Kidney transplantation in children weighing 15 kg or less is challenging but associated with good outcome

Changes in graft outcomes in recipients <10 kg over 25 years of pediatric kidney transplantation in the United States

BACKGROUND

Kidney transplant (KT) was initially associated with poor outcomes, especially in smaller recipients. However, pediatric transplantation has evolved considerably over time. We investigated the impact of weight at the time of transplant and whether outcomes changed over 25 years for <10 kg recipients.

METHODS

Using the UNOS database, pediatric recipient outcomes were analyzed between 1/1/99 and 12/31/14. KT weight was stratified: <8.6 kg (mean weight of recipients <10 kg), 8.6-9.9 kg, 10-14.9 kg, 15-29.9 kg, and ≥30 kg. Outcomes in recipients <10 kg were then compared between 1990-1999 and 2000-2014.

RESULTS

17 314 pediatric KT recipients were included; 518 (3%) had a transplant weight <10 kg. The highest rates of allograft loss and death were in recipients <8.6 kg and ≥30 kg. Recipients <8.6 kg also had higher rates of delayed graft function, rejection, and longer hospital length of stay. In the multivariable Cox regression model, transplant weight was not a predictor of allograft loss. When compared with recipients <8.6 kg, patient survival hazard ratios associated with recipient weight of 10-14.9 kg, 15-29.9 kg, and ≥30 kg were 0.61 (95%CI: 0.4, 1), 0.42 (95%CI: 0.3, 0.7) and 0.32 (95%CI: 0.2, 0.6), respectively. In the later era of transplant, recipients <10 kg had improved outcomes on univariate analysis; however, the era of transplantation was not an independent predictor of allograft loss or patient survival in Cox regression models.

CONCLUSIONS

Outcomes in children weighing 8.6-9.9 kg at the time of KT were similar to higher weight groups and improved over time; however, special precautions should be taken for recipients <8.6 kg at the time of transplant.

Long term outcomes following kidney transplantation in children who weighed less than 15 kg - report from the UK Transplant Registry

BACKGROUND

Kidney transplantation is the treatment of choice in chronic kidney disease (CKD) stage 5. It is often delayed in younger children until a target weight is achieved due to technical feasibility and historic concerns about poorer outcomes.

METHODS

Data on all first paediatric (aged < 18 years) kidney only transplants performed in the United Kingdom between 1 January 2006 and 31 December 2016 were extracted from the UK Transplant Registry (n = 1,340). Children were categorised by weight at the time of transplant into those < 15 kg and those ≥ 15 kg. Donor, recipient and transplant characteristics were compared between groups using chi-squared or Fisher's exact test for categorical variables and Kruskal-Wallis test for continuous variables. Thirty day, one-year, five-year and ten-year patient and kidney allograft survival were compared using the Kaplan-Meier method.

RESULTS

There was no difference in patient survival following kidney transplantation when comparing children < 15 kg with those ≥ 15 kg. Ten-year kidney allograft survival was significantly better for children < 15 kg than children ≥ 15 kg (85.4% vs. 73.5% respectively, p = 0.002). For children < 15 kg, a greater proportion of kidney transplants were from living donors compared with children ≥ 15 kg (68.3% vs. 49.6% respectively, p < 0.001). There was no difference in immediate graft function between the groups (p = 0.54) and delayed graft function was seen in 4.8% and 6.8% of children < 15 kg and ≥ 15 kg respectively.

CONCLUSIONS

Our study reports significantly better ten-year kidney allograft survival in children < 15 kg and supports consideration of earlier transplantation for children with CKD stage 5. A higher resolution version of the Graphical abstract is available as Supplementary information.

Postoperative surgical complications after pediatric kidney transplantation in low weight recipients (<15 kg): a systematic review

PURPOSE OF REVIEW

Kidney transplantation in low-weight recipients (<15 kg) is a challenging surgery with special characteristics. We proposed to perform a systematic review to determine the postoperative complication rate and the type of complications after kidney transplantation in low-weight recipients (<15 kg). The secondary objectives were to determine graft survival, functional outcomes, and patient survival after kidney transplantation in low-weight recipients.

