Background  The supply-demand mismatch between organ donor and patient waiting for transplant has led to the growth of transplant tourism. This type of transplant is considered unethical and illegal, as it is usually performed in poor environments and carries a higher risk of infectious, vascular, and immunological complications. Methods  In this single-centered retrospective cohort study, we compared patients who underwent transplant tourism to patients who were transplanted locally and followed up in our hospital from January 2015 to December 2018. Result  A total of 254 local transplants and 60 patients from the transplant tourism group were included. Transplant tourism recipients were younger otherwise both groups were similar in gender, body mass index, diabetes, and hypertension. Recipients in the transplant tourism group had a significantly higher rate of delayed graft function (18.3% vs. 6.3%, p 0.005), acute rejection (40% vs. 7.9%, p  < 0.001), and higher posttransplant infection in general. With more urological complications and higher graft failure at 3-years' follow-up (11.7% vs. 0.8%, p  < 0.001). Conclusion  Transplant tourism is associated with a higher risk of infection and poor graft outcomes. Extra efforts are required to cut down transplant tourism by educating patients about its clinical risk and ethical considerations. In addition, measures to increase the number of deceased donor pool to provide a better alternative options for patients are essential.

Purpose: To review the effect of renal transplantation and adding of statins on dyslipidemia in renal transplant recipients. Methods: A single center experience retrospective study of renal transplant recipients, from 2017 to 2020. Lipids’ profile and Hgb A1C were reviewed at baseline (before transplant) and at average12 months follow-up of renal transplant recipients who received statins or not. Results: 287 renal transplant recipients were included. 74% were ≥ 30 years, men: 58% and living-donor kidney recipients: 80%. Statins were prescribed to 80% of kidney recipients who were ≥30 years old and to 33% who were <30 years old. 28% of the recipients were already on statins before the renal transplantation. Whereas statins were initiated in 26% before discharge from the transplant admission, or during the first year in 14%. While 32% did not receive any statins. The most common statin used was Atorvastatin at 10 mg in 60% or 20 mg in 23% of the cases. In patients who did not receive statins: renal transplantation was associated with a significant increase of total cholesterol (TC) by 0.31 mmol/L (0.04 to 0.59: P: 0.026) and a significant increase of LDL by 0.40 mmol/L (0.16 to 0.65; P:0.001). On the other hand, and despite weight gain of average 6.9 kg (P <0.001), and increased AIC by 0.71(P<0.001); renal transplantation was associated with an increase of HDL by 0.17 mmol/L (0.09 to 0.25; P:<0.001) and down trending but not statically significant decrease of triglyceride (TG) by -0.09 mmol/L (-0.25 to 0.07; P: 0.280). In renal transplant recipients who received statins: despite weight gain of 5.6 kg (P:<0.001) and increased A1C by 0.93 (P: <0.001), HDL improved by 0.17 mmol/L (0.13 to 0.22; P<0.001) and TG decreased by -0.34 mmol/L (-0.50 to -0.17; P:<0.001). Statins were associated with a numerical decrease of TC by -0.06 mmol/L (-0.23 to 0.12; P: 0.519) and nonsignificant increase of LDL by only 0.04 (-0.10 to 0.18, P: 0.607). Statins were significantly associated with improvement of TC and LDL compared to no statins. The mean changes of TC (from baseline to 12 months) while on stains versus none were (-0.06 mmol/L ±1.16 versus 0.31 mmol/L ±1.12; P: 0.026) and the mean changes of LDL while on stains versus none were (0.04 mmol/L ±0.96 versus 0.40 mmol/L ±1.02; P: 0.008). Conclusions: Despite weight gain and the increased level of A1C seen after renal transplantation, renal transplantation was associated with improved TG and HDL. Adding statins in patients at higher risk of dyslipidemia not only maintained the beneficial effects of renal transplantation on HDL and TG but also had significant “buffering” effect against the rising of TC and LDL.

Abstract Background and Aims Due to organ shortage, many transplant centers may consider “marginal” kidney donors as those with sickle cell trait (SCT) for donation. Acceptance of kidney donors with SCT is in the grey zone, where there are no clear guidelines or consensus toward them. To form a consensus, we conducted a short survey about the suitability and acceptance of living kidney donors with SCT. Method This is a cross-sectional survey of nephrologists and transplant surgeons about Suitability and Acceptance of The Marginal Live Kidney Donors. The survey was sent to nephrologists in different countries and it was also distributed through AST& ERA-EDTA. Results Of a total of (n=122) respondents from 22 countries: 80.17% (N= 96) were nephrologists and 19.83% (N=23) were transplant surgeons. N= 88 of the respondents (72%) have more than 6 years in practice and they are heavily involved in pre- transplant evaluations of donors and recipients (68.5% of respondents perform donors’ evaluation on weekly or monthly basis and 60 % perform recipient evaluation on weekly basis). The majority (45%) of the respondents were from USA. The completion rate of the survey was 99%. The presence of sickle cell trait was not considered as a contraindication to donor nephrectomy by the majority of respondents (57.38%). Of those (N= 34) 27.87 % of respondents consider them fit for donor nephrectomy after explanation of the risks involved while (N= 36) 29.51 consider them for donor nephrectomy only if there is no other suitable donor available. Out of the total respondents (N= 52) 42.62% considered the presence of sickle cell trait a contraindication to donor nephrectomy. Conclusion With lack of consensus and guidelines we found that a significant pool of the transplant physicians and surgeons will consider donors with sickle cell trait for kidney donation especially if there is no other acceptable donor.

