Managing Immunological High Risk Kidney Transplant Patients In Nigeria, A Microcosm Of Resource-Constrained Setting; Evidence And Practice
Main Article Content
Keywords
Kidney transplantation, High risk, Highly sensitized, ATGAM, thymoglobulin, Nigeria
Abstract
Background: Black patients awaiting transplantation are more likely to be immunologically sensitized than White, Hispanic, or Asian patients. In Nigeria, the situation is compounded by multiple blood transfusions before and during dialysis, including patients on the waiting list for kidney transplantation. Tailored immunosuppressive regimens and allocation policies are being explored to address the unique genetic and immunological profiles of Black patients and improve outcomes. Comparing practice in the selected Nigerian center with international and local guidelines on induction immunosuppression is the main crux of this review. This review focused on current practices in induction regimen for kidney transplantation in immunologically high-risk patients in a Nigerian transplant setting, explores its outcome and compares this practice and its outcome with practice in other centers and international kidney transplant guidelines.
Keyword searches of academic databases - PUBMED, SCOPUS, AJOL, Cochrane, ISI, Google scholar and IBSS databases were conducted. Manual searches of other relevant journals and reference lists of primary articles.
Anti-thymocyte globulin remains the choice of induction agent, with the same dose used for both non sensitized and highly sensitized patients. Induction regimen used in the index center was given for a shorter duration of 3-5 days when compared to standard guideline recommendations of 21 doses over 28 days. However, the 3-month and 12-month graft outcome obtained was 90% and 90%, respectively, in the index center; and this was comparable to the outcome in centers where the standard protocol was employed.
There is no change in the choice of immunosuppressive agent for kidney transplant in Nigeria and other centers and guidelines reviewed. With ongoing efforts to reduce the widening gap in transplant care by having an individualized approach to care, this narrative explores current practices in a resource-constrained setting as compared to guideline recommendations and provides a basis for future studies.
References
2.Schrem H, Barg-Hock H, Strassburg CP, Schwarz A, Klempnauer J. Aftercare for patients with transplanted organs. Dtsch Arztebl Int. 2009 ;106:148-56. doi: 10.3238/arztebl.2009.0148.
3.Anwar IJ, Jackson AM, Locke JE, Kwun J. Editorial: Sensitization and Desensitization in organ transplantation. Front Immunol. 2021;12:784472
4.Poggio ED, Augustine JJ, Arrigain S, Brennan DC, Schold JD. Long-term kidney transplant graft survival-Making progress when most needed. Am J Transplant. 2021;21:2824-2832. doi: 10.1111/ajt. 16463.
5.Assessment and management of immunologic risk in Transplantation: A CCDT Consensus forum. Available at https://professionaleducation.blood.ca/sites/default/ files /Immunologic-Risk.pdf, Accessed on November 29th, 2025 by 11:00 am
6.Pratschke J, Dragun D, Hauser IA, Horn S, Mueller TF, Schemmer P, et al. Immunological risk assessment: The key to individualized immunosuppression after kidney transplantation. Transplant Rev (Orlando). 2016;30:77-84. doi: 10.1016/j.trre.2016.02.002
7.Morris, A, Cole, R, Veledar, E. et al. Influence of Race/Ethnic Differences in Pre-Transplantation Panel Reactive Antibody on Outcomes in Heart Transplant Recipients. JACC. 2013; 62:2308–2315. https://doi.org/10.1016/j.jacc.2013.06.054
8.Adesola RO, Opuni E, Idris I, Okesanya OJ, Igwe O, Abdulazeez MD, et al. Navigating Nigeria's Health Landscape: Population Growth and Its Health Implications. Environ Health Insights. 2024;18:11786302241250211. doi: 10.1177/11786302241250211.
9.Uneke CJ, Ezeoha AE, Ndukwe CD, Oyibo PG, Onwe F, Aulakh BK. Research priority setting for health policy and health systems strengthening in Nigeria: the policymakers and stakeholders' perspective and involvement. Pan Afr Med J. 2013;16:10. doi: 10.11604/pamj.2013.16.10.2318.
10.Geiling J, Burkle FM Jr, Amundson D, Dominguez-Cherit G, Gomersall CD, Lim ML, et al; Task Force for Mass Critical Care. Resource-poor settings: infrastructure and capacity building: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest. 2014;146:e156S-67S. doi: 10.1378/chest.14-0744
11.Adejumo OA, Akinbodewa AA, Okaka EI, Alli OE, Ibukun IF. Chronic kidney disease in Nigeria: Late presentation is still the norm. Niger Med J 2016;57:185-9
12.Ulasi II, Ijoma CK. The enormity of chronic kidney disease in Nigeria: The situation in a teaching hospital in South-East Nigeria. J Trop Med 2010;2010:501957.
