Transmission of clear cell tumor in a graft liver from cadaveric donor: Case report

Backes AN, Tannuri ACA, de Mello ES, Gibelli NEM, de Castro Andrade W, Tannuri U. Transmission of clear cell tumor in a graft liver from cadaveric donor: Case report. Abstract: Neoplasms in children after organ transplantation are related to the type and intensity of immunosuppression and the donor–recipient serostatus, especially in relation to the Epstein–Barr virus. The patient was a two‐yr‐old female child with biliary atresia who underwent a liver transplantation from a female cadaver donor. Two adults received kidney transplants from the same donor. Nine months after transplantation, one of the adult recipients developed an urothelial tumor in the kidney graft. Imaging tests were repeated monthly in the liver‐transplanted child and revealed no abnormalities. However, one yr and two months after the transplantation, the patient developed episodes of fever. At that time, imaging and liver biopsy showed a clear cell tumor of urothelial origin in the graft and the disease was limited to the liver. The patient underwent liver retransplantation, and she is currently free of tumor recurrence. Although rare, the occurrence of tumors in the post‐transplant period from cadaver donors, without previously diagnosed tumors, is one of the many problems encountered in the complex world of organ transplantation.     

Kidney transplantation from pediatric donors: size-match-based allocation

Abstract:  Use of kidneys from pediatric donors has been associated with worse outcome. We review our 20-yr experience using pediatric kidneys as single grafts in children and adult recipients. Charts review of 29 recipients, transplanted between 1986 and 2005, who received a graft from a donor ≤6 yr was performed. One recipient received "en bloc" graft and the remaining patients received a single kidney. Nine recipients were adults and 21 were children. Creatinine at discharge and at follow-up was recorded and actuarial graft and patient survivals were calculated using life table analysis. All 29 recipients are alive at mean follow-up of 92 months. Five grafts were lost for: primary non-function (1), recurrent FSGS at 14 month (1) and chronic rejection (3). All five recipients who lost their graft received a graft from donors ≤3 yr. Mean calculated GFR (Schwartz formula) at one and five yr were 84.2 mL/m²/1.73 and 98.3 mL/m²/1.73, respectively. Actuarial graft survival was 93.2%, 89.6%, and 81.9% at one, five and at 10 yr after transplant. The use of a single kidney graft from pediatric donors yields good long-term results. Kidneys from small pediatric donors should be allocated first to matched-weight recipients but otherwise can be transplanted in older children or in adults.     

Early outcome in renal transplantation from large donors to small and size-matched recipients - a porcine experimental model

Kidney transplantation from a large donor to a small recipient, as in pediatric transplantation, is associated with an increased risk of thrombosis and DGF. We established a porcine model for renal transplantation from an adult donor to a small or size-matched recipient with a high risk of DGF and studied GFR, RPP using MRI, and markers of kidney injury within 10 h after transplantation. After induction of BD, kidneys were removed from ～63-kg donors and kept in cold storage for ～22 h until transplanted into small (～15 kg, n = 8) or size-matched (n = 8) recipients. A reduction in GFR was observed in small recipients within 60 min after reperfusion. Interestingly, this was associated with a significant reduction in medullary RPP, while there was no significant change in the size-matched recipients. No difference was observed in urinary NGAL excretion between the groups. A significant higher level of HO-1 mRNA was observed in small recipients than in donors and size-matched recipients indicating cortical injury. Improvement in early graft perfusion may be a goal to improve short- and long-term GFR and avoid graft thrombosis in pediatric recipients.     

