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Charnaya O, Van Arendonk K, Segev D. Strategies for choosing the best living donor: A review of the literature and a proposal of a decision-making paradigm. Pediatr Transplant 2024; 28:e14779. [PMID: 38766997 PMCID: PMC11107570 DOI: 10.1111/petr.14779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 03/31/2024] [Accepted: 04/24/2024] [Indexed: 05/22/2024]
Abstract
Transplantation remains the gold-standard treatment for pediatric end-stage kidney disease. While living donor transplant is the preferred option for most pediatric patients, it is not the right choice for all. For those who have the option to choose between deceased donor and living donor transplantation, or from among multiple potential living donors, the transplant clinician must weigh multiple dynamic factors to identify the most optimal donor. This review will cover the key considerations when choosing between potential living donors and will propose a decision-making algorithm.
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Affiliation(s)
- Olga Charnaya
- Department of Pediatrics, Johns Hopkins University School of Medicine
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Pol SJ, Selkirk EK, Damer A, Mucsi I, Abbey S, Edwards B, Fung K, Gill J, Neves P, Ng SY, Parekh RS, Wright L, Wu M, Anthony SJ. "Weighing the Pros and Cons of Everything": A Qualitative Descriptive Study Exploring Perspectives About Living Donor Kidney Transplantation From Parents of Chinese Canadian Pediatric Patients With Chronic Kidney Disease. Can J Kidney Health Dis 2024; 11:20543581241249872. [PMID: 38737938 PMCID: PMC11088299 DOI: 10.1177/20543581241249872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 03/21/2024] [Indexed: 05/14/2024] Open
Abstract
Background As of 2021, more than 6000 children and youth in Canada were living with end-stage kidney disease (ESKD), for which kidney transplantation is considered the preferred treatment by health professionals. Research shows that living donor kidney transplantation (LDKT) has superior allograft and recipient survival compared to deceased donor kidney transplantation (DDKT). However, in a pediatric setting, the choice of LDKT or DDKT is a summative consideration of factors weighed carefully by the patient's family, health care team, and patient. Decision-making surrounding transplantation may be more complex for racial and ethnic minorities as culturally specific values and beliefs are interwoven within dominant understandings and concepts of health and accepted models of health care. For example, Chinese Canadians have an increased risk of ESKD, yet reduced access to LDKT compared to White patients, despite being the largest visible minority population in Canada. Objective The objective of this qualitative study is to deepen our understandings of the decision-making process surrounding DDKT versus LDKT among parents of Chinese Canadian pediatric patients with chronic kidney disease (CKD). Design Qualitative descriptive study design. Setting The Nephrology Program at The Hospital for Sick Children in Toronto, Canada. Participants Caregivers of Chinese Canadian patients with CKD, 18 years of age or older, and who spoke English, Cantonese, or Mandarin. Methods One-on-one, semistructured interviews were conducted virtually, by a member of the research team and were audio-recorded and transcribed verbatim. Thematic analysis was used to explore participants' shared experience. Results Seven interviews were conducted with 6 mothers and 1 father of 6 Chinese Canadian pediatric patients with CKD: 4 patients had undergone a kidney transplant, and 2 were not yet listed for transplant. Analysis of data highlighted that cultural influences affected whether parents shared with others about their child's illness and experience. The cultural understanding that it is inappropriate to burden others contributed to the creation of an isolating experience for participants. Cultural influences also impacted whether parents asked others to be a living donor as participants articulated this would place a physical burden on the living donor (e.g., potential risk to their health) and an emotional burden on the participant as they would be indebted to a willing donor. Ultimately, parents' decision to choose DDKT or LDKT for their patient-child was a result of evaluating both options carefully and within an understanding that the ideal treatment choice reflected what was best for all family members. Limitations Findings reflect experiences of a small sample from a single recruitment site which may limit transferability. Conclusions Parents in this study felt that they had access to the necessary evidence-based information to make an informed decision about the choice of DDKT versus LDKT for their child. Participant narratives described feeling isolated within cultural communities of family and friends and participants' suggestion of benefiting from increased support may guide future research directions. Practitioners can offer direct and indirect support to families, with recognition of the importance of cultural values and family-centered care on decision-making within families. Opportunities are needed for accessible, virtual social support platforms to increase parental feelings of culturally mediated peer support from parents who share similar experiences.