13.Olatise O O, Asaolu S O, Muoka M O, Faponle A E, Igbokwe M C, Anosike I, et al. Successful Third Kidney Transplantation in a Nigerian Kidney Transplant Center: A Case Report. Cureus. 2022; 14: e32521. doi:10.7759/cureus.32521
14.Federal Medical Center Umuahia. Available at https://en.wikipedia.org/wiki/ Federal _Medical_Centre,_Umuahia. Accessed on November 30th, 2025 by 10:15am
15.Okwuonu CG, Chukwuonye II, Mbanaso, Oviasu E. Clinical profile and outcome of haemodialysis-treated patients in a new dialysis centre in Southeast Nigeria. Abstract presented at the World Conference of Nephrology, Cape Town 2015
16.Okoye O, Mamven M. Global dialysis perspective: Nigeria. Kidney360. 2022;3: 1607-1610
17.Arogundade FA. Kidney transplantation in a low-resource setting: Nigeria experience. Kidney Int Suppl (2011). 2013;3:241-245
18.Regulatory Pulse, Legal and regulatory developments in the health and social sectors. Available at https://healthlaw.com.ng/wp-content/uploads/2025/03/Regulatory-Pulse-Newsletter_20250311_164141_0000.pdf
19.FMC, Umuahia, American University sign MoU on kidney transplant- The Nation Newspaper. Available at https://share.google/eyxLb9qlSrwu4dO76. Accessed on November 30th, 2025 by 10:15am
20.Okwuonu CG, Achor GO, Erondu NM, Ekwenna O, Alhassan S, Abali C, et al. Performance and Outcome of Pioneering Kidney Transplantation in a Resource-Constrained Setting in Southeast Nigeria. West Afr J Med. 2025;42:413-418.
21.Assessment and management of immunological risk in transplantation. A Canadian Council for Donation and Transplantation Consensus forum. 2025. Montreal, Quebec
22.Bray RA, Nolen JD, Larsen C, Pearson T, Newell KA, Kokko K, et al. Transplanting the highly sensitized patient: The emory algorithm. Am J Transplant. 2006;6(10):2307-15.
23.Hill P, Cross NB, Barnett ANR, Palmer SC, Webster AC. Polyclonal and monoclonal antibodies for induction therapy in kidney transplant recipients. Cochrane Database Syst Rev: 2017;1.CD004759.
24.Hardinger KL, Brennan DC, Klein CL. Selection of induction therapy in kidney transplantation. Transpl Int. 2013;26: 662-672.
25.Mourad G, Garrigue V, Squifflet JP, et al. Induction versus non-induction in renal transplant recipients with tacrolimus‐based immunosuppression. Transplantation 2001; 72: 1050
26.Hammond EB, Taber DJ, Weimert NA, Egidi MF, Bratton CF, Lin A, McGillicuddy JW, Chavin KD, Baliga PK. Efficacy of induction therapy on acute rejection and graft outcomes in African American kidney transplantation. Clin Transplant. 2010;24(1):40-7.
27.Kim JM, Jang HR, Ko JS, Kwon CH, Kwak MS, Hur WS. Comparison between thymoglobulin and ATGAM as an induction agent in adult kidney transplantation: a single-center experience. Transplant Proc. 2012;44:171-4. doi: 10.1016/j.transproceed.2011.11.061.
28.Muhammad Abdul Mabood Khalil, Muhammad Ashhad Ullah Khalil, Taqi F. Taufeeq Khan, Jackson Tan, "Drug-Induced Haematological Cytopenia in Kidney Transplantation and the Challenges It Poses for Kidney Transplant Physicians.
J Transplantation. 2018;2018: 9429265
29.Meesters-Ensing JI, Admiraal R, Ebskamp L, Lacna A, Boelens JJ, Lindemans CA, Nierkens S. Therapeutic Drug Monitoring of Anti-Thymocyte Globulin in Allogeneic Stem Cell Transplantation: Proof of Concept. Front Pharmacol. 2022;13:828094. doi: 10.3389/fphar.2022.828094. Erratum in: Front Pharmacol. 2024;15:1444228.
30.Shenton, B.K, Manas D, Dark JH, Talbot D, Clark KR, Bell A. Immune monitoring of anti-thymocyte globulin (ATG) treatment in transplant patients, Clinical and Applied Immunology Reviews. 2001;6:347-371
Wang H, Yang H, Du J, Dou L, Liu D. Optimizing anti-thymocyte globulin dosing in allogeneic hematopoietic stem cell transplantation: individualized approaches and clinical implications. Frontiers in Immunology.2025;16. DOI=10.3389/fimmu.2025.1634157
32.Amrani ME, Admiraal R, Willaert L, Ebskamp-van Raaij LJC, Lacna AM, Hack CE, Huitema ADR, Nierkens S, van Maarseveen EM. Quantification of T Cell Binding Polyclonal Rabbit Anti-thymocyte Globulin in Human Plasma with Liquid Chromatography Tandem-Mass Spectrometry. AAPS J. 2020;22:43. doi: 10.1208/s12248-020-0419-6
33.Ata P, Kara M, Özdemir E, Canbakan M, Gökçe AM, Bayraktar FA, Monitoring of CD3(+) T-cell count in patients receiving antithymocyte globulin induction after cadaveric renal transplantation. Transplant Proc. 2013;45:929-31. doi: 10.1016/j.transproceed.2013.02.092.