Abstract Background and Aims There is variability among transplant centers in the acceptance of living donor candidates with well-controlled hypertension. Increased gestational hypertension and preeclampsia are more common in donors than in the general population especially if the donor is hypertensive at baseline. The purpose of this survey is to form a consensus about the evaluation of marginal live kidney donors (women and men) with hypertension. Method This is a cross-sectional survey of nephrologists and transplant surgeons about Suitability and Acceptance of The Marginal live Kidney Donors. The survey was sent to nephrologists in different countries and it was also distributed through AST & ERA-EDTA. Results A total of 122 practitioners from 22 countries responded to the survey. Of those, (N=96, 80.2%) were nephrologists and (n=23 19.83%) were transplant surgeons. The majority (45%) of the respondents were from USA. Most of the respondents (N=85, 69.7%) would allow a multiparous female (MPW) with mild and controlled hypertension (on a single blood pressure medication) who is not planning to have more children to donate. The rest would either advise against donation unless there is no alternative donor (n=23, 18.85%), or decline it altogether (n=14, 11.5%). In contrast, more respondents would reject a primiparous donor woman (PPW) with the same clinical scenario who considers having children (n=51, 42.2%, P=0.00001 ), or accept it only if there is no alternative donor (n=46, 38.0%, P=0.0009). Furthermore, most would not allow donation of a 20 years old male ( M) with an apparent white coat hypertension if his 24-hour ambulatory blood pressure monitoring shows non-dipping nocturnal pattern (n=67, 54.9%), or only accept it if there is no alternative donor (n=36, 29.5%). When comparing the rejection rate among the three donors: 11% for MPW, 41% for PPW and 54% for M. (P = 0.0001 for MPW vs PPW; P=0.00001 for MPW vs M; P=0.04 for PPW vs M). Conclusion Most of the nephrologists and transplant surgeons will clear mulptiparous women with mild and controlled hypertension for kidney donation as long as there no further plans for pregnancy. However, the majority of respondents will not clear a hypertensive primiparous due to the increased risk of gestational hypertension and preeclampsia after kidney donation. Most would be also reluctant to accept very young male donors if they show indicators of higher risk of developing hypertension in future.

Abstract Background and Aims Potential kidney donors who actively smoke heavily or had intermittent illegal drug use (IIDU) are mostly excluded from donating a kidney. Tobacco use in kidney donor has been linked to worse outcomes for donors and while less evidence exists for IIDU as they mostly excluded from donation. We conducted a short survey about the suitability of these marginal living kidney donors. The purpose of this survey is to form a consensus on live kidney donor with using smoking or illegal drugs. Method This is a cross-sectional survey of nephrologists and transplant surgeons about suitability and acceptance of marginal live kidney donors. We asked physicians about accepting kidney donors who are actively smoking or using illegal drugs. The survey was mainly distributed through AST and ERA-EDTA. The role of these organization is limited to facilitate the distribution of the survey as an external study. We excluded in-training nephrologists or transplant surgeons. Results One hundred twenty-two physicians from 22 countries (80% nephrologists and 20% transplant surgeons (TS)) participated in the survey. Most physicians were experienced in pre-transplant evaluation (72% over 6 years’ experience and 68.5% of responders perform donors’ evaluation on weekly or monthly bases). Interestingly, most physicians would allow donation in active smoker with advice to quit later (56.2%) (62% of nephrologists versus only 29% of TS (p=0.002). TS would decline active smoker patients than nephrologists (42% versus 25%, p=0.09). Less physicians considered donors with IDU (after psychiatric counselling) than active smoking (30% versus 56.2%, p=0.00003). There was no difference in acceptance rate for donors with IIDU between TS and nephrologists (33.3% versus 29% respectively, p=NS) or in declining these donors (37.5% versus 45.3%, p=0.4). TS would accept more active smokers to donate if no alternative donor available than nephrologists (29.2% vs. 12.3%, p=0.04) but not IDU (29.2% vs. 25.8%, p=ns). Conclusion Active heavy smoking and intermittent illegal drug use are not viewed as solo contraindications for kidney donation by most physicians. Nephrologists and TS did not differ in attitude regarding donors with IIDU. Nephrologist seems more confident to accept donors who are actively smoking with advice to quit afterward while TS would accept them more if no alternative donor available or would decline them completely.