METHODS

A systematic review was performed according to preferred reporting items for systematic reviews and meta-analyses. Medline and Embase databases were searched to identify all studies reporting outcomes on kidney transplantation in low-weight recipients (<15 kg).

RESULTS

A total of 1254 patients in 23 studies were included. The median postoperative complications rate was 20.0%, while 87.5% of those were major complications (Clavien ≥3). Further, urological and vascular complications rates were 6.3% (2.0-11.9) and 5.0% (3.0-10.0), whereas the rate of venous thrombosis ranged from 0 to 5.6%. Median 10-year graft and patient survival were 76 and 91.0%.

SUMMARY

Kidney transplantation in low-weight recipients is a challenging procedure complicated by a high rate of morbidity. Finally, pediatric kidney transplantation should be performed in centers with expertise and multidisciplinary pediatric teams.

Pediatric kidney retransplantation focused on surgical outcomes

INTRODUCTION

Despite survival rates after pediatric kidney transplantation (KT) are on the rise it is still likely that most pediatric recipients will require more than one retransplant in their lifetime. The earlier the age at the first KT the higher is the risk of repeat pediatric kidney transplantation (RPKT).

OBJECTIVE

The current study aims to analyze the outcomes of repeat pediatric kidney transplantation (RPKT) among pediatric kidney transplant recipients focusing on surgical complications and compare the outcomes of second and subsequent grafts with those of the first kidney graft.

MATERIALS AND METHODS

Retrospective study of RPKT (<18 years) undertaken between January 2000-2020. We analyzed primary etiology of renal disease, time to graft loss (GL), etiology of initial graft failure, history of acute rejection, previous delayed graft function, HLA-mismatches at the initial transplant, surgical complications and outcomes. Additionally, we compared the characteristics and outcomes of patients who underwent RPKT (group 1) with those who received a first kidney graft (group 2).

RESULTS

Out of 229 kT, 59 patients underwent RPKT (26 females/33 males). At the time of RPKT median age was 11.37 years (SD:5.7). The most frequent primary renal disease was congenital nephrotic syndrome in 11 (18.6%). Fifty-four (91.5%) were on renal replacement therapy at the time of transplant. Fourty-one patients received their second KT (69.5%), 14 (23.7%) the third, 3 (5.1%) the fourth and 1 (1.7%) the fifth. Transplant graft nephrectomy (GN) was performed in 26 patients (44.1%) prior to retransplantation. Fifty-four (91.5%) received a cadaveric graft and 5 (8.5%) a living-related graft. An extraperitoneal approach was achieved in 53 patients (89.8%), whereas in the remaining 6 (10.2%) the graft was placed intraperitoneally. We observed 10 surgical complications (16.9%): 9 major which required reintervention and 1 minor (perirenal hematoma). No vascular complications were observed and none of the surgical complications were involved in graft loss. Graft survival at 1,3 and 5 years was 91%, 84% and 73% respectively. The most frequent cause of GL was chronic graft nephropathy in 15 (25.4%). After a mean follow-up of 9.40 years (SD: 4.7) only 2 patients died (3.4%), both with functioning grafts.

DISCUSSION

Pediatric recipients of second and subsequent kidney grafts constitute a remarkable high-risk population but are becoming more frequent at reference pediatric transplant centers.

CONCLUSIONS

RPKT is technically challenging but can yield good results. In our series overall the incidence of surgical complications and particularly vascular complications was low.

Good outcomes after pediatric intraperitoneal kidney transplant

BACKGROUND

Kidney transplantation in small children is technically challenging. Consideration of whether to use intraperitoneal versus extraperitoneal placement of the graft depends on patient size, clinical history, anatomy, and surgical preference. We report a large single-center experience of intraperitoneal kidney transplantation and their outcomes.

