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Iyengar A, McCulloch MI. Paediatric kidney transplantation in under-resourced regions-a panoramic view. Pediatr Nephrol 2022; 37:745-755. [PMID: 33837847 PMCID: PMC8035609 DOI: 10.1007/s00467-021-05070-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 07/21/2020] [Accepted: 03/24/2021] [Indexed: 01/10/2023]
Abstract
Kidney transplantation is the ideal choice of kidney replacement therapy in children as it offers a low risk of mortality and a better quality of life. A wide variance in the access to kidney replacement therapies exists across the world with only 21% of low- and low-middle income countries (LLMIC) undertaking kidney transplantation. Pediatric kidney transplantation rates in these under-resourced regions are reported to be as low as < 4 pmcp [per million child population]. A robust kidney failure care program forms the cornerstone of a transplant program. Even the smallest transplant program entails a multidisciplinary workforce and expertise besides ensuring family commitment towards long-term care and economic burden. In general, the short-term graft survival rates from under-resourced regions are comparable to most high-income countries (HIC) and the challenge lies in the long-term outcomes. This review focuses on specific issues relevant to kidney transplants in children in under-resourced regions by highlighting limitations in the capacity and health workforce, regulatory norms, medical issues, economic burden, factors beyond financial hardship and ethical considerations relevant to these regions. Finally, the perspective of strengthening transplant programs in these regions should factor in the bigger challenges that exist in achieving the health-related sustainable development goals by 2030.
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Affiliation(s)
- Arpana Iyengar
- Pediatric Nephrology, St John's Medical College Hospital, Bangalore, India.
| | - M I McCulloch
- Pediatric Nephrology, Red Cross War Memorial Children's Hospital, Cape Town, South Africa
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Hashimoto J, Oguchi H, Mikami T, Hamasaki Y, Muramatsu M, Yamaguchi Y, Sakai K. Clinicopathological Analysis of Medullary Ray Injury in 1-Year Protocol Paediatric Renal Allograft Biopsies. Nephron Clin Pract 2020; 144 Suppl 1:79-85. [PMID: 33221804 DOI: 10.1159/000511917] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 09/30/2020] [Indexed: 11/19/2022] Open
Abstract
AIM Medullary ray injury was recently reported in renal transplant biopsies. This study was performed to clarify the clinicopathological features of medullary ray injury in paediatric living renal transplant recipients. METHODS Paediatric recipients who completed a 5-year follow-up after living renal transplantation were enroled. We evaluated the clinical and pathological parameters of the presence or absence of medullary ray injury in their 1-year protocol biopsies. RESULTS Of 48 1-year protocol biopsies, 18 (37.5%) showed histological evidence of medullary ray injury. The 48 paediatric recipients were classified as those with medullary ray injury (n = 18; MRI-1Y [+] group) and those without medullary ray injury (n = 30; MRI-1Y [-] group) in the 1-year protocol biopsies. The prevalence of histological evidence of calcineurin inhibitor (CNI) nephrotoxicity, chronic obstruction or reflux nephropathy, and imaging findings of vesicoureteral reflux was 66.7, 22.2, and 7.7% in the MRI-1Y (+) group and 33.3, 13.3, and 15.4% in the MRI-1Y (-) group, respectively. Only the prevalence of CNI nephrotoxicity was significantly different between the 2 groups. There was no significant difference in the mean estimated glomerular filtration rate at 1, 3, or 5 years after transplantation between the 2 groups. CONCLUSION In total, 37.5% of 1-year protocol biopsies showed histological evidence of medullary ray injury. This finding suggests that CNI nephrotoxicity might be the main contributor to medullary ray injury in 1-year protocol biopsies. The presence of medullary ray injury had little influence on renal function, at least during the first 5 years after transplantation.