Growth following solid-organ transplantation

One of the ultimate goals of successful transplantation (Tx) in pediatric solid-organ transplant recipients is the attainment of optimal final adult height. Except for kidney Tx there are limited data to address this issue. Remarkably similar factors impact on growth in pediatric kidney, liver, and heart recipients. Age is a primary factor, with younger recipients exhibiting the greatest immediate catch-up growth. Graft function is a significant contributory factor: a reduction in glomerular filtration rate (GFR) correlates with poor growth in kidney recipients, and the need for re-Tx is associated with impaired growth in liver recipients. The known adverse impact of corticosteroids on growth has led transplant physicians/surgeons to either modify the dose or attempt steroid withdrawal. In kidney and liver recipients this is associated with the development of acute rejection episodes. In infant heart transplant recipients the avoidance of maintenance corticosteroid immunosuppression is associated with normal growth velocity in the majority of recipients. With the marked improvement in patient and graft survival rates in pediatric solid-organ graft recipients, it is timely that the quality-of-life issues receive paramount attention. In children, normal growth following solid-organ Tx should be an achievable goal that results in normal final adult height.     

Long-term outcome of intensive initial immunosuppression protocol in pediatric deceased donor renal transplantation

Olaitan OK, Zimmermann JA, Shields WP, Rodriguez-Navas G, Awan A, Mohan P, Little DM, Hickey DP. Long-term outcome of intensive initial immunosuppression protocol in pediatric deceased donor renal transplantation.
Pediatr Transplantation 2010: 14: 87–92. © 2009 John Wiley & Sons A/S.
Abstract:  To report the long-term outcome of deceased donor kidney transplantation in children with emphasis on the use of an intensive initial immunosuppression protocol using R-ATG as antibody induction. Between January 1991 and December 1997, 82 deceased donor kidney transplantations were performed in 75 pediatric recipients. Mean recipient age at transplantation was 12.9 yr and the mean follow-up period was 12.6 yr. All patients received quadruple immunosuppression with steroid, cyclosporine, azathioprine, and antibody induction using R-ATG-Fresenius^®. Actual one, five, and 10 yr patient survival rates were 99%, 97%, and 94%, respectively; only one patient (1.2%) developed PTLD. Actual one, five, and 10 yr overall graft survival rates were 84%, 71%, and 50%, respectively; there were five cases (6%) of graft thrombosis and the actual immunological graft survival rates were 91%, 78%, and 63% at one, five, and 10 yr, respectively. The use of an intensive initial immunosuppression protocol with R-ATG as antibody induction is safe and effective in pediatric recipients of deceased donor kidneys with excellent immunological graft survival without an increase in PTLD or other neoplasms over a minimum 10-yr follow up.     

Renal function after combined liver‐kidney transplantation: A longitudinal study of pediatric and adult patients

It has been proposed that the liver protects the kidney in CLKT. However, few studies have examined long‐term renal function after CLKT and contrasted renal function of CLKT patients to KT patients beyond one year after transplantation. We studied long‐term renal function of CLKT patients and compared renal function of CLKT patients to KT patients between one and five years after transplantation. Patients who underwent CLKT between 1993 and 2011 were included (n = 34; 11 children and 23 adults). Ninety‐six (27 children and 69 adults) KT patients were selected as controls. GFR was estimated (eGFR) and measured (mGFR) with ⁵¹Cr‐EDTA clearance. Mean mGFR was 63 at one and 70 at ten years after pediatric CLKT. Mean eGFR was 75 at one and 50 at ten years after adult CLKT. Difference in mean mGFR between pediatric CLKT and KT patients was 8 (95% CI ?7 to 23) and 11 (95% CI ?4 to 26) at one and five years after transplantation, respectively. Difference in mean eGFR between adult CLKT and KT patients was 8 (95% CI ?5 to 20) and 1 (95% CI ?10 to 12) at one and five years after transplantation, respectively. Longitudinal changes in GFRs were somewhat similar in CLKT and KT patients in both age‐groups but pediatric CLKT patients had on average higher GFRs than pediatric KT patients. In long‐term follow‐up, renal function remains stable in pediatric CLKT patients but declines in adult CLKT patients.     