METHODS

We conducted a retrospective review of pediatric patients who underwent kidney transplantation from April 2011 to March 2018 at a single large volume center. We identified those with intraperitoneal placement and assessed their outcomes, including graft and patient survival, rejection episodes, and surgical or non-surgical complications.

RESULTS

Forty-six of 168 pediatric kidney transplants (27%) were placed intraperitoneally in children mean age 5.5 ± 2.3 years (range 1.6-10 years) with median body weight 18.2 ± 5 kg (range 11.4-28.6 kg) during the study period. Two patients (4%) had vascular complications; 10 (22%) had urologic complications requiring intervention; all retained graft function. Thirteen patients (28%) had prolonged post-operative ileus. Eight (17%) patients had rejection episodes ≤6 months post-transplant. Only one case resulted in graft loss and was associated with recurrent focal segmental glomerular sclerosis (FSGS). Two patients (4%) had chronic rejection and subsequent graft loss by 5-year follow-up. At 7-year follow-up, graft survival was 93% and patient survival was 98%.

CONCLUSIONS

The intraperitoneal approach offers access to the great vessels, which allows greater inflow and outflow and more abdominal capacity for an adult donor kidney, which is beneficial in very small patients. Risk of graft failure and surgical complications were not increased when compared to other published data on pediatric kidney transplants.

Introducing a New Technique for Fascial Closure to Avoid Renal Allograft Compartment Syndrome in Pediatric Recipients: The Use of Tutoplast® Fascia Lata

Introduction

Renal allograft compartment syndrome (RACS) is a complication that infrequently occurs after renal transplantation. Tight muscle closure may lead to RACS due to compression of renal parenchyma or kinking of the renal vessels. Many techniques have been proposed in an attempt to achieve tension-free closure, which can be specially challenging in child recipients. We present our experience with Tutoplast^® Fascia Lata (RTI Surgical Tutogen Medical GmbH Industriestrasse 6, 91077 Neunkirchen am Brand, Germany) closure.

Methods

All pediatric patients who underwent renal transplantation in our center between 2012 and 2021 were reviewed. Eight patients with Tutoplast^® Fascia Lata placed at the time of initial transplantation were identified. Donor and recipient characteristics, Doppler ultrasound findings, and overall patient and graft survival rates were analyzed.

Results

Doppler ultrasound was performed intra-operatively after abdominal wall closure. If any sign of vascular compromise was seen, the abdominal wall was opened and the graft was revised. The Tutoplast^® Fascia Lata implant was used to perform tension-free fascia closure and, afterwards, a Doppler ultrasound was performed to confirm the optimal renal artery perfusion and venous patency. Three of the renal transplantations were from a cadaver donor, with two of them en bloc. Living donor transplantation was performed in four cases. Among which, there was a case of auto-transplantation due to bilateral renal artery stenosis. None of the patients presented any complications of either short or long term that was derived from the abdominal closure with Tutoplast^® Fascia Lata. There was also no record of graft failure till datum.

Conclusions

Restricted volume of the recipient pelvic cavity and the size discrepancy between the recipient pelvic cavity space and the donor adult kidney may lead to RACS. Other situations that occur more infrequently, i.e., as en bloc or auto-transplantation, are prone to suffer the same problem. Tutoplast^® Fascia Lata is a safe option for these patients.

Kidney Transplantation in Small Children: Association Between Body Weight and Outcome-A Report From the ESPN/ERA-EDTA Registry

BACKGROUND

Many centers accept a minimum body weight of 10 kg as threshold for kidney transplantation (Tx) in children. As solid evidence for clinical outcomes in multinational studies is lacking, we evaluated practices and outcomes in European children weighing below 10 kg at Tx.

