135TH ANNIVERSARY INTERNATIONAL MEDICAL CONGRESS 2022 30th September 2022 At BMICH, Colombo. Symposium on Solid Organ transplantation Kidney transplantation - Challenges and Experiences Kidney transplantation Causes for chronic kidney dise Chronic Kidney Disease of unkn Paediatric kidney transplant Teaching Hospital Anuradhapura The university transplant unit Live donor nephrectomy Organ preservation Iliac vessel mobilisation Renal vessels ananstomosis Ureter anastomois Surgical aspects user experience Relationship of live donors (T Area of residence of donors Live Donor profile Donor vascular variations Vascular reconstruction

1. Kidney transplantation
Challenges and experiences
The Sri Lanka Medical Association (SLMA)
135th Anniversary international medical congress
2022

2. Transplantation
Removal of organs or tissues from one individual and
placing it in another individual
 Recipient

3. Transplantation
Removal of organs or tissues from one individual and
placing it in another individual
 Recipient

4. Transplantation
Removal of organs or tissues from one individual and
placing it in another individual
 Recipient

5. Transplantation
Removal of organs or tissues from one individual and
placing it in another individual
 Recipient
GRAFT

6. Kidney transplantation
 First successful kidney transplantation in the world - 1954
 First live donor Kidney transplantation in Sri Lanka - 1985
 First cadaveric donor Kidney transplantation – 2003
 Many transplantations are done today – Government / private
 Number of potential recipients are also increasing

7. Causes for chronic kidney disease - Adults
 Diabetes mellitus - 67.1%
 Nephritis - 20.0%
 Obstructive uropathy - 4.3%
 Chronic Kidney Disease of unknown aetiology (CKDu)
- 2.8% / 94.0% (ANP)
University unit , Colombo

8. Paediatric kidney transplantation
 Causes ESRF
 Glomerulonephritis - (30%)
 Renal dysplasia - (26%)
 Reflux Nephropathy - (17%)
 Obstructive uropathy - (17%).
The evaluation of kidney transplantation in children and adolescents; a single unit
experience, Colombo : s.n., 2021. 50 Annual Academic Sessions - 2021 of The
College Of Surgeons of Sri Lanka. Vol. 39 Issue Supplement S1 , p. . ISSN 1391-491X.

9. Causes for chronic kidney disease - Adults
 Diabetes mellitus - 67.1%
 Nephritis - 20.0%
 Obstructive uropathy - 4.3%
 Chronic Kidney Disease of unknown aetiology (CKDu)
- 2.8% / 94.0% (ANP)
University unit , Colombo

10. Teaching Hospital Anuradhapura
CKDu

11. Teaching Hospital Anuradhapura
CKDu

12. Chronic Kidney Disease of Unknown aetiology
(CKDu)
 An interstitial nephritis
 Affects rice farming
community
 Cause
 Fertilizers
 Pesticides
 Dehydration
 Males > females

13.  Prevalence - 15%–23%
 KT recipients (THA)
 CKDu - 94.0%
 Male : female – 85.4% : 14.6%
Chronic Kidney Disease of Unknown aetiology
(CKDu)
J,Arudchelvam,W Laksiri. Outcome of live Donor renal transplantation among patients with chronic kidney disease of unknown
aetiology (CKDu), Presented at 45th annual Academic Sessions Of The College Of Surgeons Of Sri Lanka, August 2016. Colombo.

14.  Prevalence of CKDu – 15%
 Population of NCP - 1,259,567 (2011 census)
 ? Total patients with CKDu - 188935
Chronic Kidney Disease of Unknown aetiology
(CKDu)
World Health Organization Report on Chronic Kidney Disease of Unknown Aetiology in Sri Lanka. [Last visited on 2013 Nov 10].

15. Anuradhapura 2016
 Registered patients – 18400
 On dialysis – 280
 KT done – 18
 Dialysis access created in 2016 – 383
 In hospital deaths (2016) – 298
J,Arudchelvam,W Laksiri. Outcome of live Donor renal transplantation among patients with chronic kidney disease of unknown
aetiology (CKDu), Presented at 45th annual Academic Sessions Of The College Of Surgeons Of Sri Lanka, August 2016. Colombo
Chronic Kidney Disease of Unknown aetiology
(CKDu)

16. The university transplant unit
Colombo (2017)
 Patients on dialysis – 3023
 Renal transplantations - 38
Colombo 2017

17. Surgical aspects of kidney
transplantation

18. Live donor nephrectomy
 Lateral decubitus position
 lower costal margin over
the kidney rest
 kidney rest is raised and
the operating table is
flexed

19. Live donor nephrectomy
 Incision in line with
the 12th rib.
 Kidney, ureter, vessels
mobilised

20. Organ preservation
 Kidney perfused with cold
preservation solution
 Histidine Tryptophan
Ketoglutarate (HTK) solution

