The Role of Organ Transplantation in Pediatrics

Decision Making in the Context of Paediatric Solid Organ Transplantation Medicine

This manuscript aims to outline ethical, legal, and psychosocial key situations in the context of transplantation under special consideration of children. Besides being particularly vulnerable, children as minors by law are not meant to consent to whatever medical procedure is applied to them. Rather their next-of-kin and medical staff are to decide. In the context of transplantation thus it needs to be reflected under which circumstances a child can become an organ donor or receive an organ. This essay will not provide answers to current questions in transplantation medicine but provide an overview of present European practices and juxtapose divergent courses of action which are based on an assumed similar social-cultural background. Data are drawn from a systematic comparison of the various national organ transplantation laws and tissue acts. Ethical reflections are based on a thematically targeted literature search using PubMed Central and PhilPapers databases.

Upside-down kidney placement: An alternative in pediatric renal transplantation

PURPOSE

"Upside-down" kidney placement has been reported as an acceptable alternative in cases of technical difficulty in kidney transplantation but there are few reports in the pediatric population. The aim of our study is to analyze whether the placement of the upside-down kidney could affect graft outcome or produce more complications.

MATERIALS AND METHODS

A retrospective study was conducted of pediatric kidney transplants performed in our center between 2005 and 2017 with at least 6 months' follow-up. Epidemiological and anthropometric data, type of donor (deceased/living), graft position (normal/upside-down), reason for the upside-down placement, early, medium and long-term complications and renal function were analyzed and compared with patients transplanted in the same period with a normal graft placement.

RESULTS

From 181 transplants, 167 grafts were placed in a normal position (mean age: 10 y and mean weight: 30 kg) and 14 were placed upside-down (10 y, 37 kg) mainly because of vessel shortness after laparoscopic nephrectomy. Male predominance was observed in both groups. 57% of grafts from the control group and 64% of those from study group came from a living donor. Four vascular and two ureteral re-anastomoses were recorded in the control group and two vascular and one ureteral re-anastomosis in the study group (p > 0.05). In the latter group, no grafts have been lost due to vascular or urological causes and no patients have required dialysis.

CONCLUSIONS

When necessary, an upside-down placement for the renal graft is a safe alternative in the pediatric population.

LEVEL OF EVIDENCE

Level III.

Urologic Evaluation and Management of Pediatric Kidney Transplant Patients

Urologic causes of end-stage renal disease are estimated between 25% and 40% of causes. The goal of renal transplantation in chronic kidney disease patients is to provide renal replacement therapy with less morbidity, better quality of life, and improved overall survival compared with dialysis. A patient's urologic history can be a significant source of problems related to infections, recurrence of disease, and surgical complications. Many of the urologic risks are modifiable. Proper evaluation and management can mitigate the potential problems after transplantation, and these patients with complex urologic problems are seen to have similar graft function outcomes.

Adverse Events under Tacrolimus and Cyclosporine in the First 3 Years Post-Renal Transplantation in Children

BACKGROUND

Progress in immunosuppression has reduced acute rejection, graft loss and mortality after renal transplantation. Adverse drug reactions are well described in adults but few data are available in children. Our objectives were to analyse the adverse events reported in the first 3 years post-transplantation in children receiving tacrolimus or cyclosporine-based immunosuppression and compare them with the information of the Summary of Product Characteristics.

METHODS

This retrospective study included all children who underwent a renal transplant at Hospital Robert Debré between 2002 and 2015. Initial immunosuppression was based on induction, calcineurin inhibitor, mycophenolate mofetil and corticosteroids. Adverse events were collected from medical records and coded using the Medical Dictionary for Regulatory Activities and the implications of tacrolimus and cyclosporine analysed. Statistical analyses were performed using SAS 9.4.

RESULTS

One hundred and twenty-five children were included. During the observation period [2.7 years (0.6-4.3)], 105 patients received tacrolimus and 39 received cyclosporine. The incidence rate for gastrointestinal disorders was 0.128 and 0.056 by patient-years of exposure (p < 0.05), under tacrolimus and cyclosporine schedules. For neutropenia, it was 0.064 and 0.014 (p < 0.05). The frequencies of toxic nephropathy and gastrointestinal pain were higher than those in the Summary of Product Characteristics of tacrolimus (> 20%) and cyclosporine (> 10%). Cosmetic events for cyclosporine and neutropenia for tacrolimus were frequently observed (18 and 14.3%, respectively), although uncommon in the Summary of Product Characteristics.