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Affiliation(s)
- Sarah J. Pol
- Child Health Evaluative Sciences, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, ON, Canada
| | - Enid K. Selkirk
- Child Health Evaluative Sciences, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, ON, Canada
| | - Alameen Damer
- Child Health Evaluative Sciences, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, ON, Canada
| | - Istvan Mucsi
- Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
- Division of Nephrology, University of Toronto, ON, Canada
| | - Susan Abbey
- Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
- Centre for Mental Health, University Health Network, Toronto, ON, Canada
- Temerty Faculty of Medicine, University of Toronto, ON, Canada
| | - Beth Edwards
- Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
| | - Kenneth Fung
- Department of Psychiatry, University of Toronto, ON, Canada
| | - Jagbir Gill
- Division of Nephrology, Faculty of Medicine, The University of British Columbia, Vancouver, Canada
- Kidney Transplant Program, St. Paul’s Hospital, Vancouver, BC, Canada
| | - Paula Neves
- Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
| | - Suk Yin Ng
- Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
| | - Rulan S. Parekh
- Child Health Evaluative Sciences, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Medicine, Women’s College Hospital, Toronto, ON, Canada
- Department of Paediatrics, The Hospital for Sick Children, Toronto, ON, Canada
| | - Linda Wright
- Department of Surgery, University of Toronto, ON, Canada
| | - Minglin Wu
- Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
| | - Samantha J. Anthony
- Child Health Evaluative Sciences, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, ON, Canada
- Factor-Inwentash Faculty of Social Work, University of Toronto, ON, Canada
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Saeed B. Kidney Retransplantation in Children. EXP CLIN TRANSPLANT 2024; 22:37-43. [PMID: 38385371 DOI: 10.6002/ect.mesot2023.l32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Abstract
Pediatric kidney transplant recipients will likely require a retransplant in their lifetime. Although the significant advances in clinical management and newer immunosuppressive agents have had a significant effect to improve short-term allograft function, it is apparent that long-term allograft function remains suboptimal. Therefore, it is likely that most pediatric renal allograft recipients will require 1 or more retransplants during their lifetime. In the West, an increasing number of patients on the deceased donor wait list are awaiting a retransplant; in the US, 15% of current annual transplants are retransplants. Unfortunately, the use of a second or subsequent grafts in pediatric recipients has inferior long-term graft survival rates compared with initial grafts, with decreasing rates with each subsequent graft. Multiple issues influence the outcome of retransplant, with the most significant being the cause of the prior transplant failure. Nonadherenceassociated graft loss poses unresolved ethical issues that may affect a patient's access to retransplant. Graft nephrectomy prior to retransplant may benefit selected patients, but the effect of an in situ failed graft on the development of panel reactive antibodies remains to be definitively determined. It is important that these and other factors discussed in this presentation be taken into consideration during the counseling of families on the optimal approach for their child who requires a retransplant.
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Affiliation(s)
- Bassam Saeed
- From the Farah Association for Child with Kidney Disease, Damascus, Syria
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Neves CIMR, Leal ARGC, Santos LSD, Rodrigues LMA, Ferreira CDCC, Ferreira CMDSG, Romãozinho CPDRDM, Figueiredo AJDC. Pediatric Kidney Transplantation-Living or Deceased Donor? Transplant Proc 2023; 55:1555-1560. [PMID: 37419736 DOI: 10.1016/j.transproceed.2023.04.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 04/14/2023] [Indexed: 07/09/2023]
Abstract
BACKGROUND Kidney transplantation is ideal for children and adolescents with chronic end-stage renal disease because it offers better growth, development, and quality of life. Donor choice is vitally important in this age group, given the long life expectancy of these patients. METHODS A retrospective analysis of pediatric patients (<18 years) who underwent kidney transplantation from January 1999 to December/2018 was performed. Short- and long-term outcomes were compared between living and deceased donor transplants. RESULTS We included 59 pediatric kidney transplant recipients, 12 from a living donor and 47 from a deceased donor. Thirty-six (61.0%) patients were boys, and 5 (8.5%) had a retransplant. There were no differences between groups on sex, race, and weight of the recipient and donor, as well as the age and the etiology of the recipient's primary disease. Most recipients received induction immunosuppression with basiliximab and maintenance with triple therapy, with no differences between groups. Living donor transplants were mostly pre-emptive (58.3% vs 4.3%, P < .001) and had fewer HLA mismatches (≤3: 90.9% vs 13.0%, P < .001), older donors (38.4 vs 24.3 years, P < .001) and shorter hospital stays (8.8 vs 14.1 days, P = .004). There were no statistically significant differences regarding medical-surgical complications and graft or patient survival. However, we found that at 13 years post-transplant 91.7% of the living donor grafts were functioning vs 72.3% of the deceased donor grafts. CONCLUSION Our experience points out that a living donor graft in pediatric patients is associated with a higher probability of pre-emptive transplant, shorter hospital stay, greater HLA compatibility, and increased graft survival.