Hyperuricemia after liver transplantation in children

Uric acid may be involved in the development and progression of kidney diseases. Hyperuricemia is a common feature in adult liver transplant recipients but there is limited information in children. In order to estimate the incidence, predictors of hyperuricemia in pediatric liver transplant recipients, and to assess whether hyperuricemia may impact long-term renal function determined by measured GFR, we reviewed data of 70 children who received a first liver transplant between 1991 and 2005 (median follow-up 7.1 yr). Renal function tests performed annually included uric acid concentration, inulin and uric acid clearances. The cumulative incidence of hyperuricemia was 32% at 10-yr post-transplantation, mainly because of decreased urate excretion. The only factor significantly associated with an increased risk of hyperuricemia was older age. After adjustment for donor and recipient age, gender, primary liver disease, immunosuppression, and post-operative acute renal failure, hyperuricemia as time dependent variable tended to predict (p = 0.05) subsequent CRI. The control of serum urate concentration in eight of the 21 hyperuricemic patients either by nutritional management or by allopurinol was not followed by a significant GFR improvement. Hyperuricemia after liver transplantation in children is a frequent problem which needs further investigation.     

Early complications after liver transplantation in children and adults: Are split grafts equal to each other and equal to whole livers?

Split‐liver transplantation (LT) allows transplantation of two recipients from one deceased donor, thereby increasing pool of grafts. However, split LT may be hampered by technical problems, and split grafts are still considered suboptimal organs in some centres. We analysed the outcomes in split‐ and whole‐liver recipients in a combined adult‐to‐paediatric transplantation programme. Records of paediatric and adult patients having undergone LT from 1999 to 2013 were analysed retrospectively. All splits were performed in situ. Adult split‐graft recipients were matched 1:2 with whole‐graft recipients (matching criteria: BMI, MELD, year of transplantation, age), and matched to the paediatric recipient transplanted from the same donor. Post‐LT complications were classified according to the Clavien scale. Among children, 32 split‐ and 31 whole‐graft recipients were analysed. Among adults, 20 split‐ and 40 matched whole‐graft recipients were analysed. In both populations, the post‐operative complications did not differ between split‐ and whole‐graft recipients. There was no difference in 1‐year graft and patient survival between split‐ and whole‐graft recipients in paediatric (90% vs. 97%, 94% vs. 97%, respectively) and in adult recipients (89% in both, 89% vs. 92%, respectively). In the analysis of both recipients issued from the same donor, there was no association in the prevalence and severity of complications. A case‐by‐case analysis showed that split mortality was unrelated to LT in all but one patient (small‐for‐size left split graft). In the setting of careful donor selection, recipient matching and surgical skill, in situ split LT is an effective and safe technique to increase the number of available organs, and split livers should no longer considered marginal grafts.     

Determinants of graft survival in pediatric and adolescent live donor kidney transplant recipients: a single center experience

To study the independent determinants of graft survival among pediatric and adolescent live donor kidney transplant recipients. Between March 1976 and March 2004, 1600 live donor kidney transplants were carried out in our center. Of them 284 were 20 yr old or younger (mean age 13.1 yr, ranging from 5 to 20 yr). Evaluation of the possible variables that may affect graft survival were carried out using univariate and multivariate analyses. Studied factors included age, gender, relation between donor and recipient, original kidney disease, ABO blood group, pretransplant blood transfusion, human leukocyte antigen (HLA) matching, pretransplant dialysis, height standard deviation score (SDS), pretransplant hypertension, cold ischemia time, number of renal arteries, ureteral anastomosis, time to diuresis, time of transplantation, occurrence of acute tubular necrosis (ATN), primary and secondary immunosuppression, total dose of steroids in the first 3 months, development of acute rejection and post-transplant hypertension. Using univariate analysis, the significant predictors for graft survival were HLA matching, type of primary urinary recontinuity, time to diuresis, ATN, acute rejection and post-transplant hypertension. The multivariate analysis restricted the significance to acute rejection and post-transplant hypertension. The independent determinants of graft survival in live-donor pediatric and adolescent renal transplant recipients are acute rejection and post-transplant hypertension.     

