of ELDKT & PLDKT	Specific	Adults	Comparable, except AR higher in ELDKT; Lymphocele incidence was higher in PLDKT	PLDKT 30/45; ELDKT 15/45
Gadelkareem et al[8]	Exp Tech Urol Nephrol	Assiut University	Opinion	Suppose that lead time should not be a bias effect in PKT	Specific	Mixed	Lead time is a mere character of PKT rather than a bias	NA
Fadel et al[17]	Pediatr Transpl	Cairo University	Retrospective series	Present experience in pediatric KT	General	Pediatrics	Timely referral and parent education were recommended	PLDKT 11/148 (7%); ELDKT 59/148 (40%)
Index study	World J Nephrol	Assiut University	Retrospective series	Present experience	Specific	Mixed	Urological causes are main contributor	PLDKT 3/59 (5.1%)

¹Early living donor kidney transplantation was defined as receiving kidney transplantation within 6 mo from starting regular dialysis.

AR: Acute rejection; CLDKT: Conventional living donor kidney transplantation; CVD: Cardiovascular disease; ELDKT: Early living donor kidney transplantation; KT: Kidney transplantation; LDKT: Living donor kidney transplantation; N/A: Not applicable; PKT: Preemptive kidney transplantation; PLDKT: Preemptive living donor kidney transplantation.

Table 6 Frequency of preemptive living donor kidney transplantation in publications from other countries/registries, n (%)

Ref.	Countryand/or Registry	Total KT Number	PKT	LDKT number (Percentage of PLDKT)	PKT per donor type
					LD	DD
Migliori et al[19]	United States	1742	132 (7.6%)	1056 (9.1)	96 (73)	36 (27)
Berthoux et al[20]	ERA-EDTA	35348	2545 (7.2)	1097 (73.3)	804 (31.6)	1741 (68.4)
Asderakis et al[21]	United Kingdom	1463	161 (11)	118 (19.5)	23 (14)	138 (86)
Papalois et al[22]	United States	1849	385 (20.8)	1074 (29.1)	313 (81.3)	72 (18.7)
1Mange et al[23]	United States; USRDS	8489	1819 (21.4)	1819 (21.4)	1819 (100)	NA
Kasiske et al[24]	United States; UNOS	38836	5126 (13.2)	13078 (24)	3145 (61.4)	1981 (38.6)
Gill et al[25]	Canada; CORR	40963	5996 (14.6)	11290 (26.6)	2999 (50.5)	2967 (49.5)
Ashby et al[26]	United States; OPTN/SRTR	102331	17885 (17.5)	44033 (26.3)	11601 (65)	6284 (35)
1Ishikawa et al[27]	Japan; JRTR	834	112 (13.4)	834 (13.4)	112 (100)	NA
1Milton et al[28]	ANZDATA	2603	578 (22)	578 (22)	578 (100)	NA
1Yoo et al[29]	Korea	499	81 (16.2)	499 (16.2)	81 (100)	NA
Gore et al[30]	United States; UNOS	41090	11026 (26.8)	15940 (39.4)	6282 (57)	4744 (43)
Witczak et al[31]	Norway	3400	809 (24)	1415 (36.3)	514 (64)	295 (36)
2Kramer et al[32]	ERA-EDTA	1829	444 (21.2)	1073 (11.5)	123 (72)	321 (28)
Grams et al[33]	United States; UNOS	152731	19471 (12.8)	NA	11554 (59)	7917 (41)
1Grace et al[34]	ANZDATA	4105	660 (16.1)	2058 (16.1)	660 (100)	NA
2Patzer et al[35]	United States; USRDS	5774	1117 (19.3)	2598 (28.8)	747 (67)	370 (33)
Jay et al[2]	United States; UNOS	141254	24609 (17)	46373 (31)	14503 (59)	10106 (41)
Prezelin-Reydit et al[36]	France; REIN	22345	3112 (14)	2031 (34)	690 (22.2)	2422 (77.8)
1Kim et al[37]	South Korea	1984	429 (21.6)	1984 (21.6)	429 (100)	NA
2Prezelin-Reydit et al[38]	France; REIN	1911	380 (19.8)	240 (37.5)	90 (23.7)	290 (76.3)

¹Studies included only living donor kidney transplantation.

²Studies included only pediatric kidney transplantation.

ANZDATA: Australia and New Zealand Dialysis and Transplant Registry; CORR: Canadian Organ Replacement Registry; DD: Deceased donor; ERA-EDTA: European Renal Association-European Dialysis and Transplant Association; JRTR: Japanese Renal Transplant Registry; LD: Living donor; LDKT: Living donor kidney transplantation; PKT: Preemptive kidney transplantation; PLDKT: Preemptive living donor kidney transplantation; N/A: Not applicable; OPTN/SRTR: Organ Procurement and Transplantation Network/Scientific Registry of Transplant Recipients; REIN: Renal Epidemiology and Information Network; UNOS: United Network for Organ Sharing; USRDS: United State Renal Data System.