21. Organ preservation

22. Renal transplantation
• Curved supra inguinal
incision (Modified Gibson)
• Inverted ‘J’/ ‘Hockey stick’

23. Renal transplantation
• Iliac vessels and bladder
dissected extra
peritoneally’

24. Renal transplantation –
Iliac vessel mobilisation

25. Renal transplantation
 Renal vessels
ananstomosed to iliac
vessels

26. Renal transplantation
Ureter anastomosed to the
bladder
(Ureteroneocystostomy)

27. Surgical aspects

28. Kidney Transplantation
Teaching Hospital Anuradhapura
(FEB 2015 TO AUG 2017)
 Renal transplants - 52
 Live donor - 80.5%
 Cadaveric - 19.5%
1.J,Arudchelvam,W Laksiri. Outcome of live Donor renal transplantation among patients with chronic kidney disease of unknown
aetiology (CKDu), Presented at 45th annual Academic Sessions Of The College Of Surgeons Of Sri Lanka, August 2016. Colombo.
2.Arudchelvam, J., (2017). First case of enbloc dual kidney transplantation in Sri Lanka: a case report and review of literature. Sri
Lanka Journal of Surgery. 35(2), pp.24–25. DOI: http://doi.org/10.4038/sljs.v35i2.8387Arudchelvam, J. et al., (2016). The first
simultaneous pancreas kidney transplantion in Sri Lanka. Sri Lanka Journal of Surgery. 35(4), pp.46–47.

29.  Gender
 Male - 85.4%
 Female - 14.6%
 Mean age – 41.9 years (20-64)
J,Arudchelvam,W Laksiri. Outcome of live Donor renal transplantation among patients with chronic kidney disease of unknown
aetiology (CKDu), Presented at 45th annual Academic Sessions Of The College Of Surgeons Of Sri Lanka, August 2016. Colombo.
Kidney Transplantation
Teaching Hospital Anuradhapura
(FEB 2015 TO AUG 2017)

30. Recipient profile
Teaching Hospital Anuradhapura (THA)
94.00%
4.50% 1.50% 1.50%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
CKDu Dia Neph VUJR PCKD
recipient
recipient

31. 50%
50%
Male
Female
Proceedings of the annual Scientific Sessions of The College of Surgeons of Sri Lanka 2017
Donors (THA)

32. Relationship of live donors (THA)
42
30
16
12
blood related non related Spouse Distant Relative
0
5
10
15
20
25
30
35
40
45
LIVE DONORS
blood related
non related
Spouse
Distant Relative
Proceedings of the annual Scientific Sessions of The College of Surgeons of Sri Lanka 2017

33. Area of residence of live donors (THA)
97%
3%
AREA
NCP
OUTSIDE
Proceedings of the annual Scientific Sessions of The College of Surgeons of Sri Lanka 2017

34. Kidney transplantation - Colombo
 Total - 83
 Gender of recipients
 Male - 75.3%
 Female - 24.7%
 Mean age - 45.4 years (15-73)
 Donor type
 Live - 50 (60.2%)
 Deceased donor - 33 (39.8 %)
Colombo 2022 (unpublished)

35. Kidney transplantation
Colombo / Anuradhapura
Colombo ANP
Recipient age (years ) 45.4 (15-73) 41.9 (20-64) P - 0.6913
Male/ female(%) 75.3 / 24.7 85.4/ 14.6 P - 0.1610
Cause of CKD (CKDu) 2.8% 94.0% P < 0.0001
Cause of CKD
(DM)
67.1% 4.5% P < 0.0001
Donors (males %) 64.8% 50.0% P -0.4413

36. Live Donor profile - Colombo
 Total - 159
 Males - 103 [64.8%]
 Mean age - 38.2 years [23-63]
 Donor side
 Left - 106 [66.7%]
Arudchelvam J, Laksiri W. Anatomical variations of the renal vasculature and outcome of live donor nephrectomies: experience
of a single surgeon. Sri Lanka Journal of Surgery. 2021;39(2):28–30

37. Donor vascular variations
Number of arteries
• Single RA - 136 [85.5%]
• Early branching- 34 [21.4%]
Arudchelvam J, Laksiri W. Anatomical variations of the renal vasculature and outcome of live donor nephrectomies: experience of
a single surgeon. Sri Lanka Journal of Surgery. 2021;39(2):28–30. DOI: http://doi.org/10.4038/sljs.v39i2.8817

38. Donor vascular variations
• Multiple RA - 23 [14.5%]
[2 in 21 and 3 in 2]
Arudchelvam J, Laksiri W. Anatomical variations of the renal vasculature and outcome of live donor nephrectomies: experience of
a single surgeon. Sri Lanka Journal of Surgery. 2021;39(2):28–30. DOI: http://doi.org/10.4038/sljs.v39i2.8817

39. Vascular reconstruction and anastomosis
Reconstruction of
double arteries

40. Vascular reconstruction and anastomosis
Reconstruction of other
abnormal anatomy

41. Vascular reconstruction and anastomosis

42. Donor vascular variations and outcome
 Renal veins
 Single artery - 6.8%
 Multiple artery / EB - 25.7% [p-0.004]
Arudchelvam J, Laksiri W. Anatomical variations of the renal vasculature and outcome of live donor nephrectomies: experience
of a single surgeon. Sri Lanka Journal of Surgery. 2021;39(2):28–30. DOI: http://doi.org/10.4038/sljs.v39i2.8817

