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Asian Journal of Urology xxx (xxxx) xxx

Available online at www.sciencedirect.com 61

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9 Original Article 71
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12 Kidney transplantation in Indonesia: An 73
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14 update 75
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Q5 Tommy Supit a, Eriawan Agung Nugroho b,*, Ardy Santosa b, 78
18 Moh Adi Soedarso b, Nanda Daniswara b, Sofyan Rais Addin b 79
80
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a
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21 Department of General Surgery, Faculty of Medicine Diponegoro University, Dr. Kariadi General 83
22 Hospital, Semarang, Jawa Tengah, Indonesia
b
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23 Department of Urology, Faculty of Medicine Diponegoro University, Dr. Kariadi General Hospital, 85
24 Semarang, Jawa Tengah, Indonesia 86
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26 Received 11 June 2018; received in revised form 31 October 2018; accepted 6 December 2018 88
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KEYWORDS Abstract Objective: Indonesia has overcome several barriers to the growth of kidney trans- 92
31
plantation within the past decade. Currently, the procedure is increasingly performed in 93
32 Kidney
several centers across the country. However there are limited publications on kidney trans- 94
33 transplantation;
plantation from Indonesia, especially from centers outside Jakarta. This study aims to give a 95
34 End-stage renal
brief overview on transplantation performed, discuss current efforts and progresses of trans- 96
35 disease;
plantation in Indonesia and chiefly Semarang. 97
36 Chronic kidney
Methods: Retrospective analysis of 20 transplant cases in Semarang during 2014e2018 was per- 98
37 disease;
formed. Information from other transplant centers was acquired through formal correspon- 99
38 Indonesia;
dences with 11 central teaching hospitals in Jakarta, Surabaya, Yogyakarta, Malang, Bali, 100
39 Semarang;
Solo, Palembang, Aceh, Medan, Bandung, and Padang. 101
40 Epidemiology;
Results: There were 629 recorded kidney transplantations performed in 12 centers, we report 102
41 Update
on 245 cases with viable data. The average age of kidney recipients were younger (33.2 years 103
42
old) compared to the donors (45.2 years old). Approximately half of the kidneys were obtained 104
43
from related donors (48.5%) and there was only one case of cadaveric donor. The three leading 105
44
etiologies of end-stage renal disease were hypertension (36.0%), diabetes mellitus (26.9%), and 106
45
autoimmune disease (11.2%). There is only one center that has performed more than 100 kid- 107
46
ney transplants in Indonesia. 108
47
Conclusion: Indonesia has successfully overcome several major hurdles that had previously 109
48
hindered the growth of transplantation. Further improvement should concentrate on the 110
49
development of integrated organ transplant infrastructure, decentralization of transplant 111
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113
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114
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55
* Corresponding author. 117
56
E-mail address: eriawanspu@gmail.com (E.A. Nugroho). 118
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Peer review under responsibility of Second Military Medical University. 119
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https://doi.org/10.1016/j.ajur.2019.02.003 121
60 2214-3882/ª 2019 Editorial Office of Asian Journal of Urology. Production and hosting by Elsevier B.V. This is an open access article under 122
the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Please cite this article as: Supit T et al., Kidney transplantation in Indonesia: An update, Asian Journal of Urology, https://doi.org/
10.1016/j.ajur.2019.02.003
 AJUR271_proof ■ 26 February 2019 ■ 2/7

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2 T. Supit et al.

