Pediatric cadaver kidneys for transplantation.

A group of 24 kidneys from donors ranging in age from 1 1/2 to 10 years were transplanted singly into adults and were compared to a group of 44 adult cadaveric kidneys transplanted into adults. There were no vascular complications in either group. There were two urological complications in the 24 pediatric donor cases and none with the adult donor cases. During the first month after transplantation, the mean creatinine clearance was lower in the pediatric donor group; later the function of the pediatric donor kidneys was at least as good as the function of the adult donor grafts. In the group of pediatric donor kidneys, the outcome using kidneys from donors younger than 3 years of age was less satisfactory than for donors 3 to 10 years of age. These data suggest that transplantation of a single pediatric kidney into an adult, particularly if the pediatric donor is at least 3 years of age, will provide satisfactory renal function.     

The use of pediatric cadaver kidneys in renal transplantation (Experience with 97 cases and comparison with adult kidneys)

Pediatric cadaver donors are an important pool of kidneys for human allotransplantation. Experiences with 97 transplantations of pediatric cadaveric kidneys (age: 4 months to 15 years) and comparison with 230 transplantations of adult kidneys (age: 16–25 and 40–68 years) are presented. The cumulative patient survival was similar in both groups, however, the graft survival was significantly lower in the pediatric donor group (p<0.05). This difference was established almost exclusively within the first 3 months after transplantation. In this group the percentage of technical complications in the first month was higher (13.4%) than in the adult kidney group (6.5%). The analysis of the whole pool of harvested kidneys shows a significantly higher rate of transplanted kidneys in the pediatric group (61%) as compared with the adult group (44.7%). In both groups the mode of arterial vascular anastomosis (end-to-end or end-to-side) does not influence the graft survival.Further investigations on pediatric donor kidneys are necessary. The utilization of pediatric cadaveric kidneys for transplantation should be increased because 20–25% of all potential kidney donors are younger than 15 years.     

The influence of donor age on graft survival.

Recent papers report differing conclusions concerning use of kidneys from different donor age groups. We analyzed graft survival of 652 consecutive cadaver kidney donor-recipient pairs. Overall cumulative graft survival was 45 per cent at two years post transplantation. Kidneys from donors aged less that fifteen, sixteen to thirty. thirty-one to forty-five, and forty-six to sixty years had a cumulative graft survival of 51, 44, 39, and 40 percent, respectively. The difference is not statistically significant. When both donor and recipient ages are controlled, the pediatric aged kidney may be superior in the pediatric recipient or the older normotensive adult recipient. Use of properly selected cadaver kidneys in patients of all age ranges is encouraged.     

When is it reasonable to split pediatric en bloc kidneys for transplantation into two adults?

Background

Traditionally, kidneys from donors ≥60 years old and pediatric kidneys are considered marginal organs for transplantation. Pediatric donor kidneys are underutilized for transplantation into adult recipients due to concern for poor outcomes.

Methods

Using data from the Organ Procurement and Transplant Network, we analyzed patterns of pediatric kidney use (single vs en bloc) in the United States from 1987 to 2007. Using the Cox proportional hazards model, graft outcomes of pediatric donor kidneys transplanted as single vs en bloc grafts from different donor weight groups were compared with renal transplantation from donors ≥60 years old in an attempt to define a pediatric donor weight at which kidneys can be justifiably split to expand the donor pool.

Results

Compared with older donor kidneys, graft failure risk of pediatric single kidneys was consistently lower when the donor weight exceeded 10 kg. On the other hand, graft survival benefit for pediatric en bloc kidneys was evident starting at donor weight ≤10 kg in comparison to older donor kidneys. Pediatric en bloc kidneys performed consistently better than pediatric single kidneys for all donor weight groups.

Conclusions

Splitting of pediatric donor en bloc kidneys for transplantation into 2 adults when the donor weight exceeds 10 kg was associated with acceptable graft outcomes. This practice, along with increased use of small pediatric donor kidneys, may help to alleviate the waiting list burden in renal transplantation.     