CONCLUSIONS

The exposure-adjusted incidence rate of gastrointestinal disorders and neutropenia was higher in children under the tacrolimus schedule. Our findings contribute to the evaluation of the benefit-risk balance of immunosuppressive therapy following paediatric renal transplantation.

Renal Impairment and Complication After Kidney Transplant at Queen Rania Abdulla Children's Hospital

OBJECTIVES

Kidney transplant is the treatment of choice for end-stage renal disease, but it is not without complications. We review the medical cause of significant renal impairment and complications that developed after kidney transplant in pediatric patients who required hospital admission and intervention and/or who were followed between 2007 and 2016.

MATERIALS AND METHODS

A retrospective noninterventional chart review study was conducted in pediatric patients who received a kidney transplant and/or followed at the nephrology clinic at Queen Rania Abdulla Children's Hospital between 2007 and 2016.

RESULTS

In this study, 101 pediatric patients received a total of 103 transplants. Forty-eight patients (47%) experienced deterioration of kidney function out of a total of 53 episodes of complications; 37 of these episodes occurred early (0-6 mo after transplant), and 26 episodes occurred late. The causes of kidney function deterioration were surgical complications, acute tubular necrosis, cell- or antibody-mediated rejection, diabetes mellitus, urinary leak, recurrence of original disease, and chronic allograft nephropathy. Thirteen patients experienced graft loss; 50% of these losses were secondary to noncompliance to immunosuppressant medication treatment after transplant. A total of six patients died; 2 (23%) of these deaths occurred in the first week after transplant, whereas the other 4 patients died over a period of 10 years.

CONCLUSIONS

Pediatric kidney transplant is not without complications; however, most of these complications are treatable and reversible. The most serious complications leading to graft loss and death occur early, in the first week after transplant. Improving immunosuppressant compliance after transplant would prevent 50% of graft losses.

[Pediatric kidney transplantation]

Kidney transplantation is the first line treatment for children with terminal renal failure. In addition to the survival rate of children and transplanted kidneys, the overall condition of the child with respect to growth and development is particularly important. The aims of pediatric renal transplantation are treatment strategies which minimize the side effects of immunosuppression and permit normal growth and development.

Pediatric renal transplantation with considerations for successful outcomes

Renal transplantation in the pediatric population, although conceptually similar to that in adults, differs in many aspects. This review will focus on the issues unique to the pediatric recipient. In particular, we will focus on the incidence and etiology of end stage renal disease in children, and the results as measured by patient and graft survival. Pretransplant surgical considerations of timing of the transplant, management of congenital urologic abnormalities and the abnormal bladder will be addressed. Etiologies of renal failure unique to the pediatric population will be discussed, including autosomal recessive polycystic kidney disease, congenital nephrotic syndrome, inferior vena cava thrombosis, and primary hyperoxaluria Type 1. Lastly, special transplant surgical considerations including transplantation of an adult-size kidney (ASK) into an infant or small child and ureteral implantation, management of the urinary bladder, and fluid management in infants and small children will be discussed.

Antilymphoid antibody preconditioning and tacrolimus monotherapy for pediatric kidney transplantation

OBJECTIVE

Heavy post-transplant immunosuppression may contribute to long-term immunosuppression dependence by subverting tolerogenic mechanisms; thus, we sought to determine if this undesirable consequence could be mitigated by pretransplant lymphoid depletion and minimalistic post-transplant monotherapy.

STUDY DESIGN

Lymphoid depletion in 17 unselected pediatric recipients of live (n = 14) or deceased donor kidneys (n = 3) was accomplished with antithymocyte globulin (ATG) (n = 8) or alemtuzumab (n = 9). Tacrolimus was begun post-transplantation with subsequent lengthening of intervals between doses (spaced weaning). Maintenance immunosuppression, morbidity, graft function, and patient/graft survival were collated.

RESULTS

Steroids were added temporarily to treat rejection in two patients (both ATG subgroup) or to treat hemolytic anemia in two others. After 16 to 31 months (mean 22), patient and graft survival was 100% and 94%, respectively. The only graft loss was in a nonweaned noncompliant recipient. In the other 16, serum creatinine was 0.85 +/- 0.35 mg/dL and creatinine clearance was 90.8 +/- 22.1 mL/1.73 m2. All 16 patients are on monotherapy (15 tacrolimus, one sirolimus), and 14 receive every other day or 3 times per week doses. There were no wound or other infections. Two patients developed insulin-dependent diabetes.