1 professionals, establishment of National kidney transplant database and changing the Nation’s 63
2 paradigm on cadaveric organ donor through public education. 64
3 ª 2019 Editorial Office of Asian Journal of Urology. Production and hosting by Elsevier B.V. This 65
4 is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ 66
5 licenses/by-nc-nd/4.0/). 67
6 68
7 69
8 70
9 71
10 72
1. Introduction Hospital (Table 1). In-clinic patients with ESRD were
11 73
actively screened as potential candidates for trans-
12 74
The number of patients diagnosed with end-stage renal plantation. Patients younger than 15 years old, older than
13 75
disease (ESRD) in Indonesia is increasing annually, showing a 70 years, diagnosed with active systemic infection, active
14 76
similar trend with the global prevalence [1,2]. With its su- malignancy, significant cardiovascular, cerebrovascular or
15 77
perior outcome, kidney transplantation remains to be the pulmonary disease, and drug/alcohol addiction were
16 78
treatment of choice for ESRD [3,4]. Aside from prohibitive considered ineligible to become a recipient. Eligible,
17 79
cultural views and the governing law, the high medical cost compliant patients with active National Health Insurance
18 80
of renal transplantation had hindered its growth in status were offered the renal transplant program. The pa-
19 81
Indonesia [5,6]. The development of kidney transplantation tient and family members provided the list of potential
20 82
in Indonesia has faced several ups and downs, affected by kidney donors. Willing potential donors underwent pre-
21 83
both global and National events [7]. Nonetheless, kidney liminary screening before undergoing further tests to
22 84
transplantation in Indonesia is back on its feet and con- determine their suitability. Donor with history of malig-
23 85
tinues to improve since 2011, hallmarked by the estab- nancy, cirrhosis, left ventricular ejection fraction
24 86
lishment of National Transplant Committee and National (LVEF) < 40%, hepatitis B, hepatitis C, human immunode-
25 87
health insurance coverage for kidney transplant [8]. The ficiency virus (HIV) infection, cytomegalovirus (CMV)
26 88
procedure is now routinely performed in several centers infection, toxoplasma, tuberculosis infection, diabetes
27 89
mainly located within Java. However, the number of mellitus and obese (body mass index >35 kg/m2) was
28 90
transplantation still remains low, covering only a minority considered ineligible. The average waiting time from the
29 91
(<5%) of ESRD patients [9]. There are limited reports on time of transplant enrollment until the actual surgery was
30 92
kidney transplant from centers outside Jakarta. To address between 6 and 8 months.
31 93
the issue, this review aims to provide the latest update on Donors were hospitalized for 7 days and recipients for 3
32 94
the number and demographics of kidney transplant in days in isolation prior to surgery. Cardiologist, pulmonolo-
33 95
Indonesia, discuss current issues on its development and gist, gastroenterologist, dentists, otorhinolaryngologist,
34 96
report on the progress of smaller-growing transplant center psychiatrist and nutritionist carried out a series of anam-
35 97
such as Semarang. nesis, physical and diagnostics examinations. The standard
36 98
induction therapy uses mycophenolate mofetil (CellCept,
37 99
Genentech, California, USA) 1 g every 12 h intravenously,
38 2. Materials and methods tracolimus (Prograf, Astellas Pharma Inc., Illinois, USA)
100
39 101
0.2 mg/kg per day every 12 h orally, and basiliximab
40 102
2.1. Indonesia (Simulect, Novartis Pharmaceuticals Corp., Florida, USA)
41 103
20 mg daily intravenously, 2 h pre-transplant and continued
42 104
Information on kidney transplant from 11 centers: Jakarta 4 days post-transplant. Kidney harvest was performed using
43 105
(Dr. Cipto Mangunkusumo hospital), Surabaya (Dr. Soetomo open mini-flank nephrectomy, transplanted with open side-
44 106
hospital), Yogyakarta (Dr. Sardjito hospital, Malang (Dr. to-end anastomosis to the external iliac artery/vein fol-
45 107
Saiful Anwar hospital), Bali (Sanglah hospital), Solo (Dr. lowed by extravesical (Lich-Gregoir) ureter reimplantation.
46 108
Moewardi hospital), Palembang (dr. M. Hoesin hospital), Post-transplant immunosuppression regiment consists of
47 109
Aceh (Dr. Zainoel Abidin hospital), Medan (H. Adam Malik life-long tracolimus and azathioprine (Imuran, Prome-
48 110
hospital), Bandung (Dr. Hasan Sadikin hospital), and Padang theus Laboratories Inc., California, USA).
49 111
(Dr. M. Djamil hospital) was acquired through formal cor-
50 112
respondence started in September 2017 with the Depart-
51
ment of Urology in each central teaching hospital. 3. Results 113
52 114
Participating urologists who performed the surgery varies
53 3.1. Transplant in Indonesia 115
between institutions and are listed in the acknowledge-
54 116
ment section. Data from Jakarta were also taken from two
55 Responses from each transplant centers were acquired 117
recent publications [10,11].
56 within a period of 2 months since the start of correspon- 118
57 dence. There is a total of 629 kidney transplants recorded 119
2.2. Semarang
58 from 12 centers across Indonesia (Fig. 1). The significant 120
59 majority of kidney transplant was performed in Jakarta 121
60 Data from Semarang was obtained through retrospective 122
analysis of medical records from 26 transplants performed (n Z 491, 78.1%) between 2011 until the end of 2017.
61 Surabaya has the second most transplants (n Z 41, 6.5%) 123
62 between January 2014 and July 2018 in Dr. Kariadi General 124