METHODS

Data were obtained from the European Society of Paediatric Nephrology/European Renal Association and European Dialysis and Transplant Association Registry on all children who started kidney replacement therapy at <2.5 y of age and received a Tx between 2000 and 2016. Weight at Tx was categorized (<10 versus ≥10 kg) and Cox regression analysis was used to evaluate its association with graft survival.

RESULTS

One hundred of the 601 children received a Tx below a weight of 10 kg during the study period. Primary renal disease groups were equal, but Tx <10 kg patients had lower pre-Tx weight gain per year (0.2 versus 2.1 kg; P < 0.001) and had a higher preemptive Tx rate (23% versus 7%; P < 0.001). No differences were found for posttransplant estimated glomerular filtration rates trajectories (P = 0.23). The graft failure risk was higher in Tx <10 kg patients at 1 y (graft survival: 90% versus 95%; hazard ratio, 3.84; 95% confidence interval, 1.24-11.84), but not at 5 y (hazard ratio, 1.71; 95% confidence interval, 0.68-4.30).

CONCLUSIONS

Despite a lower 1-y graft survival rate, graft function, and survival at 5 y were identical in Tx <10 kg patients when compared with Tx ≥10 kg patients. Our results suggest that early transplantation should be offered to a carefully selected group of patients weighing <10 kg.

Pediatric kidney transplantation, a technical update

PURPOSE OF REVIEW

Pediatric kidney transplantation is the definitive therapy for infants and children suffering from renal failure. It is a distinct endeavor demanding specialized care for optimal results. This includes a dedicated preoperative workup accounting for unique predisposing urologic conditions, specialized surgical techniques, and careful hemodynamic monitoring and maintenance.

RECENT FINDINGS

Historically, size-matched renal allografts from pediatric donors to pediatric recipients suffered from poor outcomes. Advances in surgical technique performed at high volume centers have shown that these operations can be performed safely, helping expand the donor pool for these patients. Concurrently, transplantation of increasingly small for size infants with complex medical and surgical backgrounds has become a reality.

SUMMARY

On a policy front, efforts to expand access to size-matched organs, combined with advances in medical management and immunosuppression have seen pediatric renal transplantation reach new heights. Now, these breakthroughs are heightened by the ability to transplant such organs into the smallest infants. The net result will be diminished transplant waiting times and, accordingly, improved quality of life and longevity for children suffering from renal failure.

Long-term outcomes of living-donor kidney transplant children weighing less than 15 kg: Comparison of the surgical approach

INTRODUCTION

Kidney transplantation (KTx) is the most effective treatment for end-stage renal disease in children.

OBJECTIVES

We aimed to compare the long-term outcomes and surgical complications of the intraperitoneal approach (IPA) and extraperitoneal approach (EPA) for KTx in children weighing <15 kg.

STUDY DESIGN

We performed a retrospective cohort study on pediatric kidney transplant recipients, weighing <15 kg, who received their first living-related kidney transplant between January 1987 and December 2015. Patients were divided into two groups based on the surgical approach (IPA or EPA) during transplant, and clinical data were extracted from the medical records.

RESULTS

The median follow-up duration was 14.1 years (interquartile range, 9.0-19.2). Comparing the two groups (IPA group, n = 62; EPA group, n = 38), the median age and body weight were significantly lower in the IPA group (4.2 vs. 4.8 years, P = 0.03; 11.7 vs. 13.0 kg, P < 0.01). There were 26 surgical complications (26%) in 19 patients during the follow-up period. The surgical complication rate was higher in the IPA group (39% vs. 6%).

DISCUSSION

We assessed the long-term outcomes of the surgical approaches used for pediatric patients weighing <15 kg who underwent KTx and received a size-mismatched adult donor kidney. There was no significant difference in renal transplantation prognosis using the surgical approach, but IPA-related complications were more frequent in the long term. Therefore, our data suggest that in cases of donor-recipient size mismatch in pediatric KTx, the EPA, associated with fewer surgical complications, is preferable to the IPA if the patient's body size has sufficient space for allograft placement.

