Pediatric renal transplantation

Treatment of renal transplant complications with a mesh hood fascial closure technique

Early renal allograft dysfunction may be caused by a number of technical factors including thrombosis, kinking of vessels, and a Page kidney situation in which the allograft is compressed within a shallow false pelvis and limited retroperitoneal space. Without early recognition, compromised graft function, obstruction, or graft loss may ensue. We describe a technique using a polypropylene-assisted mesh hood fascial closure (MHFC) to prevent and treat this potential complication. MHFC was performed both primarily to prevent this phenomenon, and secondarily to treat this complication. Between April 2001 and October 2002, 16 patients undergoing 17 renal transplants underwent MHFC. The mean recipient body weight was 17% less than the mean donor weight. The mean follow-up period was 9 months. The mean serum creatinine level after primary MHFC was 148.4 micromol/L. Three of 4 patients with early allograft dysfunction regained function after secondary MHFC and had a mean serum creatinine level of 155.3 micromol/L. Wound complications were seen in 5 (31%) patients with no wound or mesh infections and 1 patient was diagnosed with a lymphocele. We conclude that the use of mesh in the primary closure of the incision after renal transplantation is safe and has minimal complications.

Perioperative management of the pediatric transplant patient

With advances in surgical techniques, an increasing number of children are becoming transplant candidates. Pediatric critical care physicians may need to manage both transplant donors and recipients in the pediatric intensive care unit. Care of such patients needs to be performed aggressively with complete attention to details in order to obtain successful transplant outcomes. The postoperative management of the transplant recipient includes the basic intensive care monitoring and management of postoperative patients who are critically ill. Besides this, there are some unique features among these patients which may complicate the postoperative stay in the pediatric intensive care unit and these are discussed here. It is important to remember that the successful management of a transplant patient includes the pediatric critical care physician's abilities of not only taking care of acute issues but also of coordinating care between subspecialists. The pediatric critical care physician must always continue to provide support to families of these transplant patients during their intensive care unit stay.

Salvage of a renal allograft with renal vein occlusion secondary to extrinsic compression

We report a case of renal vein occlusion in a transplant kidney that occurred secondary to extrinsic compression from a large kidney being placed extraperitoneally in a small iliac fossa. Prompt reexploration in the immediate postoperative period resulted in salvage of the graft. The abdominal wall was reconstructed using prosthetic mesh, which decreased the compartmental pressure within the iliac fossa sufficiently to allow the kidney to perfuse and the renal vein to remain patent. The patient was eventually discharged home with a functioning graft and normal flow in the vessels, as demonstrated by duplex Doppler studies.

Retroperitoneal placement of living related adult renal grafts in children less than 5 years of age--a feasible technique?

The extraperitoneal approach was used for transplantation of adult renal grafts in eight children under 5 years, three of them weighing less than 10 kg. Usually, children of this size are approached transperitoneally. The modified procedure included partial mobilization of the right liver to provide enough space for retroperitoneal graft placement and positioning of the vascular anastomoses, invariably to the aorta and caval vein. With this regimen, no significant space problems were encountered in recipients as small as 9 kg, and particularly, neither arterial nor venous complications occurred. Currently, at a mean follow-up of 2.4 years, all patients are alive with well-functioning grafts. Thus, the extraperitoneal approach represents a feasible and successful procedure in the pediatric living related renal transplantation setting for recipients under 10 kg of weight.

Evaluation of factors contributing to mortality in pediatric renal transplant recipients

From 1969 to 1985, 303 renal allografts (290 cadaveric) were placed in 215 pediatric recipients. A review of actuarial recipient and allograft survival 2 years posttransplant showed good results in patients over 6 years of age (greater than 90% for patients, about 70% for allografts) but less satisfactory results in younger patients (75% for patients, about 45% for allografts). Thirty-nine patients died. Loss of allograft function preceded death in 67% of cases and was due to rejection (61%), renal vascular thrombosis (35%), and recurrence of original disease (4%). On retrospective analysis, 13 deaths might have been preventable with current diagnostic and therapeutic modalities. Allograft dysfunction from thrombosis occurs at a higher frequency in the young child and may be confused with rejection. Treatment of rejection without biopsy, overagressive treatment of a chronically failing graft, and failure to withdraw immunosuppressive therapy in face of infection are poorly tolerated in the very young recipient and are prominent causes of preventable mortality. Transplant nephrectomy and repeated attempts at transplantation are poorly tolerated in very young patients. Patient survival is very dependent on the success of the initial allograft in children.

Complications of surgical significance in pediatric renal transplantation

From 1969 to 1986, 303 renal allografts (290 cadaveric) were placed in 215 pediatric recipients. Twenty-three patients (7.6%) had renovascular complications and 16 (5.3%) had nonrenovascular complications. The overall incidence of surgically significant complications was 12.9%. Of these, 54% were felt to be of a technical etiology. The remainder were surgically significant in that their management necessitated operative intervention.

Technical factors contributing to successful kidney transplantation in small children

Cadaveric renal transplantation in small children has not been as successful as either cadaver transplantation in older children, or adults, or living-related transplantation in small children. We report the results of cadaver renal transplantation in 17 children 6 years or younger with only 1 graft lost within 1 year after transplantation. The important technical factors that have enabled these improved results include careful intraoperative fluid management, use of adult kidneys with arterial anastomoses to the common iliac artery or aorta, and sequential immune suppression.

Factors influencing patient and graft survival in 300 cadaveric pediatric renal transplants

We reviewed the results of 300 cadaveric pediatric renal transplantations performed at our institution. The procedures provided significant survival and improvement of the quality of life in the majority of children. Recipient and graft survival was better in patients more than 5 years old than in younger children. Early nontechnical thrombosis was a major specific problem in young recipients. The original disease did affect graft survival. Uncorrected congenital bladder storage and micturition inefficiency adversely affected graft survival.

Urinary tract reconstruction in children

The successful introduction of clean intermittent catheterization and increased awareness of urinary tract physiology and urodynamics have been the basis for recent major advances in urinary tract reconstructive surgery. Surgical techniques are now available to manage anatomical and functional deficiencies of any isolated or combined components of the urinary tract. The high incidence of unsatisfactory long-term results with ileal conduit diversion has led to increased popularity in urinary tract undiversion and greater utilization of reconstructive principles. As with any new surgical field of endeavour, new operative techniques are appearing at a rapid rate. In particular, there has been a recent proliferation of surgical procedures that provide a continent, low pressure, catheterizable reservoir for urine storage. Most children with major urinary tract deficiencies can now be offered socially and cosmetically unobtrusive surgical solutions without jeopardizing renal function.

Surgical considerations in childhood end-stage renal disease

This article provides a conceptual framework that is useful to the pediatrician who provides children with renal failure with care. Operative and perioperative consideration are emphasized.

Intensive care aspects of organ transplantation in children

Children will benefit from the increasing availability of transplantation techniques as treatment for end-stage kidney and liver disease. Support of these services will involve the intensivist to as great degree as these children will frequently require invasive monitoring. Hypovolemia in the postoperative period can be devastating to later graft function and must be avoided. The drugs used to induce graft tolerance have significant effects and potential major toxicities. Their use places these children at risk of serious and life-threatening bacterial, viral, fungal, and protozoan infections. A team effort is essential to the successful care of these children. The demands are great, but the goal of a return of these gravely ill children to a normal and happy life is well worth the effort.