Please cite this article as: Supit T et al., Kidney transplantation in Indonesia: An update, Asian Journal of Urology, https://doi.org/
10.1016/j.ajur.2019.02.003
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Kidney Transplant in Indonesia 3

1 followed by Yogyakarta (n Z 36, 5.7%), Semarang (n Z 26, 63

Table 1 Demographics of kidney transplants in Semarang.
2 4.1%), and Malang (n Z 14, 2.2%). Yogyakarta has the 64
3 Characteristic Value earliest starting timeline, reporting their data since 1991. 65
4 Age, mean (range), year There are also several unrecorded transplants in Indonesia 66
5 Recipient (n Z 26) 33.0 (15 before 1990, before the advent of proper medical record 67
6 e50) system such as in our center in Semarang. However, it is 68
7 Donor (n Z 26) 46.1 (24 safe to assume the number is below 100 cases. The starting 69
8 e64) timeline from several smaller centers (e.g. Bali, Aceh, 70
9 Sex, male/female Medan, Bandung and Padang) is unknown (unreported). 71
10 Recipient (n Z 26) 18/8 The data from Jakarta were mainly extracted from a 72
11 Donor (n Z 26) 15/11 descriptive study published by Marbun et al. [11] The 73
12 Donor-recipient relationship, n (%) center reportedly performed 491 transplants within a 74
13 Related 19 (73.0) period of 7 years (2011e2017). However, complete follow- 75
14 Non-related 7 (27.0) up were achieved in 108 patients and an additional 30 76
15 Etiology of ESRD, n (%) patient with partially known data. The data obtained from 77
16 Hypertension 16 (61.5) each center other than Jakarta were limited to patient 78
17 Diabetes mellitus 3 (11.5) demographics, etiology of ESRD and recipient-donor rela- 79
18 Autoimmune 1 (3.9) tionship. The abovementioned data are summarized in 80
19 Glomerulonephritis 2 (7.7) Table 2. The majority of transplant patients were in their 81
20 Other 4 (15.4) 4th decade, with the average age of younger recipients 82
21 Recipient comorbidities, n (%) (35.4 years old) compared to the donors (41.3 years old). 83
22 Coronary artery disease 3 (17.6) There are more male recipients (65.7%) and donor (55.5%) 84
23 Cerebrovascular disease 3 (17.6) with an almost equal proportion of related (49.0%) and 85
24 Pulmonary tuberculosis 2 (11.8) unrelated (51.0%) transplant. The etiologies of ESRD in 86
25 Pleural effusion 2 (11.8) descending order of frequency are hypertension (37.4%), 87
26 Ascites 2 (11.8) diabetes mellitus (26.1%), glomerulonephritis (14.8%), 88
27 Hepatitis C 2 (11.8) autoimmune (11.3%), and other (10.3%). All kidneys were 89
28 Gastric erosion 2 (11.8) acquired from living donor, except one case of cadaveric 90
29 Depression 1 (5.8) transplantation performed in Surabaya. Jakarta is the only 91
30 HLA Matching, n (%) center that has performed more than 100 kidney 92
31 Full match 20 (76.9) transplantations. 93
32 4 miss match 1 (3.8) 94
33 3 miss match 1 (3.8) 95
3.2. Transplant in semarang
34 2 miss match 2 (7.7) 96
35 1 miss match 2 (7.7) 97
Since 1985, there were several renal transplantations per-
36 Number of transplant, n 98
formed in Telogorejo Hospital and Dr. Kariadi General
37 In 2014 4 99
Hospital, Semarang. We report 26 transplants performed in
38 In 2015 3 100
Dr. Kariadi General hospital from January 2014 until July
39 In 2016 5 101
2018 (Table 1). Medical records and related data prior to
40 In 2017 8 102
January 2014 are considered to be permanently lost and
41 In 2018 6 103
irretrievable. There were four transplants in 2014, three in
42 Mortality (%) 104
2015, five in 2016, eight in 2017 and six until July 2018.
43 In 2015 33.3 (1/3) 105
Transplant recipients were within the 15e70 years of age
44 In 2016 40.0 (2/5) 106
criteria, with at least one human leukocyte antigen (HLA)
45 In 2017 0 (0/8) 107
match with the donor and absence of donor-specific anti-
46 Q1 In 2018* 0 (0/6) 108
body (DSA).
47 Procedural time, mean, min 109
Patients in Semarang showed similar demographics with
48 Cold ischemic time 8.1 110
the overall Indonesian cases, where most recipients are
49 Warm ischemic time II 27.9 111
younger (33.0 years old) compared to the donors (46.1
50 Total ischemic time 36.9 112
years old). Similarly, hypertension (61.5%) was the major
51 Complications and outcome 113
etiology of ESRD. The recipient’s comorbidities include
52 Mean intraoperative bleeding, mean  SD, 384  192 114
cerebrovascular disease, coronary artery disease, history
53 mL 115
of pulmonary tuberculosis, pleural effusion, ascites, hep-
54 Recipient mean hospital stay, mean (range), 11 (10e14) 116
atitis C, gastric erosion and depression. The majority of
55 day 117
recipient received kidney from blood related donors
56 Infection, n (%) 2 (7.7) 118
(n Z 19, 73.0%). There were 20 (76.9%) full HLA match,
57 Cardiovascular, n (%) 3 (11.5) 119
two cases of one and two miss match, one case of four and
58 Total number of deaths, n (%) 5 (19.2) 120
three miss match. There were five (19.2%) cases of mor-
59 Redialysis, n (%) 3 (11.5) 121
talities, two of which occurred during post-operative re-
60 Retransplant, n (%) 0 (0.0) 122
covery period and the rest within 12 months after hospital
61 123
ESRD, end-stage renal disease; HLA: human leukocyte antigen. discharge. The cause of the two “early” mortalities was
62 124