CONCLUSION

The transplant approach did not influence the long-term outcomes in children weighing <15 kg, but EPA had fewer surgical complications and was technically safe.

Surgical complications in pediatric kidney transplantation-Incidence, risk factors, and effects on graft survival: A retrospective single-center study

The field of pediatric kidney transplantation remains challenging due to an ongoing lack of size-matched grafts and anatomical peculiarities. In the current study, we investigated the incidence of surgical complications in pediatric recipients, with a focus on risk factors and effects on graft outcome. We retrospectively reviewed all 2386 kidney transplantations at our institution from January 2005 until December 2018. Of these, 221 transplants were performed in pediatric recipients, defined as under the age of 18 years. Donor-recipient body surface area ratios were calculated to evaluate the effects of size mismatching. Regression analyses were performed to identify independent risk factors for surgical complications and graft survival, respectively. Perioperative surgical complications requiring revision were observed in 34 (15.4%) cases. Leading cause for revision were vascular complications such as thrombosis or stenosis (n = 15 [6.8%]), which were significantly more frequent in case of young donors, (ie, donor age <6 years; OR: 4.281; CI-95%:1.385-13.226; P = .012), previous nephrectomy (OR: 3.407; CI-95%:1.019-11.387; P = .046), and en-bloc grafts (OR: 4.923; CI-95%:1.355-17.884; P = .015), followed by postoperative hemorrhage (n = 10 [4.5%]), ureteral complications (n = 8 [3.6%]), and lymphoceles (n = 7 [3.2%]). Median follow-up was 84.13 (0.92-175.72) months. One-, 5-, and 10-year graft survival rates were 97.1%, 88.9%, and 65.1%, respectively. Except for vascular complications (HR: 4.727; CI-95%:1.363-16.394; P = .014), none of the analyzed surgical morbidities significantly influenced graft survival. In conclusion, pediatric kidney transplantation achieves excellent long-term results. However, meticulous surgical technique and continuous postoperative monitoring are imperative for early detection and treatment of imminent vascular complications, especially in case of young donors and en-bloc grafts.

Extraperitoneal pediatric kidney transplantation of adult renal allograft using an en-bloc native liver and kidney mobilization technique

Background

We describe the safety and efficacy of performing pediatric kidney transplantation with a modified extraperitoneal approach that includes mobilization of the native liver and kidney.

Methods

We retrospectively identified pediatric renal transplants performed using this technique between 2015 and 2019. Data on patient demographics, surgical technique, and intraoperative details were collected. Outcomes were measured by morbidity and re-operation at 90 days, as well as serum creatinine, allograft survival, and overall survival at 1 year.

Results

Twenty-one patients with a median age of 5 (IQR 3–9) years, weighing 17.5 (IQR 14.5–24) kg were included. Median donor age was 24 (IQR 19–31) years. No intraoperative complications occurred. One child required a right native nephrectomy to allow sufficient space. Postoperatively, all patients had immediate graft function without urine leak or allograft thrombosis. 90-day morbidity and re-operation rates were zero. Both 1-year allograft and overall survival were 100% (on follow-up of all 21 patients through 1 year post-transplant), with a median serum creatinine of 0.58 (IQR 0.47–0.70) mg/dl at 1 year post-transplant.

Conclusions

Pediatric kidney transplantation of adult renal allografts using an extraperitoneal approach with native liver and kidney mobilization has promising allograft and patient survival outcomes that eliminates peritoneal violation and may diminish the need for native nephrectomy.

Strategy to Enable and Accelerate Kidney Transplant in Small Children and Results of the First 130 Transplants in Children ≤15 kg in a Single Center

BACKGROUND

Proper care of young children in need of kidney transplant (KT) requires many skilled professionals and an expensive hospital structure. Small children have lesser access to KT.