The kidney allocation system does not appropriately stratify risk of pediatric donor kidneys: Implications for pediatric recipients

Kidney Allocation System (KAS) was enacted in 2014 to improve graft utility, while facilitating transplantation of highly‐sensitized patients and preserving pediatric access to high‐quality kidneys. Central to this system is the Kidney Donor Profile Index (KDPI), a metric intended to predict transplant outcomes based on donor characteristics but derived using only adult donors. We posited that KAS had inadvertently altered the profile and quantity of kidneys made available to pediatric recipients. This question arose from our observation that most pediatric donors carry a KDPI over 35 and have therefore been rendered relatively inaccessible to pediatric recipients under KAS. Here we explore early trends in pediatric transplantation following KAS, including: (i) use of pediatric donors, (ii) use of Public Health System (PHS) high infectious risk donors, (iii) wait time, and (iv) living donor transplantation. We note some concerning preliminary changes following KAS implementation, including the allocation of fewer deceased donor pediatric kidneys to children and stagnation in pediatric wait times. Moreover, the poor predictive power of the KDPI for adult donors appears to be even worse when applied to pediatric donors. These early trends warrant further observation and consideration of changes in pediatric kidney allocation if they persist.     

Experience with dual kidney transplants from donors at the extremes of age

BACKGROUND: Dual kidney transplantation (DKT) from donors at the extremes of age represents one approach to expanding the organ donor pool. The purpose of this study was to review our experience with DKT from older donors and en bloc KT (EBKT) from small pediatric donors. METHODS: Deceased donor KTs performed at our center between October 2001 and November 2005, were reviewed retrospectively. If the calculated creatinine clearance in an expanded criteria donor was <65 mL/min, then the kidneys were transplanted dually into a single adult recipient. If a pediatric donor weighed <15 kg, then the kidneys were transplanted en bloc. In both instances, low-risk recipients were chosen (primary transplant, low sensitization, body mass index <25 kg/m(2), human leukocyte antigen matching). Donor, recipient, and transplant characteristics, waiting time, and outcomes were examined. RESULTS: Of a total of 279 deceased donor KTs during the 49-month study period, 15 (5%) recipients underwent DKT and 5 (2%) underwent EBKT. Mean donor age was 65.4 years and 21.4 months in the DKT and EBKT groups, respectively. Patient survival rates in both groups were 100% with a mean follow-up of 22 months (minimum, 6 months). Kidney graft survival rates were 80% (12/15) and 60% (3/5) in the DKT and EBKT groups, respectively. The combined incidence of delayed graft function was 10%. Mean 12-month glomerular filtration rates were 46 mL/min and 66 mL/min in the DKT and EBKT groups, respectively. CONCLUSIONS: DKT using kidneys from marginal elderly donors and EBKT from small pediatric donors appear to offer a viable option to counteract the shortage of acceptable kidney donors.     

Increasing the supply of kidneys for transplantation

Kidney transplantation confers a survival advantage for patients with end-stage renal disease (ESRD) when compared to dialysis and improves the quality of life in a cost-effective manner. Currently there are more than 60,000 patients on the U.S. waiting list for kidney transplantation. In 2004, 16,879 kidney transplants, including 880 simultaneous kidney and pancreas transplants, were performed in this country. Recent strategies for increasing the supply of kidneys hold promise, such as systematic programs designed to improve consent rates for deceased donor organ procurement. Efforts to increase donation after cardiac death (DCD) have been highly successful and now account for more than 5% of all deceased organ donors. Transplantation of kidneys from DCD donors yields 1-year graft and patient survival rates equivalent to kidneys from brain-dead donors. Expanded criteria donor (ECD) kidneys from donors > or = 60 years of age (or donors age 50-59 years with certain comorbidities) confer a survival benefit for end-stage renal disease (ESRD) patients compared to remaining on dialysis on the waiting list. The number of live donor kidney transplants, both from biologically related and unrelated donors, is increasing. Paired live donor kidney transplants provide yet another transplantation opportunity for ESRD patients with willing but incompatible (by ABO or direct antibody) living donors.     