Extraperitoneal renal transplantation in small children results in a transient improvement in early graft function

Renal transplantation is considered more technically challenging in small children compared to adults, especially when live donor adult kidneys are used. Transplanted kidneys have traditionally been placed intraperitoneally, although over the last decade extraperitoneal positioning has been attempted. The aim of this study was to establish whether there is a difference in kidney function and outcome dependent on the surgical approach to transplantation. The medical notes of all children under the age of six who received a renal transplant at our unit between January 1998 and October 2009 were reviewed. Demographic data, operation details, HLA mismatch, immunosuppression regime, complications, and function of the graft were analyzed. A total of 30 transplants were performed in children under six yr of age. The one-yr patient and graft survival were 97% and 93%, respectively. Eighteen were undertaken via an intraperitoneal approach, with the remaining being placed extraperitoneally. There were no significant differences in the number of complications observed between the two groups, and median length of stay was comparable (extraperitoneal 19.5 days vs. intraperitoneal 20.5 days). The plasma creatinine values for the two groups were compared using multivariate linear regression analysis and adjusted for age, weight, gender and baseline plasma creatinine. Between days 2 and 14 post-operatively, there was a significant difference in absolute plasma creatinine between the two surgical approaches. However, the trend of change in mean plasma creatinine values over time did not differ significantly between the two groups. Extraperitoneal kidney transplantation in small children is safe and technically feasible. From our series, there appears to be early improved function, although there is no long-term difference in function between approaches.     

Pediatric renal transplantation: a review of the UNOS data. United Network for Organ Sharing

The UNOS Scientific Renal Transplant Registry data from October 1987 to December 1996, including information on transplants to 537 patients aged 0-2, 2399 patients aged 3-12 and 5986 patients aged 13-21, were used to examine the results of pediatric transplantation by both univariate and multivariate methods. One-year and long-term graft survival rates were adjusted for 9 covariates including donor source and age, recipient sex, race and disease, and transplant year, HLA mismatches, and transplant center. The adjusted 1- and 5-year graft survival rates were 71% and 60% for ages 0-2, 83% and 64% for ages 3-12 and 85% and 57% for ages 13-21. Except for the youngest recipients, these results compared favorably at 1 year with 86% graft survival among 78,418 adults. The projected graft half-life was highest in patients under age 2 (18 years) and lowest among teenagers (7 years) compared with adults and children (11 years). Univariate analyses revealed a significant 10% graft survival advantage with living donor kidneys for all age groups, but especially for those aged 0-2 in whom survival was 66% with a cadaver donor and 84% with a living donor. The youngest recipients experienced early rejection of the mother's kidney less often than the father's (47% vs 28% in the first 6 months, p<0.007). Results in blacks were similar to those in whites during the first year, but the 3.8 year half-life for black teenagers was the lowest among all groups. We conclude that with the exception of very young (age 2 or under) patients, 1-year pediatric renal transplant survival rates are comparable to those in adults, but in the long term, non-compliance and late acute rejection result in an accelerated graft failure rate among teenagers.     

Priority for children in cadaveric kidney sharing: the strategy adopted in Sao Paulo, Brazil