CONCLUSION

The strategy of lymphoid depletion and minimum post-transplant immunosuppression appears safe and effective for pediatric kidney recipients.

History of pediatric liver transplantation. Where are we coming from? Where do we stand?

The history of pediatric liver transplantation cannot be dissociated from one man, Thomas E. Starzl, whose pioneer efforts contributed more than anyone else to what has become a routinely successful clinical procedure. During the pre-cyclosporine era, the pediatric experience was confined nearly exclusively in Denver: first attempt in 1963, first success with survival beyond one year in 1967, cumulative experience with 84 pediatric cases in the pre-cyclosporine era (1967-1979) with a 2-year patient survival rate of 30%. The stampede for the development of other liver transplant centers came with the introduction of cyclosporine in the early eighties. Besides Pittsburgh, seven centers (Brussels, Cambridge and Hanover in Europe; Boston, Dallas, UCLA, Minneapolis in USA) had performed up to 1986 at least 20 pediatric liver transplants each with a long-term (>1 year) patient survival rate ranging between 57% and 83%. At the moment, a long-term patient survival rate in excess of 90% in elective patients -including infants - is commonly obtained in experienced centers. The shortage of size matched liver donors which was responsible for a high death rate on the cadaveric waiting list stimulated the development or technical innovations based on the segmental anatomy of the liver: reduced ('cutdown') liver graft, split graft and living liver transplantation. Challenging technical aspects in the recipient have been solved in order to reduce the incidence of surgical complications like outflow obstruction, arterial and portal thrombosis, and biliary problems. The indications of liver transplantation have been refined; regarding biliary atresia, which is the most frequent indication, a consensus has developed to propose a sequential strategy with a single attempt at hepatoportoenterostomy followed, when it fails, by liver transplantation. Some contra-indications accepted in the past are not currently valid with better understanding of the pathophysiology and/or increased clinical experience; such is the case of the hepatopulmonary syndrome. A major progress in preoperative management has been achieved through a multidisciplinary approach, particularly regarding nutrition and control of portal hypertension-related bleeding and ascites. Perioperatively, liver transplantation has derived benefit from the expertise of anesthetists managing babies with serious conditions and increased experience of the transplant surgeons regarding the knowledge of all the technical modalities, good strategy, technical skills and meticulous control of bleeding. It is well-recognized that children require more immunosuppression than adults. As in adults, the first breakthrough came with the introduction of cyclosporine which more than doubled the one-year patient survival rate. The next advance during the last decade was afforded by FK 506 - Tacrolimus which allows steroid withdrawal with the first year post-transplant in most patients. Besides its efficacy in reducing the incidence of rejection and absence of cosmetic side-effects, the steroid-sparing effect of Tacrolimus is of utmost importance to preserve the growth potential of children. The use of OKT-3 both for induction and treatment of rejection has been abandoned nearly universally because its use, cumulated with other immunosuppressants, resulted in a high incidence of lymphoproliferative disorder. In contrast, anti-IL2-receptor monoclonal antibodies, will most likely gain an increasing place in induction, with the availability of chimeric or humanized preparations. The side-effects of immunosuppression can endanger both the quality of life and the life expectancy; they are a special source of concern in pediatric recipients whose survival can be expected to be more than a few decades. Children would benefit most from the development of a marker able to identify the patients who have developed graft acceptance, allowing complete wearing of immunosuppression. Also they would benefit most from research protocols of tolerance induction. Since the vast majority of liver-transplanted children will have a reasonably normal life expectancy, the focus should be switched to their long-term rehabilitation and the assessment of their quality of life when they reach adulthood.

Pediatric kidney transplantation: historic hallmarks and a personal perspective

Over the last five decades, pediatric kidney transplantation (Tx) has proved to be a viable therapeutic alternative for children with end-stage renal disease. Patient and graft survival rates, as well as long-term quality of life, have improved dramatically during this time, as a result of advances in surgical techniques, immunosuppression, and pre- and post-operative care. The inspired, hard work of multi-disciplinary clinical teams, combined with the determination and courage of the young patients and their families, have fueled the success of pediatric kidney Tx. It is with similar optimism and drive that we face the great challenges of the future, such as maximizing the donor pool and inducing tolerance.