Abstract Background and Aims Potential kidney donors with isolated hematuria are often excluded from donating although there is a wide controversy about the definition and threshold of investigations or exclusion form donation. Many centers use the cut off of > 3 RBC in men and > 5 RBC in women. Some centers consider positive dipstick on urinalysis as the definition of microscopic hematuria. Kidney biopsy in these donors can be borderline and inconclusive. We conducted a short survey about the suitability of these marginal living kidney donors with microscopic hematuria. Method This is a cross-sectional survey of nephrologists and transplant surgeons (TS) about suitability and acceptance of marginal live kidney donors with isolated microscopic hematuria. The question was about a 35-yr. old man non-smoker with isolated microscopic hematuria (4 RBC on repeated UA and trace hematuria on dipstick) and negative imaging. The survey was mainly distributed through American Society of Transplantation, American Society of Transplant Surgeons and European Renal Association-European Dialysis and Transplant Association. In-training nephrologists or transplant surgeons were excluded. Results A total of (n= 122 from 22 countries, 80% nephrologists and 20% TS) responded to the survey. Most respondents were experienced in donor evaluation (72% of physicians have over 6 years’ experience and 68.5% of them perform donors’ evaluation on weekly or monthly bases). Interestingly, at this low level of microscopic hematuria (4 RBC on repeated UA and trace hematuria on dipstick) only very limited number of respondents (7.5%) would allow donation without further work up. Instead, most respondents (n= 75, 63%) would ask for kidney biopsy prior to taking further steps. Many physicians (n=35, 29%) choose to ask for an alternative donor to avoid the hassle of kidney biopsy which may not change the management. There was no difference in acceptance rate for donors between TS and nephrologists (7.2% versus 8.3% respectively, p=NS), requesting kidney biopsy (63.9% vs. 62.5%) or in declining these donors (28.8% versus 29.1%, p=NS). Conclusion Young kidney donors with persistent isolated microscopic hematuria (even at mild degree) require further evaluation with kidney biopsy before donation. However up to one third of the nephrologist and transplant surgeon will ask for an alternative donor to avoid the hassle of kidney biopsy which can be borderline or inconclusive.

Abstract Background and Aims There are no clear guidelines about the suitability and acceptance of living- kidney donors with obesity or abnormal blood sugar profile. Method To form a consensus about the acceptance of these donors, a survey was distributed to nephrologists and transplant surgeons in different countries and through AST and ERA-EDTA. Results Of a total of (n=122) respondents from 22 countries: 80% (N= 96) were nephrologists and 20% (N=23) were transplant surgeons. The majority were heavily involved in pre-transplant evaluations of donors and recipients and have > 6 years in practice. 75% of the respondents will accept obese donors (BMI 30-35) if donors show some weight loss before donation or at least show commitment to lose weight in the future. However, the presence of a strong family history of diabetes ( DM) in obese donors (even with normal fasting blood sugar (FBS) and hemoglobin A1C [ Hgb A1C]) mandates weight lose preferably to BMI of 30 ( n=46, 38% ) or at least to lose some weight before being considered for donation (n=30, 25%). On the other hand, morbidly obese donors (BMI 36-40) with normal FBS, Hgb A1C and negative family history of DM thought to need to decrease their weight to BMI 30 ( 47% of the respondents) or at least lose some weight before being considered for donation ( n=30, 25%). However, 22% of the respondents would decline these donors due to the risk of relapse of obesity. If an obese donor started to have impaired fasting blood sugar ( IFG), the majority (47%) will decline him/her because of the higher risk to develop DM. (33%) will delay the donation till BMI reaches below 30 and IFG is resolved as a result of weight reduction. Most of the respondents (52%) will not rely solely on isolated mildly elevated Hgb A1C (e.g. Hgb A1C = 5.7- 6) or isolated (IFG) as the critical indicator to decline a young donor with normal weight and normal FBS. Instead 2hrs- glucose tolerance test will be indicated. The presence of even mild and controlled diabetes in a middle age (e.g. 55 years old donor) thought to be a contraindication for kidney donation in 62% of the respondents. However, such donors might be allowed to donate if no alternative donor is available after clearly explaining the risks (23%). In regard to resolved DM after bariatric surgery and weight loss, 43% of the respondents said they will consider them for donation if two years passed after bariatric surgery without obesity relapse (43%). Up to one forth may consider these donors earlier (once BMI is below 30). Despite the surgical difficulties related to obesity in kidney donors, transplant surgeons seem more likely than nephrologists to accept obese donors (P= 0.046), morbidly obese ( P=NS). Conclusion Living kidney donors with isolated obesity, (IFG), mildly abnormal HgbA1C or history of bariatric surgery are still considered for kidney donation by many centers. However, donors with more than one abnormality especially at young age are not considered for donation.