Kidney transplantation in children with posterior urethral valves

Abstract:  There is controversy about the outcome of renal transplantation in patients with PUV. The objective of this study was to analyze the outcome of renal transplantation in children with PUV. Fifteen patients had a history of PUV as the etiology of their ESRD. Forty-five patients comprised a control group without lower urinary tract anomalies. Mean age and follow-up duration were not significantly different between the case and the control group (p = 0.1). The immunosuppressive protocol and the year of transplantation were similar in these two groups (p = 0.2, 0.4, respectively). Among patients with PUV, 37.5% had acute rejection; and 56.2% had chronic rejection. Among the controls, 22.2% had acute rejection and 28.8% had chronic rejection. None of these differences was significant. Mean survival time was seven yr in affected patients and 6.2 yr in the control group (p = 0.9). Among patients with PUV, the rate of graft survival in the first year after transplantation was 95%; and those in the third, fifth, and seventh yr, 91%, 65%, and 50%, respectively. For the controls, the graft survival was 83% at one yr; 80% at three yr; 71% at five yr; and 60% at seven yr after transplantation (p = 0.9). Conclusively, this study showed that a history of PUV had no effect on graft function. Graft survival was not different among these patients compared with patients free of these anomalies. We also showed that urological complications were few in these patients.     

Urological complications,vesicoureteral reflux,and long‐term graft survival rate after pediatric kidney transplantation

To describe a single‐center experience with kidney transplantation and then study some donor and recipient features that may impact on graft survival and urological complication rates. We reviewed our database searching for pediatric patients who underwent kidney transplantation from August 1985 through November 2012. Preoperative data and postoperative complications were recorded. Graft survival rates were analyzed and compared based on the type of donor, donor's age from deceased donors, and recipients' ESRD cause. Kaplan–Meier curves with log rank and Wilcoxon tests were used to perform the comparisons. There were 305 pediatric kidney transplants. The mean recipient's age was 11.7 yr. The mean follow‐up was 11.0 yr. Arterial and venous thrombosis rates were 1.6% and 2.3%, respectively, while urinary fistula and symptomatic vesicoureteral reflux were diagnosed in 2.9% and 3.6% of cases, respectively. Deceased kidney transplantation had a lower graft survival rate than living kidney transplantation (log rank, p = 0.005). Donor's age (p = 0.420) and ESRD cause (p = 0.679) were not significantly related to graft survival rate. In long‐term follow‐up, type of donor, but not donor's age, impacts on graft survival rate. ESRD cause has no impact on graft survival rate, showing that well‐evaluated recipients may have good outcomes.     

Liver retransplantation in children: The Atlanta experience

Heffron TG, Pillen T, Smallwood G, Henry S, Sekar S, Solis D, Casper K, Fasola C, Romero R. Liver retransplantation in children: The Atlanta experience.
Pediatr Transplantation 2010: 14:417–425. © 2010 John Wiley & Sons A/S. Abstract: Liver retransplantation is routinely offered at our institution. Previous reports document that patient and graft survival is significantly less after pediatric rLT compared to primary LT. This has engendered intense debate regarding optimal allocation of organs. Here, we examine our program’s approach to pediatric hepatic retransplantation related to patient factors affecting outcomes. Between 1997 and 2009, 272 LTs were performed in 234 patients (mean survival 1994 ± 1367 days) at our center. Thirty‐four patients required rLT including 10 who received their primary transplant elsewhere and four who required two retransplantations. Patient survival did not differ significantly between rLT and LT at one and three yr (p = 0.56). Graft survival between rLT and LT was also similar (p = 0.606) at one and three yr. No significant difference in graft or patient survival was noted between: Patients retransplanted <30 days after LT vs. those >30 days (p = 0.152); patients transplanted with technical variants vs. whole grafts (p = 0.966); technical variants utilized for LT vs. rLT (p = 0.713); rLT recipient age (< or >5 yr; p = 0.298); or ABOI for rLT and LT (p = 0.650). Retransplantation should be offered to optimize pediatric recipient survival after LT and offers similar survival as primary transplant.     