Abstract: Early kidney transplantation is crucial in order to accomplish both optimal mental development and the best adult height in children with end‐stage renal disease. The aim was to evaluate the efficacy of the child priority policy for cadaveric kidney sharing adopted in the State of Sao Paulo (Brazil). We performed a retrospective study of data collected by the Government Transplant Department in São Paulo, involving all patients included in the waiting list from August 13, 1998 to December 31, 2001. During the study period, the child priority policy had been changed giving: period A – from the outset up to March 14, 2001, where the rule was to direct cadaveric kidneys obtained from children <12 yr, to recipients <12 yr; period B – from March 14, 2001 onwards, where the policy had been broadened to include cadaveric donors <18 yr, destined for recipients <18 yr. We performed the analysis of the data comprising 8940 patients, 8622 being adults (mean age = 48.6 ± 14.1 yr, 3594 females) and 318 children (mean age = 11.9 ± 5.1 yr, 156 females). Over the 3.5‐yr follow‐up there were 1964 deaths [1933 adults and 31 children, odds ratio (OR) 0.37; 95% CI 0.25–0.55], 1032 living donor kidney transplants (963 adults and 69 children, OR 2.20; 95% CI 1.66–2.93), and 556 cadaveric kidney transplants (444 adults and 112 children, OR 10.11; 95% CI 7.75–12.94). Three and a half years after being enrolled on the list, 24% of the children and 75% of the adults, respectively, were still awaiting a cadaveric kidney transplant (log rank test = 539, p < 0.00001). The analysis of period A vs. period B, suggests that the raising of the inclusion age upper limit to 18 yr, resulted in a twofold increase in the percentage of children being grafted within 6 months of enrollment. Overall, our data shows a slow rate of cadaveric kidney transplantation activity in Sao Paulo. Children's chances of receiving a living donor kidney almost doubled. Moreover, 19.5% of pediatric recipients had received their kidney within the first year of being enrolled on the waiting list. The scheme adopted in Sao Paulo is encouraging, but the results remain less favorable than those observed in other countries. The adoption of the priority policy did not result in an unacceptable increase of adult waiting time, given that the number of adults on our waiting list outweighs by far the number of children.     

The use of porcine dermal collagen implants in assisting abdominal wall closure of pediatric renal transplant recipients with donor size discrepancy

Children may have kidneys transplanted from donors larger than themselves. Abdominal wall closure may be difficult, with risks of abdominal compartment syndrome and graft compromise. Meshes used to facilitate closure may cause dense intra-abdominal adhesions, making further surgery or peritoneal dialysis difficult. We present five cases in which abdominal wall closure was facilitated by porcine dermal collagen implant. Five children (2-15 yr) received transplanted kidneys from adult donors of significantly greater weight. In four recipients, the kidney was transplanted onto the aorta and vena cava intra-abdominally using a midline incision. In the fifth, the kidney was anastomosed onto the iliac vessels. The skin overlying the implant was closed normally. Maximum follow-up was three yr. In all cases, primary closure was achieved. One child received a second intra-abdominal transplant as an emergency, which later failed. The other kidneys are functioning well. One recipient developed a small incisional hernia three yr post-transplant. Another developed a skin dehiscence over the implant 23 days post-operatively. The implant was removed and skin closed. The other two recipients recovered well. Porcine dermal collagen implant is a helpful adjunct to abdominal wall closure following organ transplantation in children with donor size discrepancy.     

Biological and psychological differences in the child and adolescent transplant recipient

Solid organ transplantation has become accepted therapy for the treatment of end-stage organ dysfunction in children. As early management of the pediatric transplant recipient has improved, important age-related differences in long-term patient outcomes have become apparent. Late morbidity and mortality can, in most cases, be attributed to the consequences of long-term immunosuppression: graft loss from under-immunosuppression or an increased incidence of cancer, hypertension, renal failure or diabetes from over-immunosuppression. Age-related differences in both biological and psychological factors play an important role in the optimization of therapy in the transplanted child. Important age-related differences have been demonstrated in all phases of pharmacokinetics: absorption, distribution, metabolism and elimination. Information regarding specific age-related pharmacokinetic differences is lacking for many immunosuppressive medications. Further study using physiologically based pharmacokinetic (PBPK) models will lead to more specific recommendations for age-based immunosuppression protocols. Non-adherence is common among solid organ transplant recipients of all ages and the consequences of non-adherence include increased rejection, late graft loss and death. The biological and psychological developmental changes that occur during adolescence place the transplanted adolescent at an even higher risk of non-adherence and poor outcome than other age groups. Further studies to elucidate the importance of both age-related pharmacokinetic and behavioral factors are needed to formulate therapeutic interventions that would improve adherence and patient outcomes.     