METHODS

We describe a strategy performed in Brazil to enable and accelerate KT in children ≤15 kg based on the establishment of one specialized transplant center, focused on small children, and cooperating with distant centers throughout the country. Actions on 3 fronts were implemented: (a) providing excellent medical assistance, (b) coordinating educational activities to disseminate expertise and establish a professional network, and (c) fostering research to promote scientific knowledge. We presented the number and outcomes of small children KT as a result of this strategy.

RESULTS

Three hundred forty-six pediatric KTs were performed in the specialized center from 2009 to 2017, being 130 in children ≤15 kg (38%, being 41 children ≤10 kg) and 216 in >15 kg (62%). Patient survival after 1 and 5 years of the transplant was 97% and 95% in the "small children" group, whereas, in the "heavier children" group, it was 99% and 96% (P = 0.923). Regarding graft survival, we observed in the "small children" group, 91% and 87%, whereas in the "heavier children" group, 94% and 87% (P = 0.873). These results are comparable to the literature data. Groups were similar in the incidence of reoperation, vascular thrombosis, posttransplant lymphoproliferative disease, and estimated glomerular filtration rate.

CONCLUSIONS

The strategy allowed an improvement in the number of KT in small children with excellent results. We believe this experience may be useful in other locations.

Results in the ESPN/ERA-EDTA Registry suggest disparities in access to kidney transplantation but little variation in graft survival of children across Europe

One of the main objectives of the European health policy framework is to ensure equitable access to high-quality health services across Europe. Here we examined country-specific kidney transplantation and graft failure rates in children and explore their country- and patient-level determinants. Patients under 20 years of age initiating kidney replacement therapy from January 2007 through December 2015 in 37 European countries participating in the ESPN/ERA-EDTA Registry were included in the analyses. Countries were categorized as low-, middle-, and high-income based on gross domestic product. At five years of follow-up, 4326 of 6909 children on kidney replacement therapy received their first kidney transplant. Overall median time from kidney replacement therapy start to first kidney transplantation was 1.4 (inter quartile range 0.3-4.3) years. The five-year kidney transplantation probability was 48.8% (95% confidence interval: 45.9-51.7%) in low-income, 76.3% (72.8-79.5%) in middle-income and 92.3% (91.0-93.4%) in high-income countries and was strongly associated with macro-economic factors. Gross domestic product alone explained 67% of the international variation in transplantation rates. Compared with high-income countries, kidney transplantation was 76% less likely to be performed in low-income and 58% less likely in middle-income countries. Overall five-year graft survival in Europe was 88% and showed little variation across countries. Thus, despite large disparities transplantation access across Europe, graft failure rates were relatively similar. Hence, graft survival in low-risk transplant recipients from lower-income countries seems as good as graft survival among all (low-, medium-, and high-risk) graft recipients from high-income countries.

Is Preoperative Preparation Time a Barrier to Small Children Being Ready for Kidney Transplantation?

BACKGROUND

Small children are less frequently transplanted when compared with older. The objective of the present study was to compare the preparation time for transplantation in children of different weights and to identify factors associated with a delay in the workup of small children.

METHODS

We report on a retrospective cohort comprising all children referred for renal transplantation (RTx) workup between 2009 and 2017. The main outcome was transplantation workup time, defined as the time elapsed between the first consultation and when the child became ready for the surgery.

RESULTS

A total of 389 children (63.5% males) were selected, with a median weight of 18 kg (interquartile range, 11-32). Patients were categorized into 2 groups: group A (study group): ≤15 kg (n = 165) and group B (control group): >15 kg (n = 224). The probability of being ready for RTx was comparable between groups A and B. The cumulative incidence rate difference between groups is -0.05 (95% confidence interval, -0.03 to 0.02). The median time for RTx workup was 5.4 (2.4-9.4) in group A and 4.3 (2.2-9.0) months in group B (P = 0.451). Moreover, the presence of urinary tract malformation was associated with the need for longer transplantation workup time (P < 0.001).