Renal transplantation of the infant and young child and the use of pediatric cadaver kidneys for transplantation in pediatric and adult recipients

Transplantation of infants less than 1 year of age with kidneys from live-related parental donors has recently led to good results, whereas cadaver donor renal transplantation in this recipient age group has led to a high mortality rate (11/13). Similarly, the results of cadaver donor renal transplantation in infants and young children less than 5 years of age has been suboptimal in the past, although recent data are more encouraging. With recent availability of long-term peritoneal dialysis for the infant and young child with end-stage renal disease (ESRD), it is possible to defer transplantation until an optimal donor becomes available. Because of the possible immunologic hyperactivity of such recipients, the immunosuppressive regimen may need to be modified if improved cadaver donor survival rates are to be obtained. The use of anencephalic kidneys for transplantation has been associated with a high incidence of primary nonfunction and few recipients with long-term functioning grafts. Harvesting of kidneys from anencephalic donors declared "brain-dead" at birth may reduce the incidence of primary nonfunction and increase the availability of anencephalic kidneys for transplantation. Reports of the use of pediatric cadaver kidneys for transplantation into pediatric and adult recipients yields discrepant results. Analysis of the data indicates that if pediatric cadaver kidneys from donors less than 6 years of age are used, the potential for decreased graft survival rates and an increased incidence of technical complications exists. However, the use of pediatric cadaver kidneys can provide adequate graft function in both pediatric and adult recipients and the use of such kidneys should increase the number of kidneys available for transplantation.     

Transplantation of pediatric kidneys to adult recipients: an analysis of 13 cases

INTRODUCTION: The shortage of cadaveric donors for kidney transplantation has prompted many centers to expand the criteria used for donor selection to increase the organ supply. The use of cadaveric pediatric kidneys has been suggested as a means to overcome the shortage. However, some studies indicate that kidneys from pediatric donors show inferior results to those from adult donors. In this retrospective study we examined the outcome of kidney transplantation using cadaveric pediatric donors. MATERIALS AND METHODS: From October 1990 to May 2002, 13 adult patients received pediatric renal transplants including two that were transplanted en bloc. The patients were divided into two groups based upon donor age: group I donors were 18 months to 6 years old; the seven recipients were of mean age 47.3 years. Group II donors were 7 to 15 years old; the six recipients were of mean age 43.6 years old. Cyclosporine-based immunosuppressive regimens were used in both groups. RESULTS: The patient survival rate was 85.7% in group I and 100% in group II. The graft survival rates at the first and third posttransplant year in group I were 71.4% (5/7) and 57.1% (4/7) and in group II, 66.7% and 50%, respectively. The frequency of urinary complications in group I was 28.5% (2/7) and in group II 33.3% (2/6). There was one case of venous thrombosis in group II. CONCLUSION: Pediatric renal grafts may be used with reasonable safety. However, surgical complications remain a significant problem especially with younger pediatric grafts.     

En-bloc pediatric kidney transplantation together with a partial bladder segment: a case report

There is a continuing debate about the techniques of kidney transplantation from small donors because of the high vascular thromboses and ureteric leak rates. Transplantation of en-bloc pediatric kidneys with a partial bladder segment has potential benefits over established techniques. We transplanted cadaveric en-bloc kidneys together with a partial bladder segment from a 1.5-year-old donor to a 12-year-old boy with end-stage renal disease due to vesicoureteral reflux (VUR) of a solitary kidney. En-bloc kidneys were transplanted together with both ureters and a partial bladder segment. Using donor bladder segment augmented the recipient bladder. Thereby, potential complications of bilateral ureteroneocystostomies of small ureters were avoided. During the following 12 months, the clinical course was normal and there was no evidence of VUR. In conclusion, the technique of using en-bloc pediatric kidneys together with a partial bladder segment is feasible and safe as well as an efficient procedure to preserve the natural anti-reflux mechanism in childhood.     

