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Background Living donor kidney is the main source of donor organs in low to middle income countries. We aimed to develop a living donor risk model that predicts graft and patient survival in an emerging economy. Methods We used data from the Sindh Institute of Urology and Transplantation (SIUT) database (n = 2,283 recipients and n = 2,283 living kidney donors, transplanted between 1993 and 2009) and conducted Cox proportional hazard analyses to develop a composite score that predicts graft and patient survivals. Results Donor factors age, creatinine clearance, nephron dose (estimated by donor / recipient body weight ratio) and human leukocyte antigen (HLA) match were included in the living donor risk model. The adjusted hazard ratios (HRs) for graft failures among those who received a kidney with living donor scores (reference to donor score of zero) of 1, 2, 3 and 4 were 1.14 (95%CI: 0.94 –1.39), 1.24 (95%CI:1.03–1.49), 1.25 (95%CI:1.03–1.51) and 1.36 (95%CI:1.08–1.72) [p-value for trend =0.05]. Similar findings were observed for patient survival. Conclusions Similar to findings in high income countries, our study suggests that donor characteristics such as age, nephron dose, creatinine clearance and HLA match are important factors that determine the long term patient and graft survival in low income countries. However, other crucial but undefined factors may play a role in determining the overall risk of graft failure and mortality in living kidney donor transplant recipients.

Urinary calculi are being recognized more frequently in children and the urinary bladder is the most common site for stone formation in the lower urinary tract. Bladder calculi are grouped into three basic categories: primary idiopathic/endemic, secondary, and migrant. The incidence of vesical calculi has declined significantly in the last 70 years in developed nations owing to improvements in nutrition and socioeconomic conditions, but it is still high in developing nations. Primary idiopathic/endemic bladder calculi typically occur in children, in the absence of urinary tract infection (UTI), urinary stasis, or foreign body, and diet lacking in animal proteins is the major contributor factor. Comprehensive preventive and treatment strategies are critical for improving the quality of life of diseased children, in addition to helping to eradicate, or at least decrease, the incidence of endemic bladder calculi in developing nations.

OBJECTIVES We evaluated cystatin C concentration as a marker of glomerular filtration rate in renal transplant recipients, and its correlation with creatinine-based glomerular filtration rate by urinary creatinine clearance, and the Cockroft-Gault and Modification of Diet in Renal Disease formulas. MATERIALS AND METHODS In this cross-sectional study, we measured serum cystatin C levels and its correlation with serum creatinine, creatinine clearance, and glomerular filtration rate using the Cockroft-Gault formula and Modification of Diet in Renal Disease formulas. RESULTS One hundred two recipients between June and December 2012, were examined. The mean subject age was 31.87 ± 8.37 years; the male:female ratio was 4.3:1. Mean serum creatinine concentration was 141.44 ± 43.31 mol/L (1.60 ± 0.49 mg/dL) and serum cystatin C 122.09 ± 38.95 nmol/L (1.63 ± 0.52 mg/L). Serum cystatin C was significantly correlated with serum creatinine (r=0.90; P

Background Paediatric urolithiasis remains endemic in low resource countries. This review highlights the epidemiology, causation and management of urolithiasis in an Asian country in the context of emerging economies. Methods A literature review of recent articles with key words paediatric urolithiasis, developing countries, endemic stone disease, stone composition, metabolic risk factors, management of paediatric urolithiasis was undertaken and 51 relevant articles were selected with the main focus on experience of this center in managing stone disease in the last two decades. Results Prevalence of paediatric urolithiasis is high upto 15% affecting children under 15 years with male predominance. Bladder stones still constitutes 10–70% of the burden. Etiology remains unknown where 55% are considered idiopathic, 25% metabolic, 7% infection and 12% due to anatomical abnormalities. Hot climate, poor nutrition, diarrheal diseases are the major causative factors. Chemical composition of stones showed CaOX in 30–63%, AAU in 17–55%, struvite in 8–9%, uric acid in 3–6% and cystine in 1%. Important metabolic risk factors are hypocitraturia in 63–87%, hyperoxaluria in 40–43%, hypocalciuria in 20%, hyperuricosuria in 27%, hyperammonuria in 11–51% and hypovolemia in 31%. Minimally invasive surgery is the mainstay of surgical management. ESWL provides excellent free rates of 84% for smaller stones. PCNL is the option for majority of renal stones with success rates of 89% for simple and 71.5% for complex stones. For bladder stones PUCL and PCCL success rates were 100%. URS for ureteric stones showed clearance rate of 90%. Open surgery is required in 12% of patients with large stone burden. Conclusion Paediatric urolithiasis remains a devastating health problem in low resource settings. MIS offers relief to majority of patients with excellent stone free rates and short hospital stay. Preventable strategies have to be put in place by improving nutrition and eliminating risk factors by diet and medical intervention.