Please cite this article as: Supit T et al., Kidney transplantation in Indonesia: An update, Asian Journal of Urology, https://doi.org/
10.1016/j.ajur.2019.02.003
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4 T. Supit et al.

1 63
2 64
3 65
4 66
5 67
6 68
7 69
8 70
9 71
10 72
11 73
12 74
13 75
14 76
15 77
16 78
17 79
18 80
19 81
20 82
21 83
22 Figure 1 Total number of transplant performed in Indonesia. The number of kidney transplant is represented by the X-axis. The 84
23 bracketed year under each center denotes the period of time, which the data were reported from. The starting timelines of Bali, 85
24 Aceh, Medan, Bandung, and Padang are undefined. 86
25 87
26 88
acute myocardial infarction. Acute signs of allograft
27 89
rejection or infection were not established in either pa- Table 2 Overall demographic of kidney transplants in
28 90
tient. The third death occurred 7 months post-transplant Indonesia.
29 91
in a 39-year-old male with history of myocardial infarc- Characteristic Value
30 92
tion and gastric erosion. The cause of death was deter-
31 Age, mean (range), year 93
mined to be heart failure due to ischemic and
32 Recipient (n Z 245) 35,4 (15e57) 94
hypertensive cardiomyopathy. Septic shock was the cause
33 Donor (n Z 245) 41,3 (17e64) 95
of death for the other two mortalities with one related to
34 Age groupa, recipient/donor, year 96
bacterial pneumonia and the other with unknown primary
35 20 6/3 97
site of infection. There were three cases of allograft
36 21e30 33/19 98
rejection, one patient with three pre-transplant HLA miss
37 31e40 29/25 99
match and the other with two HLA miss match. Post-
38 41e50 32/35 100
transplant immunosuppressive regiment was dis-
39 51e60 8/21 101
continued and all three patients underwent redialysis.
40 60 0/4 102
41 Sex, male/female 103
42 4. Discussion Recipient (n Z 245) 161/84 104
43 Donor (n Z 245) 136/109 105
44 This is the first report that presents the total number of Donor-recipient relationship, n (%) 106
45 kidney transplants performed in Indonesia. The number has Related 120 (49.0) 107
46 risen significantly within the past 5 years, especially from Unrelated 125 (51.0) 108
47 centers in Java. However, it is still far below from what is Kidney source, n (%) 109
48 needed or when compared to neighboring Southeast Asian Living donor 244 (99.6) 110
49 countries like Vietnam, Thailand, and Philippines [12,13]. Cadaveric donor 1 (0.4) 111
50 Several barriers to transplantation in Indonesia that had Etiology of ESRDb, n (%) 112
51 been previously elaborated include shortage of specialists, Hypertension 76 (37.4) 113
52 high cost, lack of easy access and information within the Diabetes mellitus 53 (26.1) 114
53 community, as well as amongst medical practitioners Autoimmune 23 (11.3) 115
54 [1,6,14]. Glomerulonephritis 30 (14.8) 116
55 Other 21 (10.3) 117
56 4.1. Insurance coverage and government rules Number of transplant performed, number of centers 118
57 <10 7 119
58 The majority of Indonesians with ESRD is still treated with 10e50 4 120
59 hemodialysis (80%), which puts a significant burden on the >50 1 121
60 National Health Insurance scheme (Jaminan Kesehatan a 122
Data excluding Jakarta and Bandung.
61 Nasional, JKN), requiring an expense of 2.2 trillion IDR (1 b 123
Data excluding Yogyakarta and Bali.
62 124