34.Rasander RO, Sørensen SS, Krohn PS , Bruunsgaard H. Interruption of anti-thymocyte globuline treatment in solid organ transplantation is effectively monitored through a low total lymphocyte count. Frontiers in Immunology.2024;15. DOI=10.3389/fimmu.2024.1419726
35.Eisinger F, Mühlbacher T, Na A, Althaus K, Nadalin S, Birkenfeld AL, et al. Standardized, risk-adapted induction therapy in kidney transplantation. J Nephrol. 2023;36:2133-2138.
36.Boucquemont J, Foucher Y, Masset C, Legendre C, Scemla A, Buron F,; DIVAT consortium. Induction therapy in kidney transplant recipients: Description of the practices according to the calendar period from the French multicentric DIVAT cohort. PLoS One. 2020;15:e0240929.
37.Kidney Disease: Improving Global Outcomes (KDIGO) Transplant Work Group. KDIGO clinical practice guideline for the care of kidney transplant recipients. Am J Transplantation 2009; 9: 1–157.
38.Chadban SJ, Ahn C, Axelrod DA, Foster BJ, Kasiske BL, Kher V. KDIGO Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation. Transplantation. 2020; 104: 11-103
39.Keizer KM, de Fijter JW, Haase-Kromwijk BJ, Weimar W. Non-heart-beating donor kidneys in the Netherlands: allocation and outcome of transplantation. Transplantation. 2005;79:1195-9. doi: 10.1097/01.tp.0000160765.66962.0b.
40.Thervet E, Pfeffer P, Scolari MP, Toselli L, Pallardó LM, Chadban S, et al. Clinical outcomes during the first three months posttransplant in renal allograft recipients managed by C2 monitoring of cyclosporine microemulsion. Transplantation. 2003;76:903-8. doi: 10.1097/01.TP.0000089006.00653.64.
41.Cecka JM. The UNOS Renal Transplant Registry. Clin Transpl. 2002:1-20. PMID: 12971433.
42.Ghelichi-Ghojogh M, Mohammadizadeh F, Jafari F, Vali M, Jahanian S, Mohammadi M. The global survival rate of graft and patient in kidney transplantation of children: a systematic review and meta-analysis. BMC Pediatr. 2022 Aug 24;22(1):503. doi: 10.1186/s12887-022-03545-2. PMID: 36002803; PMCID: PMC9404642.
43.Nigeria Overview: Development news, research, data. World Bank. Available at https://share.google/cuz5ohOuG02Mjaw. Accessed in November 30th, 2025 by 6:10pm
44.Huh J, Baines L, Talbot D, MacFie C. Severe anti-thymocyte globulin-induced cytokine release syndrome in a renal transplant patient. Anaesth Rep. 2021;9:16-19. doi: 10.1002/anr3.12092.
45.Knaus HA, Rottner T, Baumann CK, Cserna J, Mitterbauer M, Schulenburg A, et al. Cytokine Release Syndrome during Antithymocyte Globulin/Anti-T Lymphocyte Globulin Serotherapy for Graft-versus-Host Disease Prophylaxis before Allogeneic Hematopoietic Stem Cell Transplantation: Incidence and Early Clinical Impact According to American Society of Transplantation and Cellular Therapy Grading Criteria. Transplant Cell Ther. 2022;28:260.e1-260.e9. doi: 10.1016/j.jtct.2022.02.016.
46.Siddiqui S, Cox J, Herzig R, Palaniyandi S, Hildebrandt GC, Munker R. Anti-thymocyte globulin in haematology: Recent developments. Indian J Med Res. 2019;150:221-227. doi: 10.4103/ijmr.IJMR_752_19.
47.Guarnera L, Ahmed A, Bravo-Perez C, Ogbue OD, D'Addona M, Brady Z, et al. Anti-thymocyte globulin in immune-mediated cytopenias: A monocentric experience and literature review. Br J Haematol. 2025;207:284–8. doi: 10.1111/bjh. 20165.
48.Khalil MAM, Khalil MAU, Khan TFT, Tan J. Drug-Induced Hematological Cytopenia in Kidney Transplantation and the Challenges It Poses for Kidney Transplant Physicians. J Transplant. 2018;2018:9429265. doi: 10.1155/2018/9429265.
49.Olund RR, Schwartz SS, Suno KP, Helle B. Interruption of anti-thymocyte globulin treatment in solid organ transplantation is effectively monitored through a low total lymphocyte count. Frontiers in Immunology. 2024;15: DOI=10.3389/fimmu. 2024.1419726
50.Mathis AS, Rao V. Deep vein thrombosis during rabbit antithymocyte globulin administration. Transplant Proc. 2004;36:3250-1. doi: 10.1016/j.transproceed. 2004.09.086.
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