CONCLUSIONS

In children >7 kg, the workup time for transplantation is not related to body weight. In a specialized center, children weighing 7-15 kg became ready within the same timeframe as children weighing >15 kg, despite the smaller children had greater difficulty being nourished, dialyzed, and a greater need for surgical correction of the urinary tract pretransplant.

Outcome of kidney transplantation from young pediatric donors (aged less than 6 years) to young size-matched recipients

INTRODUCTION

Pediatric donation is underutilized because of presumed increased risk of vascular thrombosis (VT) and graft loss. Using young pediatric donors (YPDs) for young pediatric recipients (YPRs) is suggested to be even at greater risk and therefore precluded in many centers. The aim of this study was to analyze the outcome of kidney transplantation (KT) from YPD to age-matched YPR.

PATIENT AND METHODS

A retrospective study of 118 pediatric KT performed between January 2007-July 2017. The authors identified KT with YPD (considered as those aged <6 years) and age-matched YPR. Organ allocation was performed based on the best paired size (YPR for YPR). Data were collected regarding donor and recipient characteristics, surgical and urological complications, graft loss, and outcomes.

RESULTS

Forty cases of YPD to age-matched YPR were identified (33.89% of the cohort). Mean recipient and donor age were 2.9 years (SD 1.68) and 2.24 years (SD 1.5), respectively. Mean recipient and donor weight were 12.7 kg (SD 4.1) and 13.7 kg (SD 4.15), respectively. Thirty of those young recipients (75%) weighed <15 kg. The most frequent primary renal disease was the congenital nephrotic syndrome. Nine out of 40 patients (22.5%) had received a previous KT before. Three received a combined liver-KT. Eight (20%) were classified as high immunological risk and 19 (47.5%) as high thrombotic risk. All allografts were implanted extraperitoneally and anastomosed to the iliac vessels. Major complications requiring reintervention occurred in seven patients (17.5%): three VT, three bleeding episodes, and one ureteral necrosis. Remarkably, only one surgical complication (VT) resulted in graft loss. Regarding long-term urological complications, four patients (10%) all with obstructive uropathy-developed vesicoureteral reflux to the graft. Actuarial graft survival at 1,5, and 10 years in the YPD to age-matched YPR cohort was 83% -78% -78%, respectively. Mean follow-up was 3.6 years (SD 3.2) (r = 7-10). Over time, eight patients lost their graft, not related to surgical factors in seven out of eight cases.

CONCLUSION

The authors suggest that KT using YPD for age-match YPR yields good results in expert centers, even in high-risk patients and is associated with good graft survival. In this series, surgical complications were rarely related to graft loss.

Is donor age 6 years or less related to increased risk of surgical complications in pediatric kidney transplantation?

INTRODUCTION

Despite the widespread organ shortage dilemma, there is hesitancy regarding utilization of young donors (aged ≤6 years) because previous reports have suggested that this is associated with an increased risk of surgical complications and graft loss.

OBJECTIVE

The aim of this study was to determine if donor age ≤6 years is related to increased risk of surgical complications or allograft loss in pediatric kidney transplantation (KT).

STUDY DESIGN

A retrospective study of pediatric kidney transplants (KT) undertaken between January 2000 and July 2015. The incidence of surgical and urological complications, and allograft loss were analyzed and compared between donors aged ≤6 years (Group 1) and donors aged >6 years (Group 2).