Kidney transplantation from living related donors with multiple vessels. A problem revisited

Thirty-one renal transplantations were performed using kidneys from living donors with known bilateral double renal arteries. In twenty-one patients both vessels were anastomosed but in ten patients a tiny polar vessel was sacrificed resulting in a small infarct in the grafted kidney. Results of transplantation in these patients were compared with those in recipients of related and cadaver kidneys matched for time of transplant, sex, and age of recipient. There is an increased incidence of acute tubular necrosis in recipients of transplants from living donors with double renal arteries. By several weeks after transplantation, however, renal function is identical to that in recipients of related donor organs with single arteries. Hypertension that is more common in patients with double renal arterial anastomoses is relatively easy to control with increased antihypertensive medications. Two patients had loss of the kidney transplants because of stenosis of one or both renal arterial anastomoses. Despite these losses, the results of renal transplantation from living related donors with double renal arteries are almost as successful as those from a related donor with single renal arteries.In contrast, recipients of kidneys with polar infarcts appear to undergo more episodes of rejection, infection, or both, than do recipients of related transplants with single renal arteries. In one patient with a polar infarct, delayed total ureteral necrosis developed.Living related donors with bilateral double renal arteries should be accepted as donors in preference to cadaver donors if both vessels can easily be anastomosed. If, however, a polar vessel must be sacrificed, it is suggested that a cadaver donor be utilized in preference to a related donor.     

Recovery and Utilization of Deceased Donor Kidneys from Small Pediatric Donors

The optimal use of kidneys from small pediatric deceased donors remains undetermined. Using data from the Scientific Registry of Transplant Recipients, 2886 small (< 21 kg) pediatric donors between 1993 and 2002 were identified. Donor factors predictive of kidney recovery and transplantation (1343 en bloc; 1600 single) were identified by logistic regression. Multivariable Cox regression was used to assess the risk of graft loss. The rate of kidney recovery from small pediatric donors was significantly higher with increasing age, weight and height. The odds of transplant of recovered small donor kidneys were significantly higher with increasing age, weight, height and en bloc recovery (adjusted odds ratio = 65.8 vs. single; p < 0.0001), and significantly lower with increasing creatinine. Compared to en bloc, solitary transplants had a 78% higher risk of graft loss (p < 0.0001). En bloc transplants had a similar graft survival to ideal donors (p = 0.45) while solitary transplants had an increased risk of graft loss (p < 0.0001). En bloc recovery of kidneys from small pediatric donors may result in the highest probability of transplantation. Although limited by the retrospective nature of the study, kidneys transplanted en bloc had a similar graft survival to ideal donors but may not maximize the number of successfully transplanted recipients.     

Results of en bloc renal transplants of pediatric deceased donors into adult recipients

Various strategies have evolved to expand the donor pool due to the extreme shortage of organs. Herein we reviewed our experience with en bloc pediatric kidney transplantation since 1998. METHODS: From January 1998 to December 2004, nine adult patients underwent kidney transplantation using en bloc kidneys from donors <5 years old (range, 1 to 4). The mean age of the recipients was 45.1 years (range, 34 to 57). RESULTS: In recipients of en bloc pediatric transplantation, cold ischemia time ranged from 14 to 26.2 hours (mean, 21.3 hours). Mean serum creatinine at 3, 6, and 12 months after transplantation was 1.53 +/- 0.57, 1.27 +/- 0.27, and 1.15 +/- 0.26 mg/dL compared with 1.93 +/- 1.35, 1.81 +/- 1.17, and 1.73 +/- 0.85 (P = .08) in recipients of single kidneys from ideal cadaveric donors (UNOS criteria, n = 368). Patient and graft survival at 1 year were 88.8% compared with 91.2% and 85% with ideal donors (P = NS), respectively. Three cases required additional surgery. There was one death due to a cerebral vascular accident. CONCLUSION: The present study confirmed the excellent results achieved with transplantation using en bloc kidneys from young donors.     