Please cite this article as: Supit T et al., Kidney transplantation in Indonesia: An update, Asian Journal of Urology, https://doi.org/
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Kidney Transplant in Indonesia 5

1 USD z 13.850 IDR) in year 2015 for hemodialysis [9]. Budget 4.3. Cadaveric donor 63
2 impact analysis has shown that peritoneal dialysis-first 64
3 policy for ESRD is much more economical compared to Until now, there is only one report of cadaveric kidney 65
4 hemodialysis-first policy, requiring 75 trillion IDR for 100% transplant performed in Indonesia. Cadaveric kidney is a 66
5 coverage within 5 years compared to 166 trillion IDR for the major source of kidneys donation, such as in Thailand 67
6 later [8]. Although direct economical analysis for renal where 2889 (50%) transplants were performed using kidneys 68
7 transplants in Indonesia has not been published, renal from deceased donor [12]. Limiting the use of cadaveric 69
8 transplant is predicted to be more economical compared to donor prevents timely operation, worsens prognosis, and 70
9 life-long hemodialysis [15,16]. Officials and legislatives are ultimately retards the growth of transplantation. The main 71
10 aware of this predicament. Thus in year 2016 they estab- reason for resistance against using cadaveric donor is 72
11 lished two regulations that would help mitigate the finan- misinformation and lack of community education among 73
12 cial burden and promote the growth of organ the general population. This is a major setback to the 74
13 transplantation in the country. 1) revisions were made in growth of kidney transplants in the country and has existed 75
14 the National Health Insurance (JKN) reimbursement since the beginning. There exists a common misconception 76
15 scheme, covering the cost of kidney transplantation which among Indonesians that organ transplantation is prohibited 77
16 is around USD 18 000 per case [17]. However, there are only by religious law [5]. The resistance for cadaveric donor is 78
17 seven out of 33 medical centers in the country that are fully based more on an individual cultural interpretation, 79
18 covered by JKN [18]. 2) Organ transplant from unrelated considering a consensus by religious figures and health ex- 80
19 donor are legalized by the Indonesian law [19]. With these perts was reached in 1995 allowing organ transplantation. 81
20 two regulations in motion, two fundamental barriers to Another common misconception is living with one kidney 82
21 kidney transplantation in Indonesia are reduced. will negatively affect the living quality of the donor, 83
22 rendering them unable to lead a normal life. Such notion is 84
23 4.2. Centralized transplant specialists evident that there is an urgent need for proper system for 85
24 educating the public. Early education about end-stage 86
25 renal disease, transplantation, and referral system has 87
Lack of trained specialists and supporting infrastructure
26 been proven to increase access to transplantation rate [22]. 88
has been the major and well-known problem that impedes
27 Overcoming this problem poses a great challenge since it 89
the growth of renal transplant in Indonesia. In 2017, there
28 requires changing one’s spiritual paradigm and cultural 90
are 426 practicing urologists serving a nation with 263 991
29 believe. Consequently, government officials, health experts 91
379 population, resulting in a ratio of one urologist for
30 and religious figures must work hand-in-hand in a contin- 92
every 619 698 Indonesians. Although the number of urolo-