43. Donor vascular variations and outcome
Association of complications
 Haematoma
 EB [5.9% vs. 0.8%]
 Right DN [3.8% vs. 0.9% / p>0.05].
Arudchelvam J, Laksiri W. Anatomical variations of the renal vasculature and outcome of live donor nephrectomies: experience
of a single surgeon. Sri Lanka Journal of Surgery. 2021;39(2):28–30. DOI: http://doi.org/10.4038/sljs.v39i2.8817

44. Enbloc renal transplantation
• First enbloc renal transplantation in Sri Lanka
- June 2017
Arudchelvam, J., (2017). First case of enbloc dual kidney transplantation in Sri Lanka: a case report and review of literature. Sri
Lanka Journal of Surgery. 35(2), pp.24–25. DOI: http://doi.org/10.4038/sljs.v35i2.8387Arudchelvam, J. et al., (2016).

45. Enbloc renal transplantation
• 3 ½ year old donor – youngest donor
• Cause of death – snake bite,
respiratory arrest
• Recipient – 44 year old
• At present well and having normal
creatinine
Arudchelvam, J., (2017). First case of enbloc dual kidney transplantation in Sri Lanka: a case report and review of literature. Sri
Lanka Journal of Surgery. 35(2), pp.24–25. DOI: http://doi.org/10.4038/sljs.v35i2.8387Arudchelvam, J. et al., (2016).

46. Outcome of kidney transplantation
Auradhapura
 Mean follow up – 59.42 weeks
( 3.7 – 138.8)
 Survival – 92.7%
J Arudchelvam, et.al. O u t c o m e o f l i v e d o n o r k i d n e y transplantation (ldkt) among patients with chronic
kidney disease of unknown aetiology (CKDU), ANNUAL ACADEMIC SESSIONS 2016, THE COLLEGE OF SURGEONS
OF SRI lankaat: COLOMBO

47. Outcome of kidney transplantation
University unit
 Mean follow up – 4.6 years
 Survival – 84.8%

48. Paediatric kidney transplantation
Lady Ridgeway Hospital for Children (LRH) Colombo
 Number - 23
 Mean age - 11.7 years (4-17)
 Males - 65.2%
 Mean weight - 24.6 kg.
 Live donor KT – 21 (91%)
 Pre -emptive - 14(60%)
The outcome of kidney transplantation in children and adolescents: Asingle unit experience. AANishanthan, K AN Chanaka,
AM Alabadaarachchi, J Arudchelvam, M H PGodakandage, M R N Cassim, R M PD Kularathne, S M Wijeyaratne, TD
GooneratneColombo : s.n., 2021. 50 Annual Academic Sessions - 2021 of The College Of Surgeons of Sri Lanka. Vol. 39 Issue
Supplement S1 , p. 77. ISSN 1391-491X.

49. Paediatric kidney transplantation
 Early complications
 Bleeding - 17%
 Pyelonephritis - 4%
 Lower respiratory tract infection - 4%
 Immediate post op death - 4%
 Acute rejection - 34%
 Serum creatinine at discharge - 122 mmol/l
The outcome of kidney transplantation in children and adolescents: Asingle unit experience. AANishanthan, K AN Chanaka, AM
Alabadaarachchi, J Arudchelvam, M H PGodakandage, M R N Cassim, R M PD Kularathne, S M Wijeyaratne, TD
GooneratneColombo : s.n., 2021. 50 Annual Academic Sessions - 2021 of The College Of Surgeons of Sri Lanka. Vol. 39 Issue
Supplement S1 , p. 77. ISSN 1391-491X.

50. Paediatric kidney transplantation
 Mean follow-up - 24 months (4-60)
 Survival – 96.0%
The outcome of kidney transplantation in children and adolescents: Asingle unit experience. AANishanthan, K AN Chanaka,
AM Alabadaarachchi, J Arudchelvam, M H PGodakandage, M R N Cassim, R M PD Kularathne, S M Wijeyaratne, TD
GooneratneColombo : s.n., 2021. 50 Annual Academic Sessions - 2021 of The College Of Surgeons of Sri Lanka. Vol. 39 Issue
Supplement S1 , p. 77. ISSN 1391-491X.

51. Life long treatment and follow up –
poor social back ground
 Poor home condition
 Exposure to same risk factors for CKDu
 Infections
 Pneumonia
 Fungal

52. Life long treatment and follow up
 Unusual infections - Fungal
 ANP (from January 2014 to April 2015)
 6 cases
 Males – 5 (83.3%)
 Mean age - 50.2years (42 - 55)
 Multiple skin lesions (3-5) involving
hands and feet
 Antifungal therapy and local excision
 Recurrence - 2 (33.3%)
N Herath, N Madarasingha, R Dassanayake, J,Arudchelvam, et.al.Post Renal Transplant Endemic Fungal Infection; A Case Series.
August 2015 Volume 33, Issue Supplement S ISSN 1391-491X.

53. The future directions
 Prevention of Chronic Kidney disease
 CKDu
 DM
 Improve deceased donor numbers
 Introduce more facilities to the transplantation centres
 Improve the social and economic status

54. Thank You