14 years of kidney transplantation in children. Results with special reference to cyclosporin A treatment

In Hannover, between 1970 and 1983 a total of 115 kidney transplantations were performed in 97 children aged between 2 and 16 years. On 31st December 1983, 85 children (= 88%) were alive and 77 of them (= 79,4%) had a functioning graft, while 8 (= 8,2%) had to return to dialysis treatment. Of 115 grafts transplanted 39 (= 33,9%) were lost again. Late complications in children with longlasting graft function included hypertension, steroid-cushing, osteo-porosis and growth retardation. Since September 1982 the new immunosuppressive drug cyclosporin A was used in combination with a low dose prednisolone therapy. Results of 28 kidney transplantations with cyclosporin A treatment are compared to 37 kidney transplantations with cyclosporin A treatment are compared to 37 kidney transplantations with conventional immunosuppression with azathioprin plus prednisolone. The two year survival rate of grafts was 96% under cyclosporin A, compared to 68% under conventional immunosuppression. The survival rate of patients after two years did not differ in both groups (96 vs. 94%). The growth rates under cyclosporin A are significantly better than under conventional immunosuppression.     

Outcome of cadaver kidney transplantation in small children

Cochat P, Castelo F, Glastre C, Martin X, Stamm D, Long D, Lavocat M-P, Hadj-Aïssa A, Lyonnet D, Floret D. Outcome of cadaver kidney transplantation in small children. Acta Pædiatr 1994;83:78–83. Stockholm. ISSN 0803–5253 Small children have often been reported to have poor outcome after kidney transplantation (KT). Recent reports from North America have shown that the use of living-related donors improves patient and graft survival. We report the experience in one centre of primary cadaveric KT using sequential immunosuppression in nine children aged 8–30 months and weighing 5.4–9.8 kg; donors were 0.7–12.3 years old. Four patients had pre-emptive KT and the other five were on peritoneal dialysis; the mean ± SD waiting time was 2.0 ± 2.4 months. Perioperative care has been published previously. The surgical approach was intraperitoneal if the aorta and vena cava were used (n= 7) and extraperitoneal for common iliac vessels anastomosis (n = 2); the duration of surgery was 3.5 ± 0.9 h and the time for vascular anastomosis was 32 ± 6 min. The recipients received ATG, azathioprine, prednisone and delayed administration of cyclosporin A. The patients were followed for 12–98 (median 41) months and showed good graft function (inulin clearance 63–100 ml/min/1.73 m²); only one child with recurrent haemolytic uraemic syndrome lost his graft three months post-transplantation and died after he had received a second graft. None of the recipients required post-transplant dialysis; arterial hypertension involved four children and was related to graft artery stenosis in two. Growth improved by 0.24 ± 0.48 SD score of height per year. Compared to earlier reports on cadaver transplantation in small children (about 40% graft survival after five years) and to the outcome of chronic peritoneal dialysis, the present results are better and appear to be similar to those obtained with living-related donor transplantation.     

An overview of paediatric lung transplantation

Paediatric lung transplantation is indicated in selected children with end-stage lung disease that is not amenable to conventional medical or surgical therapy. The indications and complications differ from adult lung transplant patients. Due to the long waiting times for suitable cadaveric lungs, other types of lung transplantation, such as living donor lobar and split-lung procedures, have been utilised in paediatric patients. Unlike adult candidates, cystic fibrosis and primary pulmonary hypertension are the primary indications. Most recipients are in the adolescent age group. Complications that occur with greater frequency in paediatric lung recipients include somatic growth and graft function, post-transplant lymphoproliferative disease and medical non-adherence. While long-term outcome remains similar between adult and paediatric lung transplant recipients, there is a lower risk of bronchiolitis obliterans in very young recipients and in those who receive living donor lobar lung transplantation. Research into these clinical problems is hampered by the fact that only a small number of paediatric transplants are performed at each centre. Hence, improvement in outcome for these children will be dependent on developing methods to produce better tolerance, understanding the mechanisms/treatment of bronchiolitis obliterans and multi-centre studies that focus on the problems that primarily affect the paediatric lung transplant recipient.     