31 uous effort to educate the community regarding the safety 93
gist has increased significantly from 229 in 2009, the
32 and religious permission of cadaveric organ transplantation. 94
urologist-to-patient ratio is severely low compared to the
33 95
USA that has a ratio of 1:26 520 in 2016, and UK 1:73 330 in
34 4.4. Kidney transplant in semarang 96
2014 [20,21]. A similar problem of nephrologist and
35 97
nephrology-trained nurses shortage is also present. One
36 The situation of kidney transplantation in Semarang has also 98
prominent trend from the presented data is the centrali-
37 been affected by the events elaborated by Mochtar et al. [7] 99
zation of kidney transplant within Java, mainly in bigger
38 The first recorded kidney transplant in Semarang was in 100
cities such as Jakarta, Surabaya, and Yogyakarta. Several
39 1977. Afterwards there were several unrecorded kidney 101
causes might have resulted in the uneven spread of spe-
40 transplants, mainly performed in Dr. Kariadi General Hospi- 102
cialists, but we think low incentive is the main reason for
41 tal. The renal transplant system was restarted in 2014 and 103
centralization.
42 since then the procedure has been regularly performed in 104
Without full-time transplant specialists working in rural
43 the institution. In-hospital ESRD patients are individually 105
hospital, procurement of appropriate medical facilities is
44 offered the transplant program by the nephrologist team. 106
less likely to happen. Thus, the vicious cycle of specialists
45 Although there has been a constant annual increase of kid- 107
unwilling to work in a hospital without modern facilities
46 ney transplant performed since 2014, the manual patient 108
ensues. Kidney transplant reimbursement by the National
47 recruitment system will eventually limit the center from 109
Health Insurance might have backfired in this aspect, since
48 ever reaching its maximum potential. The average waiting 110
specialists working smaller hospital will eventually refer
49 time for Semarang patients was 6e8 months from the start of 111
patients with complex diseases to bigger tertiary hospitals
50 enrollment until the operation. The waiting time and total 112
that are covered with larger insurance capitation. Contin-
51 number of transplant can be greatly increased by a coordi- 113
uous efforts are being made to rectify this problem, such as
52 nated National database online system. 114
the expansion of urology residency training program,
53 We report on 26 cases of living-donor transplantations 115
obligatory work program in rural area for new graduates,
54 from January 2014 until July 2018. In contrast, Cipto Man- 116
and continuous transplant supervision by the National
55 gunkusumo Hospital in Jakarta performed 491 transplants 117
Transplantation Committee headed by a team from Cipto
56 within 6 years [11]. There were five (19.2%) mortalities in 118
Mangunkusumo Hospital (RSCM) [7]. However, such mea-
57 Semarang, all within 12 months post-transplant. The mor- 119
sures may only temporarily solve the problem. Complete
58 tality rate is similar to Jakarta (n Z 28, 20.28%) as reported 120
decentralization of specialists into rural areas is a long-
59 by Marbun et al. [11] In Semarang two patients (40.0%) died 121
term goal that requires commitment from all responsible
60 during post-operative recovery due to acute myocardial 122
bodies: government, medical associations, and individual
61 infraction, one patient (20.0%) died because of 123
specialists.
62 124