Outcomes in infants listed for liver transplantation: A retrospective cohort study using the United Network for Organ Sharing database

LT in neonates and young infants can be challenging due to a variety of factors. To describe the waitlist mortality rates and outcomes of patients listed and transplanted as infants identified from the UNOS database. Infants listed for LT between January 1985 and September 2010 were identified from the UNOS database. Mortality on the waitlist as well as outcomes post‐LT was compared between infants aged ≤60 days (Group 1), 61–179 days (Group 2), and 180–364 days (Group 3). Of 6763 infants listed for LT (Group 1 n = 496, Group 2 n = 2404, Group 3 n = 3863), mean age at listing was 196 ± 87 days (Group 1, 29 ± 16 days; Group 2, 132 ± 32 days; Group 3, 257 ± 52 days). Waitlist mortality was highest in Group 1 (Group 1 vs. 3 HR 3.01, 95% CI 2.19–4.15, Group 2 vs. Group 3 HR 0.82, 95% CI 0.66–1.03). One‐ and five‐yr graft survival was 59.6% and 42% (Group 1), 66% and 45% (Group 2), and 66.8% and 41% (Group 3) (one‐yr survival p = 0.20; five‐yr survival p = 0.19). Infants listed for LT at age ≤60 days had greater waitlist mortality risk than older infants. Infants undergoing LT at age ≤60 days had similar rates of patient and graft survival to older infants.     

Pediatric renal transplantation: A single Belgian center experience over 20 years

Between 1980 and 2000, 100 renal transplantations were performed in 91 children at the pediatric unit of the University Hospital Leuven. The proportion of living-related donors (LRD) was 20%. Patient survival rates were 94% at 3 yr, 91% at 5 yr, and 87% at 10 yr. The commonest causes of death were bacterial infections and cardiovascular complications, which underscores the need for aggressive preventative procedures in this area after transplantation. The overall actuarial graft survival was 82% at 3 yr (n = 73), 74% at 5 yr (n = 53), and 56% at 10 yr (n = 29). In the LRD group, the graft survival was 10% better than the overall actuarial graft survival rate. The overall incidence of acute rejection was 55% but has shown a decrease to 34% in more recent years (1993-99). The major causes of graft failure were chronic rejection and recurrence of the initial disease, and these remain a major concern. Improvement of these results could be achieved by tight immunosuppression management, early aggressive treatment of infection and rejection, and careful educational and psychological support.     

Long‐term outcomes of living donor kidney transplants in pediatric recipients following laparoscopic vs. open donor nephrectomy

We compared long‐term outcomes of LDKT in pediatric recipients following either laparoscopic (LDN) or ODN. In our retrospective single‐center study, we compared 38 pediatric LDKT recipients of a laparoscopically procured kidney with a historic ODN group comprising 17 pediatric recipients. In our center, the first pure laparoscopic non‐hand‐assisted LDN for a pediatric LDKT recipient was performed in June 2001. Demographic data of donors and recipients were comparable between groups. Mean follow‐up was 64 months in the LDN group and 137 months in the ODN group. Patient survival was comparable between groups. Graft survival at one and five yr was 97% (LDN) vs. 94% (ODN) and 91% (LDN) vs. 88% (ODN; p = n.s.), respectively. Serum creatinine at one and five yr was 1.16 ± 0.47 mg/dL (LDN) vs. 1.02 ± 0.38 mg/dL (ODN) and 1.38 ± 0.5 mg/dL (LDN) vs. 1.20 ± 0.41 mg/dL (ODN), respectively. The type and frequency of surgical complications did not differ between groups. DGF and acute rejection rates were similar between groups. In the ODN group, a higher proportion of right donor kidneys was used. In the ODN group, all kidneys had singular arteries, whereas in the LDN group five kidneys had multiple arteries. Arterial multiplicity was associated with a higher incidence of DGF. In our experience, LDN does not compromise long‐term graft outcomes in pediatric LDKT recipients. Arterial multiplicity of the donor kidney may be a risk factor for impaired early graft function in the pediatric population.     