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Affiliation(s)
- Junya Hashimoto
- Department of Nephrology, Toho University Faculty of Medicine, Tokyo, Japan
| | - Hideyo Oguchi
- Department of Nephrology, Toho University Faculty of Medicine, Tokyo, Japan,
| | - Tetuo Mikami
- Department of Pathology, Toho University Faculty of Medicine, Tokyo, Japan
| | - Yuko Hamasaki
- Department of Nephrology, Toho University Faculty of Medicine, Tokyo, Japan
| | - Masaki Muramatsu
- Department of Nephrology, Toho University Faculty of Medicine, Tokyo, Japan
| | | | - Ken Sakai
- Department of Nephrology, Toho University Faculty of Medicine, Tokyo, Japan
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Jensen KK, Røder O, Bistrup C. Surgical complications and graft survival in pediatric kidney transplant recipients treated with a steroid-free protocol: experiences from a Danish university hospital. Transplant Proc 2013; 45:3258-61. [PMID: 24182796 DOI: 10.1016/j.transproceed.2013.07.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2013] [Revised: 07/03/2013] [Accepted: 07/24/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND The outcome of pediatric kidney transplantation depends on several factors, among these are the complications, which occur in relation to the surgical procedure. In this study, we present our experience with pediatric kidney transplantation in a steroid-free immunosuppression regimen, from a surgical point of view. METHODS Patient charts of pediatric kidney transplantations in the period 1998-2011 were reviewed. Surgical complications, acute rejection, and patient and graft survivals were recorded. RESULTS Sixty-one renal transplantations were performed in 58 patients. Thirty patients (49.1%) experienced a surgical complication, of which 11 (18%) required an explorative laparotomy. Overall the five-year Kaplan-Meier patient survival rate was 96.2% and the graft survival rate was 88.6%. Nine patients (14.7%) had an acute rejection episode within the first year after transplantation. No correlation was observed between surgical complications and acute rejection episodes or graft loss. CONCLUSIONS This study indicated a high incidence of surgical complications among pediatric kidney transplantations when using a steroid-free immunosuppression regimen. Despite this, we observed high overall patient and graft survival, supporting the trend toward steroids avoidance in pediatric kidney transplantation.
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Affiliation(s)
- K K Jensen
- Department of Thoracic and Vascular Surgery T, Odense University Hospital, Odense, Denmark.
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Rizvi SAH, Sultan S, Zafar MN, Naqvi SAA, Lanewala AA, Hashmi S, Aziz T, Hassan AS, Ali B, Mohsin R, Mubarak M, Farasat S, Akhtar SF, Hashmi A, Hussain M, Hussain Z. Pediatric kidney transplantation in the developing world: challenges and solutions. Am J Transplant 2013; 13:2441-9. [PMID: 23865679 DOI: 10.1111/ajt.12356] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Revised: 05/07/2013] [Accepted: 05/21/2013] [Indexed: 01/25/2023]
Abstract
The prevalence of pediatric RRT and transplantation are low in developing countries, 6-12 and <1 to 5 per million child population (pmcp), respectively. This is due to low GDP/capita of <$10 000, government expenditure on health of <2.6-9% of GDP and paucity of facilities. The reported incidence of pediatric CKD and ESRD is <1.0-8 and 3.4-35 pmcp, respectively. RRT and transplantation are offered mostly in private centers in cities where HD costs $20-100/session and transplants $10 000-20 000. High costs and long distance to centers results in treatment refusal in up to 35% of the cases. In this backdrop 75-85% of children with ESRD are disfranchised from RRT and transplantation. Our center initiated an integrated dialysis-transplant program funded by a community-government partnership where RRT and transplantation was provided "free of cost" with life long follow-up and medication. Access to free RRT at doorsteps and transplantation lead to societal acceptance of transplantation as the therapy of choice for ESRD. This enabled us to perform 475 pediatric transplants in 25 years with 1- and 5-year graft survival of 96% and 81%, respectively. Our model shows that pediatric transplantation is possible in developing countries when freely available and accessible to all who need it in the public sector.