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Affiliation(s)
| | - Ana Rita Gomes Carlos Leal
- Department of Nephrology, Hospital and University Center of Coimbra, Coimbra, Portugal and Medical School of Coimbra University, Coimbra, Portugal
| | - Lídia Simões Dos Santos
- Department of Nephrology, Hospital and University Center of Coimbra, Coimbra, Portugal and Medical School of Coimbra University, Coimbra, Portugal
| | - Luís Miguel Amaral Rodrigues
- Department of Nephrology, Hospital and University Center of Coimbra, Coimbra, Portugal and Medical School of Coimbra University, Coimbra, Portugal
| | | | | | | | - Arnaldo José De Castro Figueiredo
- Department of Urology and Renal Transplantation, Hospital and University Center of Coimbra, Coimbra, Portugal and Medical School of Coimbra University, Coimbra, Portugal
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Husain SA, King KL, Owen-Simon NL, Fernandez HE, Ratner LE, Mohan S. Access to kidney transplantation among pediatric candidates with prior solid organ transplants in the United States. Pediatr Transplant 2022; 26:e14303. [PMID: 35615911 PMCID: PMC9378581 DOI: 10.1111/petr.14303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 03/30/2022] [Accepted: 04/24/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pediatric kidney transplant candidates require timely access to transplant to optimize growth and neurodevelopmental outcomes. We studied access to transplant for pediatric candidates with prior organ transplants. METHODS We used US registry data to identify pediatric kidney transplant candidates added to the waiting list 2015-2019 and used competing risk regression to study the association between prior transplant status and probability of receiving a kidney transplant, treating wait-list removal and death as competing events. RESULTS Of 4962 pediatric kidney transplant candidates included, 89% had no prior transplant and 11% had received a prior organ transplant (kidney 87%, liver 5%, heart 5%). Prior transplant recipients were older at listing (median 15 vs. 12 years) and more likely to have PRA≥98% (22% vs. 0.3%) (both p < .001). There was no significant difference in the proportion of candidates from each group who were preemptively wait-listed. Unadjusted competing risk regression showed a lower risk of kidney transplant after wait-listing among candidates with prior organ transplant (HR 0.52, 95%CI 0.47-0.59, p < .001). This association remained significant after adjusting for candidate characteristics (HR 0.73, 95%CI 0.63-0.83, p < .001). Among deceased donor kidney recipients, median KDPI was similar between groups, but recipients with prior transplants were more likely to receive kidneys from donors with hypertension (4% vs. 1%, p = .01) and donors after cardiac death (11% vs. 4%, p < .001). CONCLUSIONS Pediatric kidney transplant candidates with prior organ transplants have reduced access to transplant after wait-listing. Allocation system changes are needed to improve timely access to transplant for this vulnerable group.