Kidney transplanted children come of age

BACKGROUND

The aim of renal replacement therapy in children is to restore their potential for normal growth and development in order to reach mature adulthood. Because pediatric kidney transplantation started in the late 1960s, it is now possible to document the progress and outcome of these patients from transplantation in childhood to survival into adulthood.

METHODS

In this single-center study, all 150 children born before December 1977 and having received a kidney transplant between 1970 and 1993 were selected for long-term follow-up. The mean age at transplantation was 12.1 years (range 3.2 to 16.7), and the mean follow-up was 13.1 years (range 2.0 to 25.0). In December 1995, 124 grown-up patients with a mean age of 25.4 years (range 18.4 to 40.3) were alive, 89 with a functioning graft. Fifty had the first graft functioning longer than 10 years. The fate of all patients was traced, and those living were analyzed in regard to their somatic and socioeconomic states.

RESULTS

The actuarial 25-year survival rate for the patients was 81%, and for the first graft it was 31%. The best graft survival rates were observed after living related donation, preemptive transplantation, and immunosuppression with cyclosporine. The latter benefit, however, vanished after eight years. The mean creatinine clearance declined over the years from 76 to 45 ml/min/1.73 m2, and the incidence of hypertension increased to more than 80% of the patients. Malignancies occurred in 2.6%. Final height was stunted in 44% of noncystinotic patients, whereas all patients with cystinosis were extremely growth retarded. Twenty-seven percent suffered from additional disabilities. A majority of adult patients were rehabilitated in regard to education and socioeconomic status, and 14% were unemployed.

CONCLUSIONS

The results indicate that renal transplantation in children leads to a high degree of rehabilitation in adulthood. The life of a kidney transplant, however, is limited, which points out the need for more specific immunosuppression with fewer side-effects in order to reach the goal of lifelong graft function.

New immunosuppressive agents for pediatric transplantation

Pediatric transplantation has always been challenging for transplant surgeons. Although the higher immunoreactivity and the faster metabolism showed by this unique population when compared with adults requires a heavy immunosuppressive regimen, the possibility of disrupting the delicate balance of correct psychophysical development calls for a regimen of more selective and less toxic immunosuppressive drugs. In the past decade several new drugs have been investigated and some of them appear to be very promising, although pleiotropic toxicities have not yet been eliminated. An appropriate pharmacokinetic approach and the evaluation of synergistic multi-drug combinations by rigorous mathematical models would lead to highly selective immunosuppressive regimens which may result in virtually no toxicity.

Organ transplantation in children

Organ transplantations have opened a new field in medicine and particularly in pediatrics. The kidney was the first organ to be regularly transplanted and there are now more than 2000 children who have received a kidney graft. Cadaver kidneys or living-related donor (LRD) kidneys can be used since an adult kidney may be grafted in a young child. Cadaver graft survival exceeds 85% at 1 year in recent single centre reports and patient survival is above 95%, the results being even better with LRD. Some complications may be observed in the long term, such as bone osteonecrosis, hypertension or infections. Rehabilitation is generally remarkable and growth which remained abnormal in 1/3 of cases under conventional treatment seems to improve markedly with cyclosporin. In the future, the development of kidney transplantation could lead hopefully to a drastic decrease in the number of children on dialysis. Liver transplantation is now performed in children with biliary atresia and metabolic diseases. There is no age limit for grafting a liver, the only problem being to find a pediatric cadaver donor of similar size. It is also possible to use an adult liver after hepatectomy. There were 170 liver grafts recorded in children in Europe in December 1986, and the long-term survival thanks to cyclosporin is exceeding 80% in some units. Thanks to cyclosporin, programs of cardiac transplantation for children are rapidly developing. The main indications are gross-congenital cardiac malformations or severe functional abnormality not compatible with life. Newborns have been grafted with success. The only problem is also to find a suitable pediatric donor.(ABSTRACT TRUNCATED AT 250 WORDS)

Pediatric liver transplantation

Liver transplantation, which once was an experimental procedure of no practical interest, has become the preferred treatment for infants and children dying of almost all non-neoplastic end-stage liver diseases. Liver replacement is being provided by many well-trained teams on all of the continents, as is evident from the program today--the first international symposium on pediatric liver transplantation. I have been honored in giving the first paper in the process of introducing the remarkable work of a gifted younger generation of physicians and surgeons.

