Pediatric cadaver kidney transplants into adults

Trasplante renal pediatrico con injertos de donantes infantiles de corta edad (. 6 anos). complicaciones y evolucion funcional

GOALS

To evaluate functional results and complications in a group of pediatric patients who received kidney transplants from donors aged 6 years or less.

MATERIAL & METHODS

Thirty-four consecutive renal transplants were reviewed. Of 34 patients, 19 (55.8%) received kidneys from donors aged below 3 years (Group A) and 15 (44.2%) from donors aged 3-6 years (Group B). Long-term functional patient and graft survival results along with complications were compared in both groups.

RESULTS

Seven patients in group A (36.7%) had vascular complications, in comparison to 3 in group B (20%, p<0.05). Kidneys preserved in Eurocollins (EC) solution had more vascular complications (35.3%) in comparison to University of Wisconsin (UW) solution kidneys (23.5%, p<0.05). Ten-year graft survival rate in group A was significantly lower in comparison to group B (35.5% vs 58.6%, p<0.05). In relation to preservation solution type used, 10-year graft survival rate was also significantly better in UW group (26.8% vs 63%, p<0.001).

CONCLUSIONS

The exclusion of donors younger than 3 years and the utilization of optimal preservation solutions produces a decrease in figures of vascular complications and a significant improvement in graft survival rates.

Outcome of en bloc and single kidney transplantation from very young cadaveric donors

BACKGROUND

The optimal use of very young cadaveric kidneys (from donors less than 4 years old) remains controversial. High rates of technical complications and poor functional results compared with adult donor kidneys have been reported. The use of en bloc transplantation to overcome these problems has been advocated, although en bloc transplantation halves the number of potential transplants from very young donors.

METHODS

We studied the technical and functional results of 91 transplants from very young donors performed at our institution between 1984 and 1995. This included 59 single and 22 en bloc procedures involving first transplants and 7 single and 3 en bloc procedures involving retransplantation. Individual surgeon preference dictated the use of either the single or en bloc technique. Kidneys smaller than 6 cm tended to be transplanted en bloc, and lighter patients were generally given preference for receiving pediatric kidneys. Patients received sequential cyclosporine-based quadruple immunosuppression.

RESULTS

En bloc kidneys had a 1-year and 5-year graft survival of 82% and 70%, respectively. Single kidneys had a 1-year and 5-year graft survival of 64% and 40%. Kidneys that avoided acute rejection episodes and that were transplanted into heavier or male recipients had better long-term survival. Kidneys from donors less than 2 years old did poorly whether transplanted en bloc or singly. Better HLA matching improved short-term, but not long-term, graft survival, whereas cold ischemic time did not have statistically significant association with differences in graft survival. Eleven percent of the transplants had ureteral leaks, but only one kidney was lost. Ten transplants had vascular complications leading to graft loss, whereas two episodes of arterial stenosis were successfully treated with percutaneous angioplasty.

CONCLUSIONS

En bloc transplantation optimizes the outcome of transplantation with very young kidneys. We recommend induction therapy and cyclosporine immunosuppression with cyclosporine levels similar to adult target levels to minimize rejection episodes and, thus, improve outcome. These kidneys should be distributed nationally, because better HLA matching is associated with improved short-term graft survival. Our high ureteral leak rate indicates that alternatives to unstented ureteroneocystostomy should be considered.

Long-term results with single pediatric donor kidney transplants in adult recipients

PURPOSE

We investigated whether transplantation of single pediatric donor kidneys into adults leads to an increased incidence of functional allograft impairment and complications, as previously reported.

MATERIALS AND METHODS

To evaluate long-term functional outcome using single pediatric donor kidneys 60 adults (study group) who underwent transplantation between March 1973 and December 1988 using single pediatric donor kidneys 6 years old or younger (mean donor age plus or minus standard deviation 41.1 +/- 17.9 months) were compared to 58 matched adults (control group) who underwent transplantation with adult kidneys (mean donor age 29.7 +/- 10.8 years). The groups were identical for era of transplantation, recipient age, sex and followup (82 versus 83 months).

RESULTS

There was no difference in patient survival between the study and control groups (p = 0.26). In the study group there were an increased requirement for early dialysis (45 versus 24%, p = 0.02), a higher incidence of proteinuria (greater than 0.8 gm./24 hours, 67 versus 48%, p = 0.04) and a higher incidence of rejection within the first 6 months (80 versus 64%, p = 0.05). There was also an increased incidence of graft failure from acute rejection in the study group. Early differences in serum creatinine levels in the 2 groups dissipated after 3 months. Renal allograft histopathology revealed no significant difference in the incidence of focal segmental glomerulosclerosis in the study versus control groups after transplantation (22.9 versus 13.3%, p = 0.70). However, focal segmental glomerulosclerosis manifested sooner after transplantation in study than control patients (mean 37 versus 82 months). After transplantation proteinuria developed in study patients with focal segmental glomerulosclerosis at a mean of 4.6 months compared to 31.8 months in controls with post-transplant focal segmental glomerulosclerosis. Graft survival in the study group was superior when cyclosporine was given rather than conventional noncyclosporine based immunosuppression. Five-year graft survival rates were 48 versus 44% for cyclosporine treated and 33 versus 44% for conventionally treated study versus control patients.

CONCLUSIONS

These data suggest that with cyclosporine immunosuppression transplanting single pediatric kidneys into adults yields the same long-term functional graft outcome as adult donor kidneys.