RESULTS

A total of 171 pediatric KTs were performed at the current center during the study period. Twenty-eight patients were excluded; as a result, the study comprised 143 patients: 60 (Group 1) and 83 (Group 2). Mean recipient weight was 17 kg (SD 9.7; range 3.2-47) in Group 1 and 38.2 kg (SD 15.3; range 7.8-73) in Group 2. Despite a significantly higher proportion of risk factors in Group 1, no significant between-group differences were observed in terms of: surgical complications (OR 0.4; range 0.1-1.2), early urological complications (OR 2.2; range 0.4-11), late urological complications (OR 0.3; range 0.8-1.4), lymphoceles (OR 6.2; range 0.7-51.7) and allograft loss (OR 1.5; range 0.7-3.1, summary Table). Graft survival at 1 and 5 years was: 81% and 70% (Group 1) and 92% and 79% (Group 2), respectively (P = 0.093). Mean follow-up was 90.13 ± 49.7 months.

DISCUSSION

The main finding of this retrospective study was that pediatric donor kidneys from donors aged ≤6 years could safely be used in pediatric recipients without an increased risk of surgical and urological complications or graft loss. Nevertheless, KT with small donor kidneys is challenging and should be performed at experienced pediatric centers.

CONCLUSION

In line with these results, the outcomes of KT using donors aged ≤6 years were encouraging and similar to those obtained with older donors. Thus, this study supported using kidney grafts from young donors, given the organ shortage and potential high mortality risk while awaiting KT.

Vascular thrombosis in pediatric kidney transplantation: Graft survival is possible with adequate management

OBJECTIVE

Vascular thrombosis (VT) in pediatric kidney transplantation (KT) is a dreaded event that leads to graft loss in almost 100% of cases. In recent years, VT has become the most common cause of early graft loss. The aim of this study was to analyze our experience in diagnosis and treatment of VT and the impact of a new management protocol on patient outcome.

METHODS

We conducted a retrospective study of 176 consecutive KT performed at our institution by the pediatric urology team between January 2000 and December 2015 and identified patients with VT. A protocol of prevention and early detection of VT was introduced in 2012.

RESULTS

Out of 176 KT, nine cases of VT were identified (5.1%). The mean recipient age was 5.1 years (SD 4.9 years) and mean weight was 22.28 kg (SD 15.6 kg). Diagnosis was intraoperative in two cases and within the first 24 h after surgery in the remaining seven. Immediate surgical exploration was performed after diagnosis in all. Of the five episodes that occurred before 2012, all developed complete graft ischemia requiring transplantectomy. However, in the four cases diagnosed after 2012, graft perfusion could be restored in three, and abdominal wall closure with a mesh and delayed sequentially closure under ultrasound guidance was performed. With a follow-up of 30, 25, and 20 months, the three recovered grafts are still functioning normally.

CONCLUSIONS

Increased awareness and the application of a protocol for prevention, detection and treatment of VT in pediatric KT can prevent graft loss. Immediate surgical intervention is mandatory after diagnosis. Avoiding compartment syndrome with delayed sequential closure may be useful to improve graft survival.

Renal transplantation in children under 3 years of age: Experience from a single-center study

RTx remains challenging in children under 3 years of age. This single-center study reviewed the medical records of children <3 years transplanted since 1987 (N = 32, Group 1). They were matched for donor type and RTx period with children aged 3-13 years (N = 32, Group 2) and 13-18 years (N = 32, Group 3). There were no between-group significant differences regarding distributions of gender, primary renal disease, proportion of dialysis before RTx, and growth (SDS). Compared to Groups 2 and 3, Group 1 had more peritoneal dialyses (P < .001), more EBV mismatches (P = .04), and longer warm ischemia times (P < .001). The risk of graft loss was not significantly different among age groups (hazard ratio, 2.4 in Group 2 and 2.0 in Group 3 vs Group 1; P = .2). Death occurred in four patients (3 in Group 1 and 1 in Group 2) and graft loss occurred in 28 patients, mainly due to chronic allograft nephropathy. In recipients <3 years of age, the outcomes of RTx are close to those obtained in older pediatric age groups. Thus, young patients may be transplanted in experienced multidisciplinary teams without additional risks provided that particular attention is paid to donor selection and prevention/early diagnosis of comorbidities and complications.