Transplantation in children

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.

Results of renal transplantation in children

From 1968 to 1978, 66 renal transplants were performed on 58 pediatric patients with end stage renal failure. With a mean followup of 6 years 46 patients (79.3 per cent) are alive and 35 (60.3 per cent) currently have a functioning renal allograft. Live donor allografts yielded fewer surgical complications and better long-term functional survival rates than cadaver allografts. Patient rehabilitation following a successful renal transplant was excellent. However, despite resumption of growth in most cases normal linear growth was achieved rarely. Renal transplantation provides the best long-term solution to the problem of end stage renal disease in children.

Treatment of end-stage renal disease in children: a 15-year experience

From 1964-1979, 154 children 1 to 16 years of age with end-stage renal disease (ESRD) were treated in a regional pediatric dialysis and transplant program. The incidence of ESRD was 1.6 per million total population per year. The survival rate of children undergoing dialysis for an average of 10 months was 93%. After living donor kidney transplantation (LD), patients survival rates in 60 children were 89% at 5 years, 83% at 10 years, and 74% at 15 years. After cadaver donor kidney transplantation (CD), patient survival rates in 85 children were 70% at 5 and 10 years. LD kidney survival was 71% at 5 years, 55% at 10 years, and 40% at 15 years, whereas CD kidney survival was 43% at 5 years and 31% at 10 years. The survival of first and second transplants was similar. Patient and kidney survival have improved since 1972. The survival rate of 26 children 1 to 5 years of age was 46%, but patients with Wilms' tumor accounted for most of the deaths. We attribute these favorable long-term results in children to an integrated program of dialysis and transplantation with special pediatric facilities.

Pediatric and adult renal transplants: a comparative study

In order to compare the results of renal transplantation in pediatric and adult recipients, a retrospective analysis of first transplants done at a single institution over a 6-yr period was carried out. The study included 21 pediatric and 196 adult recipients of cadaveric grafts, and 18 pediatric and 156 adult recipients of living related grafts. Pediatric and adult recipient groups were shown to be similar to each other with respect to donor-recipient HLA antigen matching and to causes of graft failure and patient mortality. Actuarial graft and patient survival data for pediatric recipients was found to be better than for the corresponding adult recipient groups, although the differences were not statistically significant. When clinical results, technical problems, and psychosocial adaptation are considered critically, transplantation is clearly preferable to both hemodialysis and to no treatment for pediatric patients with end stage renal disease (ESRD). There is a considerable discrepancy between the estimated incidence of ESRD in children and the number of children being tranplanted for this disease. Many patients are, therefore, receiving less than optimum treatment. Efforts to correct this discrepancy are in order.

Renal homotransplantation in children

Ninety-six renal transplants in 77 pediatric patients are reported with follow-up as long as 12 1/2 years. Thirteen of the first 14 patients are living with a functioning kidney after eight to 12 1/2 years. The patient survival for the entire group is 78%. Sixty-four percent are living with a functioning transplanted kidney. Splenectomy was initially performed at the time of transplant but has been discontinued because of concern that splenectomy in the immunosuppressed patient was related to an increased occurrence of septic complications. Anencephalic newborn infants have been found to be a satisfactory source of cadaver donor kidneys. Growth and development have been satisfactory when the transplant is performed prior to 12 years of age, if it functions well, and if an alternate-day regimen of steroid administration is followed. Both boys and girls have now passed through puberty with their transplanted kidneys, have married, become parents, and are leading essentially normal lives. A plea is made for earlier transplantation in small children with irreversible progressive renal failure before they develop severe stunting of growth and before the need for prolonged dialysis.

A 14-year experience with kidney transplantation

Between November, 1962 and August, 1975, 668 kidney transplants were done in 556 consecutive patients at Denver, Colorado. The Denver experience has been divided into 7 periods of time, according to the conditions of care during each period. The results in related transplantation have changed little during the decade beginning in 1966. The results in unrelated transplantation have not materially changed since 1968. The long-term patient survival after related transplantation has been better than after cadaver transplantation. The results of transplantation in 57 children ages 3 to 18 years have been slightly better than the results of adult transplantation.

The outcome of kidney transplantation and the feasibility of improving this therapy with present techniques are limited by our inability to accurately match each patient with the immunologically best donor and by our inability to precisely control the immune system of the recipient. Rejection is still the main reason for graft loss, and sepsis remains the main cause of patient mortality. More specific and less toxic means of achieving graft acceptance are needed before a higher level of patient service can be realized. However, even with the tools now available, thousands of recipients throughout the world have been returned to useful lives.