Variables affecting estimated glomerular filtration rate after renal transplantation in children: A NAPRTCS data analysis

Moudgil A, Martz K, Stablein DM, Puliyanda DP. Variables affecting estimated glomerular filtration rate after renal transplantation in children: A NAPRTCS data analysis.
Pediatr Transplantation 2010: 14:288–294. © 2009 John Wiley & Sons A/S. Abstract: Short‐term graft survival has improved in renal transplants without significant effect on long‐term graft survival. As GFR decline precedes graft loss, an understanding of variables affecting eGFR after TX may help improve graft survival. NAPRTCS data were analyzed to assess effects of donor, recipient, and other variables on Schwartz eGFR after transplantation. For 8438 children with a functioning graft at day 30, data were censored for children dying with a functioning graft, and those with <3 yr follow‐up. Multivariate linear regression and repeated measures analyses identified factors related to eGFR at day 30 after TX and during follow‐up. Young, female, non‐black, children without ATN and acute rejection in the first 30 days, TX after 1995, those with better eGFR at day 30, and receiving tacrolimus had better long‐term eGFR. Transplant from ideal (6–35 yr) donors had best short‐term eGFR, young donors (<5 yr) had lower eGFR and poor graft survival. After one yr, eGFR improved in surviving grafts of young donors and matched ideal donors. Acute rejection, BP medications, and hospitalizations in prior six months had negative association with subsequent eGFR. Regardless of variables, eGFR deteriorated with time. Slope of eGFR decline has not changed in the recent era indicating the need for innovative therapies.     

ABO‐incompatible pediatric liver transplantation in very small recipients: Birmingham’s experience

Gelas T, McKiernan PJ, Kelly DA, Mayer DA, Mirza DF, Sharif K. ABO‐incompatible pediatric liver transplantation in very small recipients: Birmingham’s experience.
Pediatr Transplantation 2011: 15: 706–711. © 2011 John Wiley & Sons A/S. Abstract: Liver transplantation (LT) for very small recipients is challenging but in experienced centres, good results can be achieved. Despite the risk of antibody‐mediated acute rejection, some studies have demonstrated the safety of ABO incompatible liver transplantation (ILT) in children and particularly in infants. The aim of our study was to describe the outcome of liver transplantation in infants <5 kg and the safety of using ILT in this group. All LT performed between 1991 and 2010 in children <5 kg were reviewed. Twenty‐nine patients were included, five of whom had an ILT. Acute liver failure was encountered in 20 cases. The recipient age and weight at transplantation were respectively 63 days (range: 14–268 days) and 4 kg (range: 2.4–5 kg). The graft‐to‐recipient ratio was 6.1% (range 2.3–9%). An aortic conduit and delayed abdominal closure were used respectively in 76% and 81% of the procedures. The ABO compatible liver transplantation (CLT) and ILT groups were similar regarding recipient’s demographics, graft types or technical transplantation data. The one‐ and five‐yr patient and graft survival were respectively 62%, 62% and 62%, 57.9% with a median follow‐up of 95 months. Vascular complications occurred in six cases (21.4%) and biliary complications were encountered in five patients (17%). Acute and chronic rejection developed respectively in 37% and 26% of the recipients. The five patients undergoing ILT are all alive without graft lost after a median follow‐up of 34 months (range 7–55 months). When compared with the CLT group, no significant differences were found regarding patient or graft survival, vascular or biliary complications and rejection rates. In our experience, ILT in small infants has short and long term outcomes comparable to ABO‐compatible grafts and excellent results can be achieved with a standard immunosuppressive protocol. To avoid mortality on the waiting list for neonatal recipients, ABO‐incompatible liver grafts can be used safely.     

Long‐term outcome of pediatric kidney transplantation: A single‐center experience from Greece

Pediatric kidney Tx has critically altered the outcome in ESRD pediatric patients. The aims of this study were to determine long‐term graft and patient survival in a homogeneous ethnic population. We reviewed the medical charts of pediatric kidney Tx performed between 1990 and 2012 in Greece. Seventy‐five kidney Txs were performed from LRD and 62 from DD. The 10‐ and 20‐yr graft survival was higher in LRD Tx compared with DD Tx. Both patient and graft survival at 10 and 20 yr after Tx were similar in LRD Tx from grandparents compared with parents (92.9% vs. 93.4% 20‐yr patient survival, 71.4% vs. 78.7% and 57.1% vs. 72.1%, 10‐ and 20‐yr graft survival, respectively). However, there was a decreasing tendency in LRD Tx rates in period 2001–2012 compared with period 1990–2000 (47.1% vs. 62.7%). Risk factors for poor five‐yr graft survival were DD Tx, and induction treatment with ALG compared with basiliximab, but their effect attenuated at 10 yr after Tx. In conclusion, Tx from LRD may offer efficient survival outcomes irrespective of donor age, suggesting that even older LRD could be an excellent option for the 1st kidney Tx in children and adolescents.     