Outcomes and predictive factors of pediatric kidney transplants: An analysis of the Thai Transplant Registry

As universal coverage for pediatric kidney transplantation (KT) was introduced in Thailand in 2008, the number of recipients has been increasing. We evaluated predictive factors for graft failure to understand how to improve clinical outcomes in these children. Using data obtained from the National Transplant registry, we assessed the risk of graft failure using the Kaplan–Meier method and Cox proportional hazards regression. Altogether, 201 recipients aged <21 yr at the time of KT were studied. Living donors (LD) were significantly older than deceased donor (DD). Mean cold ischemia time of DD was 17 h. The mean donor glomerular filtration rate (GFR) was 84.0 mL/min/1.73 m². Induction immunosuppressive therapy was administered more frequently in DD than in LDKT. Delayed graft function (DGF) occurred in 36 transplants. Over 719 person years of follow‐up, 42 graft failures occurred. Graft survival at one, three, and five yr post‐transplant were 95%, 88% and 76%, respectively. Two factors independently predicted graft failure in multivariate analysis. The hazard ratios for graft failure in patients with DGF and in patients with donor GFR of ≤30 mL/min/1.73 m² were 2.5 and 9.7, respectively. Pediatric recipients should receive the first priority for allografts from young DD with a good GFR, and DGF should be meticulously prevented.     

Using pediatric liver grafts (≤6 yr) for adult recipients: A considerable option?

In LT, the common policy is to allocate pediatric liver grafts to pediatric recipients. Pediatric organs are also offered to adults if there is no pediatric recipient. However, they are rarely accepted for adult recipients. So far, there is no information available reporting outcome of LT in adult recipients using pediatric livers from donors ≤6 yr. In this study, we included nine adult recipients (seven females and two males) who received grafts from children ≤6 yr from January 2008 to December 2013. We evaluated the graft quality, the GBWR and analyzed the recipients’ perioperative course. Laboratory samples and graft perfusion were analyzed. Nine adults with a median age of 49 yr (range: 25–65) and a median weight of 60 kg (range: 48–64) underwent LT with a pediatric donor graft. Median donor age was five yr (range: 3–6). Median GBWR was 1.02 (range: 0.86–1.45). After a median follow‐up of 3.9 yr (range: 11 months–6.6 yr), patient survival was 100%; graft survival was 89%. One patient needed re‐transplantation on the second postoperative day due to PNF. Eight recipients were discharged from the ICU after 2–9 days with a regular graft function. Doppler scans revealed regular flow patterns at any time. Only if denied for pediatric recipients, the use of pediatric livers from donors ≤6 yr for adult recipients is a considerable option.     

Hypertension in pediatric kidney transplantation

Arterial hypertension (HTN) in children after kidney transplantation is an important risk factor not only for graft loss but also for cardiovascular morbidity and mortality. The prevalence of posttransplant HTN ranges between 60% and 90%. The etiology of posttransplant HTN is multifactorial and includes residual chronic native kidney disease, immunosuppressive therapy, and chronic allograft dysfunction among other causes. Clinic blood pressure (BP) should be measured at each outpatient visit. However, ambulatory blood pressure monitoring (ABPM) is the gold standard method for BP evaluation in children after kidney transplantation, as it often reveals masked and nocturnal HTN; given this, it should be regularly performed in each transplanted child. All classes of antihypertensive drugs are used in the treatment of posttransplant HTN because it has never been proven that one class is better than another. However, in several retrospective studies, the use of calcium channel blockers is associated with better graft function. The optimal target BP for transplanted children is still a matter of debate; it is recommended to target the same BP as for healthy children, that is, <95th percentile. Control of HTN in transplanted children remains poor – only 20%–50% of treated children have normal BP. There is a great potential for improvement of antihypertensive treatment that could potentially result in improvement of both graft and patient survival in children after kidney transplantation.