BACKGROUND Long-term follow-up and management of donors was undertaken in a specialist kidney transplant unit in Pakistan to identify risk and prevent adverse outcomes in living related kidney donors. METHODS In an observation cohort study between 1985 and 2012, 3748 donors were offered free medical follow-up and treatment 6 to 12 months after donation and annually thereafter. Each visit included history, physical examination, blood tests for renal, lipid, glucose profiles, and 24-hour urine for proteinuria and creatinine clearance. Preventive intervention was undertaken for new onset clinical conditions. Donor outcomes were compared with 90 nondonor healthy siblings matched for age, sex, and body mass index. RESULTS Of the 3748 donors, 2696 (72%) were in regular yearly follow-up for up to 27 years (median, 5.6; interquartile range, 7.9). Eleven (0.4%) died 4 to 22 years after donation with all-cause mortality of 4.0/10 000 person years. Six (0.2%) developed end-stage renal disease 5 to 17 years after donation, (2.7/10 000 person years). Proteinuria greater than 1000 mg/24 hours developed in 28 patients (1%), hypertension in 371 patients (13.7%), and diabetes in 95 patients (3.6%). Therapeutic intervention-controlled protein was less than 1000 mg/24 hours, blood pressure was below 140/90 mm Hg, and glycemic control in 85% up to 15 years after onset. Creatinine clearance fell from 109.8 ± 22.3 mL/min per 1.73 m predonation to 78 ± 17 at 1 year, 84 ± 19 at 5 years, and 70 ± 20 at 25 years. Comparison of 90 nondonor sibling and donor pairs showed significantly higher fasting glucose and hypertension in nondonors. CONCLUSIONS Long-term follow-up of donors has demonstrated end-stage renal disease in 0.6% at 25 years. Regular follow-up identified new onset of disease and allowed interventions that may have prevented adverse outcomes.

PURPOSE OF STUDY The present review summarizes the findings of most important reports on pediatric transplants from the developing world and highlights the challenges and results of the activity. RECENT FINDINGS In the past 3 years, 10 reports appeared in the literature on pediatric renal transplantation and further six more in the past 5 years. The experience ranges from 1 to 28 years for 11-300 transplants. Recipients were older than 6 years and donors were living relatives in more than 94% of the series. Cyclosporine, azathioprin and steroids are the mainstay of immunosuppression and in many centres the high costs of drugs resulted in noncompliance and discontinuation of immunosuppression. Therefore, acute rejection rates were high, more than 40% in half of the series. One-year and 5-year survival rates for grafts were 89-98% and 67-84% and for patients 88-98% and 65-90%, respectively. Major causes of graft loss were chronic rejection, acute rejection and infection and for the patients, it was infection. Growth analysis is not generally reported but when reported the deficit remains or gets worse. SUMMARY Pediatric transplantation activity in the developing world is limited to older children using mostly living related parental donors. High rejection and infection rates result in poor patient and graft survival.

We evaluated the role of clean intermittent self-catheterization through a continent catheterizable Mitrofanoff channel in an augmented bladder in children with bladder dysfunction and outlet obstruction.We retrospectively analyzed the records of 82 patients treated at a public sector hospital with pediatric urology services in a developing country. Patients came from all provinces of the country with diverse ethnic, cultural, linguistic, socioeconomic and educational backgrounds.Mean +/- SD patient age was 9.07 +/- 3.38 years (range 2.5 to 15) with a male-to-female ratio 2.5:1.0. The main congenital and acquired abnormalities were posterior urethral valves in 29% of patients, neuropathic bladder in 22%, nonneurogenic neurogenic bladder in 17%, exstrophy plus epispadias in 10% and urethral stricture in 7%. Augmentation cystoplasty was performed using various bowel segments. The Mitrofanoff channel was made using appendix in 70 cases and by the spiral Monti method in 12. A stoma was created in the right iliac fossa using VQZ plasty in 72 patients and an umbilical stoma was created in 10. Complications included bladder calculus in 3 patients, stomal stenosis in 2, subacute intestinal obstruction in 4 and acute intestinal obstruction in 1. Compliance was observed in greater than 90% of the patients at a mean followup of 860 days.In a developing country setting with a low socioeconomic and educational level it is possible to successfully perform augmentation cystoplasty with clean intermittent self-catheterization through a continent catheterizable channel in children with bladder dysfunction and outlet obstruction. The active role of pediatric urologists in the care, teaching and counseling together with free care to all are the reasons for acceptance and compliance.

Background. Long-term effects of uninephrectomy for kidney donation are of particular interest in the currently increasing practice of living-donor transplantation. We have retrospectively analyzed the general health status and renal and cardiovascular consequences of living-related kidney donation. Methods. Data of living-related kidney donors who were regularly followed up in a dedicated clinic at the Sindh Institute of Urology and Transplantation between July 2000 and January 2004 was retrieved. They had donated their kidneys from 1986 onward. Data on weight, blood pressure, creatinine clearance, level of proteinuria, and new onset diabetes mellitus were analyzed. Results. Seven hundred and thirty-six donors with a mean age of 36±10.9 years (M:F 1.1:1) were evaluated. With a mean postnephrectomy duration of 3±3.2 years (range 6 months-18 years), the creatinine clearance fell to 87% of prenephrectomy values, and 49 (6.7%) had a creatinine clearance of less than 60 mL/ min. Hypertension developed in 76 (10.3%) donors, and 179 (24.3%) had proteinuria exceeding 150 mg/24 hr. Overweight (27.8%) and obese subjects (11.5%) had a higher prevalence of hypertension and new onset diabetes mellitus. One donor developed end-stage renal failure. Conclusion. Donor nephrectomy has minimal adverse effects on overall health status. Regular donor follow-up identifies at-risk populations and potentially modifiable factors.