When organs match and health beliefs don't. Bioethical challenges

This paper addresses the problems that psychologically unprepared individuals may experience when the socioethnic aspects of their health belief systems are not addressed in the decision-making process for renal transplantation. Case studies of two Hispanic adolescents are presented. A cognitive behavioral therapeutic approach that specifically concentrates on changing health beliefs related to organ transplant is recommended to help maximize the probability of a successful transplant. Past assumptions by psychosocial transplant teams that make self-esteem the primary basis on which to predict transplant or therapeutic outcome are challenged. The exchange of scientific cognition modifying strategies to address health beliefs that are deleterious to biologic and psychologic survival are recommended as a critical part of biomedical engineering practice for the next decade.

Liver and kidney transplantation in children receiving cyclosporin A and steroids

The new immunosuppressive agent, cyclosporin A, was used with low doses of steroids to treat eight patients undergoing hepatic transplantation and three patients undergoing cadaveric renal transplantation. Seven of the eight liver recipients are well, including one who was given two livers. The three kidney recipients who had developed cytotoxic antibodies after previously rejecting grafts with conventional immunosuppressive therapy, have had good results despite conditions which usually preclude attempts at transplantation. The ability to control rejection effectively and safely without chronic high-dose steroid therapy may make the described therapeutic regimen valuable for pediatric recipients of whole organs.

Dental management of the patient with biliary atresia

Biliary atresia is a disease of unknown origin characterized by partial or total absence of the biliary tract. While this condition is rare, the medical and surgical management makes the ramifications for dental treatment increasingly complex. This article reviews the disease and its complications and documents dental treatment of two patients.

Renal transplantation in children

From July 1967 to September 1974, 26 kidney transplantations were carried out in 16 children aged 6 to 17 years, in Gotherburg. The average age at the primary transplantation was 12 years and average body weight 29.7 kg. Five patients had familial juvenile nephronophthisis, 5 chronic glomerulonephritis, 5 chronic pyelonephritis, and one bilateral Wilms's tumour. Four patients were predialytic. Fourteen grafts came from living related donors. The surgical technique was standard as was the immunosuppression with azathioprine and cortisone; exceptionally antilymphocyte globulin was used. Thirteen patients were alive in September 1974, observed 2-65 months, 8 with a normal serum creatinine, 3 with moderately elevated serum creatinine, and 2 on hemodialysis. The 6- and 12-month survivals of patients are 100% and 93% respectively. Normal growth and full rehabilitation in recipients of functioning grafts make renal transplantation justified as a therapeutic procedure in terminally uremic children.

Renal transplantation in children. Analysis of 25 consecutive transplants in 19 recipients

Eighteen children aged 6 to 17 years received 24 cadaveric renal transplants between January 1965 and July 1971, and a further child received a kidney donated by her father. 12 children are alive with good functioning grafts and another 2 children are alive on haemodialysis awaiting a further renal graft. The clinical problems of renal transplantation in children are discussed with particular reference to the side effects of immunosuppressive therapy.

Renal homotransplantation in pediatric patients

Fifty-seven patients were treated with renal homotransplantation from 1½ to 7⅔ years ago; 23 patients were 12 years or younger and the other 34 patients were 13 to 18. Family members (usually parents) were the primary donors in 45 cases. Unrelated volunteers or cadavers donated the other 12 homografts. Immunosuppression was with azathioprine and prednisone, and in some cases also with ALG. Forty-two of the 57 recipients survived for at least 1 year. Additional deaths occurred at 17½ and 19 months leaving 40 recipients (70.2%) alive. Six survivors had successful retransplantation following late failure of their original homografts. Control of rejection was not particularly different than in adult cases. “Homograft glomerulonephritis” was found in chronically tolerated transplants, but no more frequently than in older patients. Many postoperative problems in the pediatric age group were the consequence of retardation of growth caused either by pre-existing uremia or by the need for high dose postoperative steroid therapy, orthopedic accidents such as femoral and vertebral fractures, and psychiatric complications which led to two suicides. In spite of these difficulties, the meaningful rehabilitation that was obtained in the chronic survivors makes us regard pediatric patients as favorable candidates for therapy with renal transplantation.

Emotional reactions of children and adolescents to renal transplantation

Coping defenses of children undergoing renal transplantation were taxed as the child progressed through the crucial phases of surgical procedures. Four of 12 children displayed serious disruption of defense mechanisms at some point during hospitalization with recovery of equilibrium when the stress was removed. Hemodialysis evoked a forceful emotional reaction. The most vulnerable period appeared to be immediately postoperative when ego resources could be depleted if surgical complications occurred. Profound depression or regression could be seen in a previously functional child.