Variability in tacrolimus blood levels increases the risk of late rejection and graft loss after solid organ transplantation in older children

Late graft rejection impairs the long-term function of organ transplants in children. Previous studies suggest patients with wide variation in tacrolimus levels may have higher rates of late kidney and liver graft rejection. The reproducibility of this finding and impact on graft and recipient survival have not been reported. We investigated factors associated with late rejection > 6 months post-transplant in 144 heart, kidney, liver, and lung transplant recipients (ages 8-18, ≥ 1-yr survivors, receiving tacrolimus-based immunosuppression), comparing late rejectors (n = 61, 42%) to non-rejectors (no rejection > 6 months); groups had similar mean tacrolimus concentrations ≤ 6 months post-transplant. For all organ types, increased standard deviation in intrapatient tacrolimus blood levels was an independent risk factor for late rejection (OR 1.6 [CI 1.1-2.1]; p = 0.02). Each 1-point increase in s.d. > 2 of tacrolimus level > 6 months post-transplant associated with 1.58 increase in hazard of graft loss (p = 0.003). Graft survival (conditional on one-yr survival) was significantly better for those with s.d. < 2 at > 6 months post-transplant: 98% at three and five yr, versus 88%, 70%, at three and five yr, in patients with s.d. > 2 (p = 0.003). In conclusion, high s.d. in serial tacrolimus concentrations associated with increased risk of late rejection and graft loss in pediatric organ transplant recipients, providing opportunities for screening and interventions.     

Three‐yr safety and efficacy of everolimus and low‐dose cyclosporine in de novo pediatric kidney transplant patients

The three yr results of a multicenter trial in de novo pediatric KT treated with a proliferative signal inhibitor and low dose CNI are presented. Thirty‐seven children (9.1 ± 5 yr old) received basiliximab, cyclosporine A (CyA C2:1400 ng/mL), (MMF C0:1.5–3 μg/mL), and prednisone. Three wk later everolimus was started (C0:5–10 ng/mL), CyA was reduced (C2:600 ng/mL after 90 days 300 ng/mL), and MMF discontinued. During the three‐yr period patient and graft survivals were 96%. One patient died for causes unrelated to the immunosuppression. Cumulative acute rejection rate including protocol and indication biopsies was 21.9%. None of the patients had signs of chronic humoral rejection. Incidence of dnDSA was 5%, 11%, and 22% at one, two, and three yr post‐transplant, respectively. Mean glomerular filtration rate measured at one yr and three yr post‐transplant was 105.5 ± 31 and 110.7 ± 27 mL/min/1.73 m², respectively. A growth velocity of 7.7 ± 6.7 cm/yr was achieved with positive catch‐up growth. No malignancy or post‐transplant lymphoproliferative diseases were diagnosed. In conclusion, the treatment based on basiliximab induction, everolimus, low‐dose cyclosporine, and low‐dose prednisone leads to good long‐term efficacy in de novo pediatric KT recipients.     

Limited surgical interventions in children with posterior urethral valves can lead to better outcomes following renal transplantation