Please cite this article as: Supit T et al., Kidney transplantation in Indonesia: An update, Asian Journal of Urology, https://doi.org/
10.1016/j.ajur.2019.02.003
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6 T. Supit et al.

1 cardiomyopathy, and two patients (40.0%) caused by sepsis. Author contributions 63

2 The main cause of death in Jakarta was sepsis (n Z 8, 64
3 40.0%), followed by unknown cause (n Z 7, 35.0%), pul- Study conception and design: Tommy Supit, Eriawan Agung 65
4 monary edema (n Z 2, 10.0%), hepatitis (n Z 2, 10.0%) and Nugroho, and Ardy Santosa. 66
5 stroke (n Z 1, 5.0%). Marcelino et al. [10] published the Data acquisition: Tommy Supit, and Eriawan Agung 67
6 only Indonesian data available for comparison, which was Nugroho. 68
7 based on laparoscopic living-donor nephrectomy (LLDN) Data analysis: Tommy Supit, Eriawan Agung Nugroho, 69
8 technique. In terms of procedural time, the average first Ardy Santosa, Moh Adi. 70
9 warm ischemic time (WIT) of open technique in Semarang Soedarso, Nanda Daniswara, and Sofyan Rais Addin. 71
10 was longer compared to the LLDN in Jakarta (6.6 min vs. Drafting of manuscript: Tommy Supit, and Eriawan 72
11 4.3 min). Expectedly, the average intraoperative blood loss Agung Nugroho. 73
12 was also higher in open technique (384  192 mL vs. Critical revision of the manuscript: Tommy Supit, Eria- 74
13 194  198 mL). However, no urinary retention, operative wan Agung Nugroho, Ardy Santosa, Moh Adi Soedarso, 75
14 wound site infection or severe pain (Visual Analogue Scale Nanda Daniswara, and Sofyan Rais Addin. 76
15 7) was recorded. Performing kidney transplant: Eriawan Agung Nugroho, 77
16 Based on the outcome of 17 patients that surpassed the Ardy Santosa, Moh Adi Soedarso, Nanda Daniswara, and 78
17 12-month mark, the 1-year survival rate of transplant Sofyan Rais Addin. 79
18 patient in Semarang is 70.6%. Compared to Jakarta, the 1- 80
19 year survival is 88.5% and 3-year survival is 79.7% [11]. 81
20 Compared abroad, the 1-year survival rates for living Conflicts of interest 82
21 donor kidney transplants are 97.2% in USA, 98.0% in 83
22 Australia and New Zealand, 95.8% in Europe, and 97.7% in The authors declare no conflict of interest. 84
23 Canada [23]. The limited number of transplant in Semar- 85
24 ang contributes to the low number of survival rate. It also 86
25 highlights the need of training and expertise. Better sur- Acknowledgements 87
26 vival rate can be achieved with more transplants number 88
27 as well as reaching the plateau of learning curve within 89
We would like to acknowledge all personnel and urologists Q2
28 the coming years. The transplant team in Semarang is also 90
(listed below) across Indonesia involved in renal trans-
29 in the process of applying LLDN technique to achieve 91
plantation, for the data and ongoing contributions in the
30 better operative results [10,24]. An exclusive hospital- 92
field.
31 patient communication and medical record system for 93
Jakarta: Chaidir A. Mochtar, Nur Rasyid, Arry Rodjani,
32 kidney transplant patients is also being established to 94
Irfan Wahyudi, and Agus Rizal A. H. Hamid.
33 ensure a long-term and complete follow-up. The initial 95
Surabaya: Doddy M. Soebadi, Wahjoe Djatisoesanto,
34 goal of our institution is to establish a firm kidney trans- 96
Tarmono, Fikri Rizaldi, and Johan Renaldo.
35 plant center capable of covering Central Java, aiding the 97
Yogyakarta: Danarto, Trisula Utomo, Untung Tranggono,
36 decentralization of kidney transplant. 98
and Indrawarman.
37 99
Malang: Besut Daryanto, Kurnia Penta Seputra, Paksi
38 100
39
5. Conclusions Satyagraha, and Pradana Nurhadi.
101
Bali: Anak Agung Gede Oka, Gede Wirya Kusuma Duarsa,
40 102
This is the first report on the number of overall kidney Kadek, Budi santosa, and I Wayan Yudiana.
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transplantation data in Indonesia. Kidney transplantation in Solo: Suharto Wijanarko, Setya Anton Tusarawardaya,
42 104
Indonesia can be considered to be still in its infancy. There Bimanggono Hernowo Murti, and Wibisono.
43 105
has been a consistent increase of kidney transplantation, Palembang: Arizal Agoes, Didit Pramundhito, and Marta
44 106
however still concentrated within the capital city. Major Hendry.
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barriers that have been surmounted include the establish- Aceh: Dahril and Jufriady Ismy.
46 108
ment of National Health Insurance full coverage in 11 Medan: Syah Mirsya Warli, Ramlan Nasution, Dhirajaya
47 109
appointed hospitals and a National law that permits organ Dharma Kadar, and Ginanda Putra Siregar.
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transplantation. As of 2018, the five leading centers that Bandung: Tjahjodjati, Ferry Safriadi, Kuncoro Adi, Aaron
49 111
performed the most transplants are Jakarta, Surabaya, Tigor Sihombing, and Jupiter Sibarani.
50 112
Yogyakarta, Semarang and Malang. Currently, there are Padang: Dody Efmansyah, Alvarino, Yevri Zulfiqar,
51 113
limited Indonesian data to compare the intra- and post- Etriyel Myh, and Peri Eriad Yunir.
52 114
53 operative results of our center. However, improved expe- 115
54 rience and expertise are imperative to achieve better and 116
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Please cite this article as: Supit T et al., Kidney transplantation in Indonesia: An update, Asian Journal of Urology, https://doi.org/
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Please cite this article as: Supit T et al., Kidney transplantation in Indonesia: An update, Asian Journal of Urology, https://doi.org/
10.1016/j.ajur.2019.02.003