Donor Kidney Adapts to Body Dimensions of Recipient: No Influence of Donor Gender on Renal Function After Transplantation

Female kidneys and kidneys from small donors have been suggested to perform worse after kidney transplantation. Here, we evaluate the impact of gender and body dimensions on posttransplantation GFR in living donor transplantation. Two hundred and ninety‐three donor–recipient pairs, who were transplanted at our center were evaluated. All pairs had detailed renal function measurement (¹²⁵I‐iothalamate and ¹³¹I‐hippuran) 4 months predonation in the donor and 2.5 months posttransplantation in donor and recipient. For 88 pairs, 5 years of recipient follow‐up was available. Delta GFR was calculated as (recipient GFR–donor single kidney GFR). Recipients of both male and female kidneys had similar renal function at early and long term after transplantation. Male recipients had higher ERPF, ΔGFR and ΔERPF at both time points. Kidneys of donors smaller than their recipient had higher ΔGFR and ΔERPF than kidneys of larger donors at both time points (p < 0.05). In multivariate analysis, ΔGFR was predicted by donor/recipient BSA‐ratio together with transplantation related factors (R² 0.19), irrespective of donor and recipient gender. In conclusion, in living donor transplantation, female kidneys perform as well as male donor kidneys. Kidneys adapt to the recipient's body size and demands, independent of gender, without detrimental effects in renal function and outcome up to mid‐long term.     

Use of marginal organs from non-heart-beating cadaveric kidney donors.

BACKGROUND: The severe shortage of cadaver donor kidneys for transplantation has prompted many centers to utilize older donor kidneys, which have been associated with lower graft survival rates. The aim of the present study was to examine the availability and feasibility of considering kidneys from donors over the age of 60. METHOD: We studied 252 cadaveric renal transplant recipients (156 males, 96 females) who received kidneys from uncontrolled non-heart-beating donors between 1987 and 1997. We performed in situ cooling with especially designed double-balloon catheters to minimize warm ischemic kidney damage. Recipients were classified according to donor age (age 60), and we examined graft survival rates. All patients were followed for a minimum of 1 year after transplantation. RESULTS: Graft survival rates for recipients of kidneys from the older donor group at 1, 5, and 10 years after transplantation were 77%, 37%, and 30%, respectively. Corresponding values for the younger donor kidney recipients were 87%, 64%, and 47%, respectively (P=0.0011). Improved survival rates were noted when older kidneys were used for lighter weight recipients (<54 kg). No other significant factors impacted on older donor graft survival rates. CONCLUSION: Older donor kidneys are associated with poorer graft survival rates. However, kidney transplants from older donors can be quite effective in lighter weight recipients (<54 kg).     

A comparison of pedriatric and adult kidney donors for adult recipients

The high demand for organs for transplantation has made it necessary to consider using even the oldest and youngest of potential donors in order to increase the organ supply. In this retrospective study, the outcome of kidney transplantation using cadaveric pediatric donors was compared with that of an adult control series. Graft procurement took place in two regions of Italy (Emilia-Romagna and Piemonte) over an 11-year period. A group of pediatric donors ( < 15 years old, n = 30) was compared with an adult donor group (n = 67). All recipients were adults who received cyclosporin as immunosuppression. Actuarial patient and graft survival rates did not differ significantly between the two groups (patient survival 96 % and 96 % for pediatric donors versus 98 % and 92 % for adult donors at 1 and 5 years post-transplantation; graft survival 76 % and 68 % for pediatric donors versus 88 % and 74 % for adult donors 1 and 5 y post-transplantation). Complications were also evaluated, but no difference was found (the only exception being the creatinine level in the 5th year). Renal transplantation with cadaveric donors starting at 4 years of age gave results comparable to kidneys coming from adults. These data show that cadaveric pediatric donor kidneys may be used in adult recipients with good results. The ethical implications of the subject are extensively reviewed. Received: 5 November 1997 Received after revision: 15 October 1998 Accepted: 18 December 1998     

Assessment of factors determining graft size in transplant of cadaver kidneys from child donors