There is currently no consensus as to the most appropriate means by which children with posterior urethral valves (PUV) are to be managed prior to transplantation. We compared (i) renal allograft survival and function in patients with PUV vs. those with non-obstructive causes of ESRD and (ii) graft outcomes in children who had limited interventions (Group 1) vs. those with more extensive urologic surgeries to decompress the urinary tract (Group 2). Twenty-six pediatric renal transplant recipients had ESRD due to PUV (Group 1, n = 16; Group 2, n = 10). The study group was compared to 23 matched controls with ESRD due to non-obstructive causes. Five yr patient and graft survival was similar in all patients with PUV (Groups 1 and 2) when compared to all other kidney recipients in the transplant program, 96.2% vs. 98.0% and 87.5% vs. 87.0%, respectively. Although calculated creatinine clearance (Ccr), was similar between the PUV group and controls for the first 4 yr, the 5 yr graft function was significantly lower in the PUV group. (53.7 +/- 15.7 vs. 70.2 +/- 21.0 mL/min/1.73 m2; p = 0.03). When the two PUV groups were compared, graft survival was equivalent, but graft function was significantly better at 5 yr in Group 1(60.4 +/- 10.8 vs. 33.8 +/- 9.3 mL/min/1.73 m2; p = 0.02). Thus, patients with PUV managed by a limited intervention approach of vesicostomy with delayed valve ablation or primary valve ablation, had better outcomes. When ESRD is virtually certain, additional pre-transplant surgeries affecting the urinary tract should be avoided.     

Kidney transplants for children under 1 year of age - a single-center experience

From September 20, 1970 to October 24, 2001, we performed 46 kidney transplants in infants under 1 yr old at the University of Minnesota. This article reviews the preoperative care, surgical technique, and immunosuppression. Recipients included 16 females and 30 males; the youngest recipient was 6 wk old. The mean pretransplant height was 62.8 cm, which increased to 77 cm at 1 yr post-transplant and to 104 cm at 5 yr. We used 40 living donors (all but 1 were related to the recipient) and 6 cadaver donors. The overall actuarial graft survival was 85% at 1 yr and 70% at 5 yr. In the cyclosporine era, graft survival improved to 91% at 1 yr and 80% at 5 yr. Death with function was the most common cause of graft loss (n = 5), followed by biopsy-proven chronic rejection (n = 4), biopsy-proven recurrent disease (n = 3), and graft thrombosis (n = 2). Patient survival was 91% at 1 yr and 86% at 5 yr. In the cyclosporine era, patient survival was 100% at 5 yr and 85% at 10 yr. We concluded that an early transplant is the best treatment option for infants under 1 yr old with chronic renal failure. Whenever possible, adult living kidney donors should be used.     

Risk factors for urological complications following living donor renal transplantation in children

The aim of this study was to detect possible risk factors for UC and UTI following pediatric renal Tx and effect of these complications on outcome. One hundred and eight children who underwent living donor Tx between 2009 and 2015 were retrospectively included. Extraperitoneal approach was used with stented tunneled extravesical procedure. Mean recipient age was 9.89 ± 3.46 years while mean weight was 25.22 ± 10.43 kg. Seventy‐three (67.6%) recipients were boys while 92 (85.2%) were related to donors. Urological causes of ESRD were present in 33 (30.6%) recipients (14 [13%] posterior urethral valve, 16 [14.8%] VUR, and 3 [2.8%] neurogenic bladder). Augmentation ileocystoplasty was performed in 9 (8.3%) patients. Mean follow‐up was 39.3 ± 17.33 months. UC were detected in 10 (9.3%) children (leakage 4 [3.7%], obstruction 3 [2.8%], and VUR 3 [2.8%]) while UTIs were reported in 40 (37%) children. After logistic regression analysis, UC were significantly higher in children with cystoplasty (44.4% vs 6.1%; P = .001). UTIs were significantly higher in girls (51.4% vs 30.1%; P = .001) and in children with urological causes of ESRD (51.5% vs 30.7%; P = .049). UC and UTI were not significantly associated with increased graft loss or mortality. UC were significantly higher in children with cystoplasty while UTIs were significantly higher in girls and children with urological causes of ESRD. Presence of UC did not affect the rate of graft loss or mortality due to its early detection and proper management.     

A multicenter study of primary graft failure after infant heart transplantation: Impact of extracorporeal membrane oxygenation on outcomes