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Affiliation(s)
- S. Ali Husain
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians & Surgeons, New York, NY
- The Columbia University Renal Epidemiology (CURE) Group, New York, NY
| | - Kristen L. King
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians & Surgeons, New York, NY
- The Columbia University Renal Epidemiology (CURE) Group, New York, NY
| | - Nina L. Owen-Simon
- Department of Surgery, Columbia University College of Physicians & Surgeons, New York, New York
| | - Hilda E. Fernandez
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians & Surgeons, New York, NY
- Department of Pediatrics, Division of Nephrology, Columbia University College of Physicians & Surgeons, New York, NY
| | - Lloyd E. Ratner
- Department of Surgery, Columbia University College of Physicians & Surgeons, New York, New York
| | - Sumit Mohan
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians & Surgeons, New York, NY
- The Columbia University Renal Epidemiology (CURE) Group, New York, NY
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
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Kiberd BA, Vinson A, Acott PD, Tennankore KK. Optimal Sequencing of Deceased Donor and Live Donor Kidney Transplant Among Pediatric Patients With Kidney Failure. JAMA Netw Open 2022; 5:e2142331. [PMID: 34989796 PMCID: PMC8739763 DOI: 10.1001/jamanetworkopen.2021.42331] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
IMPORTANCE In the US, live donor (LD) kidney transplant rates have decreased in pediatric recipients. Pediatric patients with kidney failure will likely need more than 1 kidney transplant during their lifetime, but the optimal sequence of transplant (ie, deceased donor [DD] followed by LD or vice versa) is not known. OBJECTIVE To determine whether pediatric recipients should first receive a DD allograft followed by an LD allograft (DD-LD sequence) or an LD allograft followed by a DD allograft (LD-DD sequence). DESIGN, SETTING, AND PARTICIPANTS This decision analytical model examined US pediatric patients with kidney failure included in the US Renal Data System 2019 Report who were waiting for a kidney transplant, received a transplant, or experienced graft failure. INTERVENTIONS Kidney transplant sequences of LD-DD vs DD-LD. MAIN OUTCOMES AND MEASURES Difference in projected life-years between the 2 sequence options. RESULTS Among patients included in the analysis, the LD-DD sequence provided more net life-years in those 5 years of age (1.82 [95% CI, 0.87-2.77]) and 20 years of age (2.23 [95% CI, 1.31-3.15]) compared with the DD-LD sequence. The net outcomes in patients 10 years of age (0.36 [95% CI, -0.51 to 1.23] additional life-years) and 15 years of age (0.64 [95% CI, -0.15 to 1.39] additional life-years) were not significantly different. However, for those aged 10 years, an LD-DD sequence was favored if eligibility for a second transplant was low (2.09 [95% CI, 1.20-2.98] additional life-years) or if the LD was no longer available (2.32 [95% CI, 1.52-3.12] additional life-years). For those aged 15 years, the LD-DD sequence was favored if the eligibility for a second transplant was low (1.84 [95% CI, 0.96-2.72] additional life-years) or if the LD was no longer available (2.49 [95% CI, 1.77-3.27] additional life-years). Access to multiple DD transplants did not compensate for missing the LD opportunity. CONCLUSIONS AND RELEVANCE These findings suggest that the decreased use of LD kidney transplants in pediatric recipients during the past 2 decades should be scrutinized. Given the uncertainty of future recipient eligibility for retransplant and future availability of an LD transplant, the LD-DD sequence is likely the better option. This strategy of an LD transplant first would not only benefit pediatric recipients but allow DD kidneys to be used by others who do not have an LD option.
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Affiliation(s)
- Bryce A. Kiberd
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Amanda Vinson
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Philip D. Acott
- Department of Pediatrics, Dalhousie University, Halifax, Nova Scotia, Canada
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Sheng Y, Sun Y, Huang CY, Kim MO. Synthesizing external aggregated information in the penalized Cox regression under population heterogeneity. Stat Med 2021; 40:4915-4930. [PMID: 34134178 DOI: 10.1002/sim.9101] [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: 07/29/2020] [Revised: 03/29/2021] [Accepted: 05/27/2021] [Indexed: 11/06/2022]
Abstract
Synthesizing external aggregated information has been proven useful in improving estimation efficiency when conducting statistical analysis using a limited amount of data. In this paper, we develop a unified framework for combining information from high-dimensional individual-level data and potentially low-dimensional external aggregate data under the Cox model. We summarize various forms of external aggregated information by population estimating equations and propose a penalized empirical likelihood approach to borrow information from these estimating equations. The proposed methods possess the flexibility to handle the case where individual-level data and external aggregate data are from heterogeneous populations. Specifically, a penalized empirical likelihood ratio test is developed to check for the potential heterogeneity, and a semiparametric density ratio model is postulated to account for the heterogeneity. Moreover, we study the impact of uncertainty in the auxiliary information on the efficiency gain and propose a modified variance estimator to adjust for the uncertainty. The proposed estimators enjoy the oracle property and are asymptotically more efficient than the penalized partial likelihood estimator that does not exploit the external aggregated information. Simulation studies show improvement in both estimation efficiency and variable selection over the competitors. The proposed approaches are applied to the analysis of a pediatric kidney transplant study for illustration.