BACKGROUND: Kidneys from child donors are very efficient at adapting to the recipient organism. This research aims to verify the size of kidney grafts from pediatric donors after transplant and to identify factors responsible for the size attained by these kidneys. Moreover, it aims to seek relationships between size and function of the transplanted pediatric kidney. METHODS: Seventy-seven renal transplants performed at least 6 months earlier, with cadaver donor 15 years old or younger, had ultrasound measurements of the graft and renal function assessment. Potential factors for graft volume were analyzed using bivariate analysis, followed by multiple linear regression. RESULTS: After a follow up of 4.2+/-3.3 years posttransplant, the grafts presented the following range of measures: length 10.61+/-1.13 cm, width 4.67+/-0.84 cm, and depth 4.76+/-0.99 cm. Graft volumes were 126.62+/-47.76 cm. Bivariate analysis showed that (1) age of both donor and recipient at transplantation; (2) sex of recipient; (3) occurrence of acute rejection episodes were statistically significant. After multivariate analysis, age and sex of recipients were the only significant factors influencing graft volume; child kidneys reached greater volumes when transplanted into adult and male individuals. Larger volume kidneys presented significantly more proteinuria. No difference was evident with regard to creatinine clearance values or urinary retinol binding protein among kidneys of differing sizes. CONCLUSIONS: The size of the recipient (age and sex) is the main factor responsible for volumes achieved by kidneys from pediatric donors. The volume attained by these kidneys demonstrated no relationship with glomerular or tubular function of the organ.     

Disseminated Intravascular Coagulation (DIC) in a Kidney Donor Associated with Transient Recipient DIC

It has been controversial whether or not to accept kidneys for transplantation from donors with disseminated intravascular coagulation (DIC). We report two recipients who received the kidneys from a donor with DIC following traumatic head injury. Despite evidence of donor kidney glomerular fibrin deposits and ongoing low-grade DIC in the recipients, which resolved after 5–7 days; both recipients did well suggesting that donors with DIC can be successfully used for renal transplantation.     

Outcome in recipients of dual kidney transplants: an analysis of the dual registry patients

BACKGROUND: A novel but controversial method to increase the utilization of aged donor kidneys is the transplantation of both kidneys as a dual transplant. Initial single-center reports demonstrated outcomes similar to single kidneys from younger donors. In this report, we compare outcome in recipients of kidneys from donors > or =54 years of age who received a single kidney transplant reported to the United Network for Organ Sharing Scientific Registry versus a dual kidney transplant reported to the Dual Kidney Registry. METHODS: A retrospective analysis was performed, comparing four donor and nine recipient and outcome variables between recipients of a single versus a dual transplant between March 1993 and March 1999. RESULTS: Dual versus single transplants from donors > or =54 years of age have a significantly decreased incidence of delayed graft function, and lower serum creatinines up to 2 years after transplant despite having kidneys from significantly older donors with poorer HLA matching. CONCLUSIONS: Dual kidney transplants improve graft performance and outcome in recipients of kidneys from donors > or =54 years of age.     

Transplantation of pediatric donor kidneys to adult recipients. Is there a critical donor age?

Cadaver kidneys remain a scarce resource, yet single pediatric donor kidneys are underutilized at some centers. Between 1967 and 1984, 133 single pediatric and 318 adult donor cadaver transplants were performed. Patient and graft survival, renal function, and complications in adult recipients grouped by donor age were compared. Recipient age for all groups was similar (34-36 years). Life table analysis revealed no difference in graft survival in recipients of kidneys from donors aged 2, 3, 4, 5-10, and 11-15 when compared with adult donors. Graft survival in these groups improved over time with current 1-year survival over 75%. Recipients from donors less than 24 months of age demonstrated significantly poorer results, with no kidney surviving greater than 2 months. Serum creatinine of grafts functioning greater than 6 months was similar in all groups. It is concluded that single pediatric kidneys from donors greater than 2 years of age can be successfully transplanted to adults with good long-term results.