Primary graft failure is the major cause of mortality in infant HTx. The aim of this study was to characterize the indication and outcomes of infants requiring ECMO support due to primary graft failure after HTx. We performed a retrospective review of all infants (<1 yr) who underwent Htx from three institutions. From 1999 to 2008, 92 infants (<1 yr) received Htx. Sixteen children (17%) required ECMO after Htx due to low cardiac output syndrome. Eleven (69%) infants were successfully weaned off ECMO, and 9 (56%) infants were discharged with a mean follow‐up of 2.3 ± 2.5 yr. Mean duration of ECMO in survivors was 5.4 days (2–7 days) compared with eight days (2–10 days) in non‐survivors (p = NS). The five‐yr survival rate for all patients was 75%; however, the five‐yr survival rate was 40% in the ECMO cohort vs. 80% in the non‐ECMO cohort (p = 0.0001). Graft function within one month post‐Htx was similar and normal between ECMO and non‐ECMO groups (shortening fraction = 42 ± 3 vs. 40 ± 2, p = NS). For infants, ECMO support for primary graft failure had a lower short‐term and long‐term survival rate vs. non‐ECMO patients. Duration of ECMO did not adversely impact graft function and is an acceptable therapy for infants after HTx for low cardiac output syndrome.     

Pediatric renal transplantation--a single center experience of 15 yr from India

Renal transplantation is the optimal treatment for children with ESRD. We undertook this study to establish the outcome of pediatric renal transplants in a resource-constrained environment in a developing country. A retrospective analysis on 90 pediatric renal transplants (age at transplant 2 rejection episodes (p = 0.05), while sepsis (p = 0.01) was the most important contributor to patient loss. Pediatric renal transplantation in India can be accomplished successfully. The graft and patient survival in our study, the largest from India, is comparable to those published from developed countries and is encouraging given the limited resources.     

Graft loss due to recurrent disease in pediatric kidney transplant recipients on a rapid prednisone discontinuation protocol

Chavers BM, Rheault MN, Gillingham KJ, Matas AJ. Graft loss due to recurrent disease in pediatric kidney transplant recipients on a rapid prednisone discontinuation protocol. Abstract: Recurrent disease is the fourth most common cause of graft loss (GL) in pediatric KTx recipients. We studied the incidence of recurrent disease and GL due to recurrent disease in pediatric KTx recipients on a RDP protocol. Between 2002 and 2010, we performed 74 KTxs in patients aged 5–18 yr using an RDP protocol, 25 (34%) were at risk of recurrence of primary disease. Outcomes were compared to 69 historical controls (18 [26%] at risk of recurrence), KTx between 1996 and 2000. Follow‐up period was 39 ± 25 months in RDP and 124 ± 38 months in controls. The incidence of recurrent disease at three yr post‐KTx was 16% in RDP and 28% in controls (p = NS). Mean time to recurrent disease was 22 ± 26 months in RDP and 46 ± 48 months in controls (p = 0.54). Nine (12%) grafts were lost in the RDP group (1‐recurrence) and 32 (46%) in the control group (4‐recurrence). Time to GL was 85 months in the RDP recipient and 46 ± 21 months in controls. An RDP protocol in pediatric KTx recipients may not be associated with increased risk of graft loss due to recurrent disease.     

Liver transplantation in pediatric patients: twenty years of experience at the University of Wisconsin

Developments in surgical technique, immunosuppression, organ procurement and preservation, and patient selection criteria have resulted in improved long-term patient and graft survival after pediatric liver transplantation. In this study, we examined the results of 196 liver transplants performed in 155 pediatric patients at University of Wisconsin Children's Hospital. Patients were divided into two groups according to age at the time of liver transplant. Infants under 12 months of age comprised Group 1 (n=74) and children from one to 18 yr comprised Group 2 (n=122). Outcomes for whole, reduced-size, and split liver transplantation were compared in infants and children. Biliary atresia was the most common indication in both groups. Patients underwent 128 whole size, 50 reduced size, and 18 split liver transplants. Forty-one retransplantations were performed in 14 infants (18.9%) and in 27 children (22.1%). One hundred eleven patients (56.6%) had one or more rejection episode [37 infants (50.0%) and 74 children (60.6%)]. Thirty-nine patients (19.8%) developed CMV infections, 42 (21.4%) developed EBV infections, and 14 developed PTLD (six infants and eight children). Thirty-six patients (18.3%) developed HAT. Seven patients (4.5%) developed malignancy (one infant and six children). Out of 155 patients, 33 (21.3%) died during the study period. The most common etiology of mortality included central nervous system pathology (n=7; 4.5%), sepsis (n=6; 3.8%), and cardiac causes (n=6; 3.8%). One-, five-, and 10-yr actuarial patient survival was 86, 79, and 74% in infants and 90, 83 and 80% in children. Graft survival at one, five, and 10 yr was 77, 73 and 71% in infants and 88, 81 and 78% in children, respectively. Despite its technical challenges, the outcomes of liver transplantation in pediatric patients with end-stage liver disease are excellent and result in significant long-term patient and graft survival.     