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Affiliation(s)
- S A H Rizvi
- Department of Urology, Sindh Institute of Urology and Transplantation, Dewan Farooq Medical Complex, Karachi, Pakistan
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Vitola SP, Gnatta D, Garcia VD, Garcia CD, Bittencourt VB, Keitel E, Pires FS, D'Avila AR, Silva JG, Amaral RL, Santos LN, Kruel CDP. Kidney transplantation in children weighing less than 15 kg: extraperitoneal surgical access-experience with 62 cases. Pediatr Transplant 2013; 17:445-53. [PMID: 23730951 DOI: 10.1111/petr.12104] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/30/2013] [Indexed: 11/30/2022]
Abstract
Small children are a challenging group in whom to perform KT. This retrospective study analyzed the results of 62 KTs in children weighing <15 kg, performed between 1998 and 2010, using extraperitoneal access and anastomosis of the renal vessels of donors to the aorta and IVC or iliac vessels of the recipients. Thirty-two (51.6%) grafts were LRDTs and 30 (48.4%) were DDRTs-28 of them pediatric. The mean age at KT was 3.7 ± 2.2 yr (1-12), and the mean weight was 12.3 ± 2.1 kg (5.6-14.9). Ten children weighed <10 kg, and five (8.1%) children presented previous thrombosis of the venous system. At one and five yr, patient survival was 93.2% and 84.2%, and graft survival was 85.2% and 72.7%. There were no differences between the rates for LRDT and DDRT. There were six vascular complications (four vascular thromboses, one laceration, and one renal artery stenosis) and two perirenal collections. Extraperitoneal access is a valid KT technique in children weighing <15 kg.
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Affiliation(s)
- S P Vitola
- Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Programa de Pós-Graduação em Ciências Cirúrgicas, Porto Alegre, Brazil.
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Ravlo K, Chhoden T, Søndergaard P, Secher N, Keller AK, Pedersen M, Bibby BM, Jørgensen TM, Møldrup U, Ostraat EØ, Birn H, Nørregaard R, Marcussen N, Leuvenink HG, Jespersen B. Early outcome in renal transplantation from large donors to small and size-matched recipients - a porcine experimental model. Pediatr Transplant 2012; 16:599-606. [PMID: 22584014 DOI: 10.1111/j.1399-3046.2012.01707.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Kidney transplantation from a large donor to a small recipient, as in pediatric transplantation, is associated with an increased risk of thrombosis and DGF. We established a porcine model for renal transplantation from an adult donor to a small or size-matched recipient with a high risk of DGF and studied GFR, RPP using MRI, and markers of kidney injury within 10 h after transplantation. After induction of BD, kidneys were removed from ∼63-kg donors and kept in cold storage for ∼22 h until transplanted into small (∼15 kg, n = 8) or size-matched (n = 8) recipients. A reduction in GFR was observed in small recipients within 60 min after reperfusion. Interestingly, this was associated with a significant reduction in medullary RPP, while there was no significant change in the size-matched recipients. No difference was observed in urinary NGAL excretion between the groups. A significant higher level of HO-1 mRNA was observed in small recipients than in donors and size-matched recipients indicating cortical injury. Improvement in early graft perfusion may be a goal to improve short- and long-term GFR and avoid graft thrombosis in pediatric recipients.