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Affiliation(s)
- Ying Sheng
- Department of Epidemiology & Biostatistics, University of California at San Francisco, San Francisco, California, USA
| | - Yifei Sun
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, USA
| | - Chiung-Yu Huang
- Department of Epidemiology & Biostatistics, University of California at San Francisco, San Francisco, California, USA.,Helen Diller Family Comprehensive Cancer Center, University of California at San Francisco, San Francisco, California, USA
| | - Mi-Ok Kim
- Department of Epidemiology & Biostatistics, University of California at San Francisco, San Francisco, California, USA.,Helen Diller Family Comprehensive Cancer Center, University of California at San Francisco, San Francisco, California, USA
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Mahajan RG, Chang JH, Runge B, Carpenter C, Sandoval PR, Ratner LE, Uy NS, Jain NG. Considerations for utilizing medullary sponge kidney allografts in pediatric patients. Pediatr Transplant 2021; 25:e13992. [PMID: 33813776 DOI: 10.1111/petr.13992] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 01/24/2021] [Accepted: 02/03/2021] [Indexed: 01/17/2023]
Abstract
BACKGROUND Medullary sponge kidney (MSK) disease predisposes patients to recurrent nephrolithiasis, which affects one in every 5000 people in the United States. METHODS We report a rare case of a pediatric recipient of a living donor MSK transplant and discuss considerations when discussing risks and benefits of accepting MSK allografts for this population. RESULTS The recipient was admitted due to concerns for nephrolithiasis, hydronephrosis, and urinary tract infection at 1-month post-transplant. The hydronephrosis was resolved by surgical removal of an encrusted ureteral stent; this was followed by supplementation with oral medications to prevent future episodes of nephrolithiasis. The recipient did not have any further episodes after this as seen at a 1-year follow-up. The donor has remained well through this period. CONCLUSIONS With increasing organ shortages, the use of variety of donors may need to be considered to enlarge the organ pool.
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Affiliation(s)
- Ruchi G Mahajan
- Division of Pediatric Nephrology, Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Jae-Hyung Chang
- Division of Nephrology, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Brian Runge
- Division of Renal and Pancreas Transplant Department, Department of Surgery, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Christina Carpenter
- Division of Urology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Pedro R Sandoval
- Division of Renal and Pancreas Transplant Department, Department of Surgery, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Lloyd E Ratner
- Division of Renal and Pancreas Transplant Department, Department of Surgery, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Natalie S Uy
- Division of Pediatric Nephrology, Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Namrata G Jain
- Division of Pediatric Nephrology, Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
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Su X, Shang W, Liu L, Li J, Fu Q, Feng Y, Zhang H, Deng R, Wu C, Wang Z, Pang X, Nashan B, Feng G, Wang C. Transplantation of a single kidney from pediatric donors less than 10 kg to children with poor access to transplantation: a two-year outcome analysis. BMC Nephrol 2020; 21:250. [PMID: 32616005 PMCID: PMC7330989 DOI: 10.1186/s12882-020-01895-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Accepted: 06/15/2020] [Indexed: 12/20/2022] Open
Abstract
Background Access to kidney transplantation by uremic children is very limited due to the lack of donors in many countries. We sought to explore small pediatric kidney donors as a strategy to provide transplant opportunities for uremic children. Methods A total of 56 cases of single pediatric kidney transplantation and 26 cases of en bloc kidney transplantation from pediatric donors with body weight (BW) less than 10 kg were performed in two transplant centers in China and the transplant outcomes were retrospectively analyzed. Results The 1-year and 2-year death-censored graft survival in the en bloc kidney transplantation (KTx) group was inferior to that in the single KTx group. Subgroup analysis of the single KTx group found that the 1-year and 2-year death-censored graft survival in the group where the donor BW was between 5 and 10 kg was 97.7 and 90.0%, respectively. However, graft survival was significantly decreased when donor BW was ≤5 kg (p < 0.01), mainly because of the higher rate of thrombosis (p = 0.035). In the single KTx group, the graft length was increased from 6.7 cm at day 7 to 10.5 cm at 36 months posttransplant. The estimated glomerular filtration rate increased up to 24 months posttransplant. Delayed graft function and urethral complications were more common in the group with BW was ≤5 kg. Conclusions Our study suggests that single kidney transplantation from donors weighing over 5 kg to pediatric recipients is a feasible option for children with poor access to transplantation.