Renal transplantation in developing countries. Healthcare in developing countries less funded than developed nations (0.8 to 4% vs. 10 to 15%, respectively), and must contend against ∼1/3 of the population living below the poverty line ($1US/day), poor literacy (58% males/29% females), and less access to potable water and basic sanitation. Cultural and societal constraints combine with these economic obstacles to translate into poor transplantation activity. Donor shortage is a universal problem. Paid donation comprises 50% of all transplants in Pakistan. Post-transplant infections are a major problem in developing countries, with 15% developing tuberculosis, 30% cytomegalovirus, and nearly 50% bacterial infections. The solutions to these problems may seem simplistic: alleviate poverty, educate the general population, and expand the transplant programs in public sector hospitals where commerce is less likely to play a major role. The SIUT model of funding in a community-government partnership has increased the number of transplantations and patient and organ survival substantially. Over the last 15 years, it has operated by complete financial transparency, public audit and accountability. The scheme has proven effective and currently 110 transplants/year are performed, with free after care and immunosuppressive drugs. Confidence has been built in the community, with strong donations of money, equipment and medicines. We believe this model could be sustained in other developing nations.

The use of organs from live donors is an important component of transplantation today. The Ethics Committee of the Transplantation Society (TTS) has previously published a statement on ethical considerations pertaining to the live kidney donor (1). Evolving technologies have now allowed for the successful transplantation of organs from the live lung, liver, pancreas and intestine (extrarenal) donors. TheEthicsCommitteeofTTSwasconvenedattheVancouver Forumtodeliberateupontheuseoflivedonorsforextrarenal transplantation. The following is a summary of the committee’s deliberations. We believe that live extrarenal donation should proceed within the context of the ethical principles established for live kidney donation. The physical and psychosocialwelfareofahealthydonormustbeputincontextof the needs of the recipient and impact of the recipient’s illness upon the donor. In principle, the Ethics Committee of TTS recommends that live lung, liver, pancreas and intestine donationshouldonlybeperformedwhentheaggregatebenefits to the donor-recipient pair (survival, quality of life, psychological,andsocialwellbeing)outweightheriskstothedonorrecipientpair(death,medical,psychological,andsocialmorbidities). At the Vancouver Forum, emerging data pertaining to the aggregate risks and benefits of live lung, liver, pancreas and intestine transplantation provided more information regardingthefactorsthatenterintotheethicaldecisiontoplace a healthy person in harms way. It is now evident that live donors are the sole source of organs for transplantation in many societies; however the limited availability of information about outcomes for the donors and recipients mandates that live lung, liver, pancreas and intestine organ donation and transplantation must proceed with thoughtful independent oversight and transparency. As organs recovered from deceased donors offer substantial (and sometimes superior) benefits to potential recipients, with no risk to a healthy, live donor, efforts to maximize the use of organs from deceased donors must not be impeded by the development of live organ donation. Thisconsensusstatementcomesfromthedeliberations oftheEthicsGroupoftheVancouverForumwhichwascharged withdefiningtheessentialethicalelementsoftheprocessforthe transplantcenterperforminglivelung,liver,pancreasandintestine donor. Special emphasis upon elements and issues of informed consent, assurance of donor autonomy and the patient selection process is included for clarity.

DNA methods have resulted in improved renal allograft survival rates in cadaveric renal transplantation. This paper describes the impact of DNA typing by PCRSSP on a living related renal transplant (LRRT) programme. It evaluates error rates in serology, acute rejections, graft function and survival rates between the two typing methods. Serological typing was done on CTS 120 antisera Class 1 and 60 antisera Class 2 and 72 antisera Terasaki Class1 and 72 antisera Class2 Antigens. Low resolution PCR-SSP typing was done by 24 primers for HLA A , 48 for HLA B and 24 for HLA DR. Of the 585 transplants, 159 (Group I) were serology based, 172 serology and PCR-SSP for HLA DR (Group II) and 254 on serology and PCR-SSP for HLA A and B and only PCR-SSP for HLA DR (Group III). Error rates in serology as compared to PCR-SSP were 24% for HLA A, 16% for HLA B and 35% for HLA DR. Acute rejection in Group I were 39% Group II 30% and Group III 26% (p 0.02). Graft function of serum creatinine1.5 mg/dl at 1 year was found in 26% of Group I patients as compared to 48% of Group III (p0.0001). One and three year graft survival was 93% and 87% for Group II as compared to 81% and 69% for Group I respectively (p 0.0001). Matching by this combination of serology and PCR-SSP is not only economical for a developing country but also improves graft survival by 12% at 1 and 18% at 3 years.