Pediatric renal transplantation: a single center experience over 14 years

Between 1989 and 2003, 100 transplants were performed in 96 patients at the pediatric nephrology unit of the Calvo Mackenna Children's Hospital. Mean age 10.9 +/- 3.9 yr (1-17.6), 30% from LD. Donors were younger than 5 yr in five patients and all recipients received an 'en bloc' graft. Original disease was hypo/dysplasia 27%, reflux nephropathy 22 and 17% chronic glomerulonephritis. The immunosuppressive protocol during the first period (n = 56, 1989-2000): Cyclosporine, steroids and azathioprine, and during the second period (n = 44, 2001-2003): FK, steroids, MMF and anti-CD25 antibody (mAbs). AR was reported in 22 patients, 11% in LD, 31% in DD (p < 0.01). The AR rate decreased from 40 to 8% after anti-CD25 monoclonal induction. Patient actuarial survival rate at 1, 3 and 5 yr was 100% for LD and 96% for DD. The overall actuarial graft survival at 1,3, and 5 yr was 96.7, 96.7 and 71% for LD and 89, 76 and 73% for DD donors. Graft survival rate improved from the first period (1989-2000) to the second period (2001-2003; p = 0.05). No difference in graft survival rate with HLA-A,B,DR matching was found. Graft survival rate was better when cold ischemia time was <24 h (p < 0.01). CMV infections increased from 19 to 40% when MMF and anti-CD25 Ab were introduced (p < 0.01). The height/age Z score at 1, 3 and 5 yr post-transplant was -2.2, -2.1, -2.2, respectively, for children older than 7 yr and -1.8, -1.9, -2.1 for those transplanted younger than 7 yr of age who were switched to alternate day steroids (p < 0.01). The cause of graft lost was: chronic rejection eight, non-adherence four, AR four and vascular thrombosis two. The cause of death in two patients was fungus septicemia and accelerated rejection. Pediatric renal transplantation can be performed in our group with acceptable morbidity, low mortality and graft survival rates similar to other reports in North America and Western Europe. Graft survival rate improved with newer immunosuppression and greater experience at the center. Management of non-adherence and chronic rejection remain the major challenges.     

Renal transplantation in children: Critical analysis of age related surgical complications

Irtan S, Maisin A, Baudouin V, Nivoche Y, Azoulay R, Jacqz‐Aigrain E, El Ghoneimi A, Aigrain Y. Renal transplantation in children: Critical analysis of age related surgical complications.
Pediatr Transplantation 2010: 14:512–519. © 2010 John Wiley & Sons A/S. Abstract: To determine age‐related risk factors of urological and vascular complications. We performed a retrospective analysis of the data of 202 renal transplantations in 193 children between 1989 and 2007 at a single institution. Out of 193 grafts (combined renal and liver grafts were excluded), we observed urological complications in 42 cases (21.7%) leading to graft loss in one case and vascular complications in 27 cases (13.9%) leading to graft loss in seven. The urological complications were VUR (n = 25, 12.4%), ureteral stricture (n = 10, 5%), anastomotic leak (n = 4, 2%), ureteral necrosis (n = 2, 1%), and incrustative pyelitis (n = 1, 0.5%). Vascular complications were arterial stricture (n = 14, 7.2%), arterial thrombosis (n = 4, 2%), venous thrombosis (n = 2, 1%), and others (n = 7). Donors aged less than six yr were a risk factor of vascular complications leading to graft loss (p = 0.0001), whereas patients with PUV had more urological complications (p = 0.001). Overall patient and graft survival is 93.1% and 84% at five yr, respectively. Surgical complications remain a major cause of graft loss (12%) and morbidity in children’s kidney transplantation (38.9%). Young age of donors is the major risk factor of early graft loss as a result of vascular complication. However, donor selection based on age is limited by the shortage of organs.