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Affiliation(s)
- Kristian Ravlo
- Department of Nephrology Anaesthesiology, Aarhus University Hospital Institute of Clinical Medicine, The Netherlands
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Lledó-García E, Hernández-Fernández C, Subirá-Ríos D, Díez-Cordero JM, Durán-Merino R, Herranz-Amo F, Verdú-Tartajo F, Moralejo-Gárate M, Bueno-Chomón G, Ogaya-Pinies G, Morales D, Luque-de Pablos A. Cadaver Donor Kidney Retransplantation in the Pediatric Patient: Complications and Long-Term Outcome. J Urol 2011; 185:2582-5. [DOI: 10.1016/j.juro.2011.01.028] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2010] [Indexed: 10/18/2022]
Affiliation(s)
- Enrique Lledó-García
- Departments of Urology and Pediatric Nephrology (DM, ALdP), Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Carlos Hernández-Fernández
- Departments of Urology and Pediatric Nephrology (DM, ALdP), Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - David Subirá-Ríos
- Departments of Urology and Pediatric Nephrology (DM, ALdP), Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - José Maria Díez-Cordero
- Departments of Urology and Pediatric Nephrology (DM, ALdP), Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Ramón Durán-Merino
- Departments of Urology and Pediatric Nephrology (DM, ALdP), Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Felipe Herranz-Amo
- Departments of Urology and Pediatric Nephrology (DM, ALdP), Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Fernando Verdú-Tartajo
- Departments of Urology and Pediatric Nephrology (DM, ALdP), Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Mercedes Moralejo-Gárate
- Departments of Urology and Pediatric Nephrology (DM, ALdP), Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Gonzalo Bueno-Chomón
- Departments of Urology and Pediatric Nephrology (DM, ALdP), Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Gabriel Ogaya-Pinies
- Departments of Urology and Pediatric Nephrology (DM, ALdP), Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Dolores Morales
- Departments of Urology and Pediatric Nephrology (DM, ALdP), Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Augusto Luque-de Pablos
- Departments of Urology and Pediatric Nephrology (DM, ALdP), Hospital General Universitario Gregorio Marañón, Madrid, Spain
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Second cadaveric kidney transplantations in the pediatric population. Transplant Proc 2011; 43:363-6. [PMID: 21335223 DOI: 10.1016/j.transproceed.2010.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To evaluate the functional outcomes and complications among a series of second in comparison to first kidney transplantations in pediatric patients. MATERIALS AND METHODS We reviewed 163 consecutive kidney transplants in pediatric recipients performed from 1978 to present: 120 cases (69.3%) were first transplants (group A) and 43 (24.8%), second transplant (group B). We analyzed the incidences of delayed graft function (DGF), medical and surgical complications, as well as medium- and long-term graft survivals. RESULTS We observed DGF among 51 group A patients (43%) versus 32.5% of group B. Ten patients suffered vascular complications in group A (8.3%) versus one in group B (2.3%) (P < .05). The 15-year graft survivals were 54.2% for group A and 45% for group B. The 15-year patient survivals were 84.9% in group A versus 93.6% in group B. CONCLUSIONS Second kidney transplantations for children are a satisfactory option that achieves good functional results as well as acceptable graft and patient survivals.
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Vesicoureteral reflux, reflux nephropathy, and end-stage renal disease. Adv Urol 2008:508949. [PMID: 18670633 PMCID: PMC2478704 DOI: 10.1155/2008/508949] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2008] [Accepted: 06/12/2008] [Indexed: 12/20/2022] Open
Abstract
Objective. To review the contribution of vesicoureteral reflux and reflux nephropathy to end-stage renal disease.
Data Source. Published research articles and publicly available registries.
Results. Vesicoureteral reflux (VUR) is commonly identified in pediatric patients and can be associated with reflux nephropathy (RN), chronic kidney disease (CKD), and rarely end-stage renal disease (ESRD). Patients with reduced GFR, bilateral disease, grade V VUR, proteinuria, and hypertension are more likely to progress to CKD and ESRD. Because progression to ESRD is rare in VUR and often requires many decades to develop, there are limited prospective, randomized, controlled trials available to direct therapy to prevent progression to ESRD.
Conclusions. Identification of patients with increased risk of progression to CKD and ESRD should be the goal of clinical, biochemical, and radiological evaluation of patients with VUR. Treatment of patients with VUR should be directed at preventing new renal injury and preserving renal function.
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