Transplantation of pediatric cadaver kidneys into adult recipients

Between July 1987 and July 1993, 762 renal allografts were transplanted into adult recipients at our institution. A total of 83 adults received cadaveric renal transplants from donors aged 5 months to 10 years, while 100 adults who received adult cadaver kidneys during the same period served as a comparison group. Cyclosporine based immunosuppression was used. No difference between the 2 groups was found with respect to recipient age, recipient sex, primary renal disease, HLA matching or the number of recipients with a previous transplant. Actual patient (graft) survivals at 1 and 3 years were 91% (77%) and 86% (68%), respectively, for recipients of pediatric kidneys compared to 99% (92%) and 90% (80%), respectively, for recipients of adult kidneys. Pediatric kidney recipients were more likely to encounter renovascular complications (13% versus 4%, p = 0.023) and more likely to have episodes of acute rejection (p = 0.018). Serum creatinine was equal in the 2 groups at 1 year following transplantation (p = 0.63).

Kidney transplantations at King Faisal Specialist Hospital and Research Centre

During the five year period from 1987G to 1991G, 161 kidney transplantations were performed at King Faisal Specialist Hospital and Research Centre (KFSH&RC); 79 from cadaveric donors (CD) and 82 from living related donors (LRD). All cadaveric kidneys except one were harvested within Saudi Arabia and 67% were from Saudi nationals. The immunosuppresive protocol was a triple drug regimen comprising cyclosporin-A (CyA), azathioprine (Aza), and prednisone. The actuarial graft survival rates at one and three years were 85% and 76% for the cadaveric donor transplants and 96% and 91%, respectively for the living related donor transplants (P<0.01). The corresponding patient survival rates for cadaveric donor transplants (CDTxs) were 97% and 94% and for the living related donor transplants (LRDTxs), 99% and 97% (NS). These results compare well with the best results in the Western world. The most serious surgical complications were vascular thromboses (five cases) and infections of the arterial anastomosis line with bleeding (two cases), all leading to loss of the cadaveric graft. The most common causes of death were virus infection, varicella, cytomegalovirus, and hepatitis B and C. The organ donation rate, from cadaveric donors as well as living related donors, is stil low in Saudi Arabia. Lack of organs is the main obstacle to an expansion of this promising transplantation activity. Continuous education of the multinational medical profession as well as the lay population is necessary to improve the situation.

The organ donor

Vascularized organ transplantation is now a widely applied therapy for patients with end-stage diseases of the heart, lungs, liver, kidneys, and pancreas. A critical shortage of donor organs exists in the United States and, as a consequence, prospective transplant recipients die while waiting for a life-saving transplant. The apparent shortage of cadaver organs is, in large part, caused by the reluctance and failure of the physician and the public to promote cadaver organ donation. Educational awareness programs for both professional personnel and the public at large are needed to increase the number of potential donors and multiorgan procurements carried out. All victims of trauma with severe closed head injury or cerebrovascular catastrophe secondary to anoxia should be considered as potential organ donors and referred to the local organ procurement agency for evaluation.

Evaluation of pediatric cadaver kidneys transplanted into adult recipients receiving cyclosporine

The major problem in clinical transplantation is the imbalance between the need for cadaveric organs and the available numbers of donors. If pediatric kidneys were transplanted into adult recipients when no pediatric recipient was available, the potential number of renal donors would be increased by 15 to 20%. Some centers are reluctant to use pediatric kidneys for adult recipients because of recent reports indicating poorer patient and allograft survival, increased delayed graft function, increased post-transplant hypertension and increased technical complication. (There also has been concern that the nephrotoxic effect of cyclosporine A would retard the organ growth that is necessary to provide normal renal function in adults.) A retrospective analysis was performed on 18 adult recipients who received kidneys from cadaver donors 14 months to 12 years old (group 1). These patients were compared to 106 adult recipients who received kidneys from donors greater than 12 years old (group 2). Actuarial patient survival at 1 year was 85% for group 1 and 95.8% for group 2 (p equals 0.13), while 1-year actuarial allograft survival was 83.1% for group 1 and 81.1% for group 2 (p equals 0.87). There was no significant difference between groups 1 and 2 in the frequency of delayed graft function, serum creatinine at 1, 3 and 6 months after transplantation, incidence of post-transplant hypertension or frequency of surgical complications. It is of interest that the pediatric kidneys had significant growth during the initial post-transplant month. Sonographic examination at postoperative days 1 and 30 demonstrated a mean increase in size from 80.7 to 143.5 cm. (p less than 0.001). In this series pediatric kidneys were safe and effective donor organs in adult recipients, and increased the available number of organs by 15%.

Influence of recipient and donor age in pediatric renal transplantation. Collaborative Transplant Study

The influence of recipient and donor age on the outcome of first cadaver kidney transplants was analyzed in a series of 1325 pediatric recipients and in 4230 transplants from pediatric kidney donors. Graft survival improved significantly with increasing recipient age (P less than 0.0001) and donor age (P less than 0.0001). Combined analysis of recipient and donor age groups revealed an overriding effect of donor age on graft outcome. Kidneys from donors younger than 3 years old consistently yielded poor results regardless of recipient age. Kidneys from adult donors gave the best results even in young recipients 0-5 years of age. With adult donor kidneys in cyclosporin-treated patients, high 1-year graft survival rates of 86 +/- 9% (SE) in 15 0- to 5-year-old recipients, 85 +/- 3% in 137 6- to 12-year-old recipients, and 83 +/- 1% in 6027 13- to 40-year-old recipients were observed.

En bloc kidney and bladder transplantation from an anencephalic donor into an adult recipient

The visceral block, composed of both kidneys and their vascular pedicles, inferior vena cava, ureters and bladder, was removed from a 3-day-old male anencephalic donor and transplanted into a 32-year-old adult in chronic renal failure. The urinary tract was reconstructed by vesicovesicostomy for technical ease, and prevention of reflux and ureteral stenosis. Maximum urine output was 150 ml. per day and the kidney grafts were lost owing to rejection 5 months after transplantation.