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Affiliation(s)
- Xiaojun Su
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, People's Republic of China
| | - Wenjun Shang
- Kidney Transplant Center, The First Affiliated Hospital of Zhengzhou University, 1 Construction Road, Zhengzhou, 450052, People's Republic of China
| | - Longshan Liu
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, People's Republic of China
| | - Jun Li
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, People's Republic of China
| | - Qian Fu
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, People's Republic of China
| | - Yonghua Feng
- Kidney Transplant Center, The First Affiliated Hospital of Zhengzhou University, 1 Construction Road, Zhengzhou, 450052, People's Republic of China
| | - Huanxi Zhang
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, People's Republic of China
| | - Ronghai Deng
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, People's Republic of China
| | - Chenglin Wu
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, People's Republic of China
| | - Zhigang Wang
- Kidney Transplant Center, The First Affiliated Hospital of Zhengzhou University, 1 Construction Road, Zhengzhou, 450052, People's Republic of China
| | - Xinlu Pang
- Kidney Transplant Center, The First Affiliated Hospital of Zhengzhou University, 1 Construction Road, Zhengzhou, 450052, People's Republic of China
| | - Björn Nashan
- Organ Transplant Center, The First Affiliated Hospital of University of Science and Technology of China, Hefei, 230027, People's Republic of China
| | - Guiwen Feng
- Kidney Transplant Center, The First Affiliated Hospital of Zhengzhou University, 1 Construction Road, Zhengzhou, 450052, People's Republic of China.
| | - Changxi Wang
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, People's Republic of China. .,Guangdong Provincial Key Laboratory on Organ Donation and Transplant Immunology, Guangzhou, People's Republic of China.
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Abstract
Kidney transplantation is the preferred treatment for end-stage renal disease (ESRD) in children and confers improved survival, skeletal growth, heath-related quality of life, and neuropsychological development compared with dialysis. Kidney transplantation in children with ESRD results in 10-year patient survival exceeding 90%. Therefore, the long-term management of these patients is focused on maintaining quality of life and minimizing long-term side effects of immunosuppression. Optimal management of pediatric kidney transplant recipients includes preventing rejection and infection, identifying and reducing the cardiovascular and metabolic effects of long-term immunosuppressive therapy, supporting normal growth and development, and managing a smooth transition into adulthood.
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Affiliation(s)
- Pamela D Winterberg
- Division of Pediatric Nephrology, Emory University School of Medicine, Children's Pediatric Institute, 2015 Uppergate Drive NE, 5th Floor, Atlanta, GA 30322, USA.
| | - Rouba Garro
- Division of Pediatric Nephrology, Emory University School of Medicine, Children's Pediatric Institute, 2015 Uppergate Drive NE, 5th Floor, Atlanta, GA 30322, USA
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Gander R, Asensio M, Molino JA, Royo GF, Ariceta G, Muñoz M, López M. Is donor age 6 years or less related to increased risk of surgical complications in pediatric kidney transplantation? J Pediatr Urol 2018; 14:442.e1-442.e8. [PMID: 29636297 DOI: 10.1016/j.jpurol.2018.03.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Accepted: 03/13/2018] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Despite the widespread organ shortage dilemma, there is hesitancy regarding utilization of young donors (aged ≤6 years) because previous reports have suggested that this is associated with an increased risk of surgical complications and graft loss. OBJECTIVE The aim of this study was to determine if donor age ≤6 years is related to increased risk of surgical complications or allograft loss in pediatric kidney transplantation (KT). STUDY DESIGN A retrospective study of pediatric kidney transplants (KT) undertaken between January 2000 and July 2015. The incidence of surgical and urological complications, and allograft loss were analyzed and compared between donors aged ≤6 years (Group 1) and donors aged >6 years (Group 2). RESULTS A total of 171 pediatric KTs were performed at the current center during the study period. Twenty-eight patients were excluded; as a result, the study comprised 143 patients: 60 (Group 1) and 83 (Group 2). Mean recipient weight was 17 kg (SD 9.7; range 3.2-47) in Group 1 and 38.2 kg (SD 15.3; range 7.8-73) in Group 2. Despite a significantly higher proportion of risk factors in Group 1, no significant between-group differences were observed in terms of: surgical complications (OR 0.4; range 0.1-1.2), early urological complications (OR 2.2; range 0.4-11), late urological complications (OR 0.3; range 0.8-1.4), lymphoceles (OR 6.2; range 0.7-51.7) and allograft loss (OR 1.5; range 0.7-3.1, summary Table). Graft survival at 1 and 5 years was: 81% and 70% (Group 1) and 92% and 79% (Group 2), respectively (P = 0.093). Mean follow-up was 90.13 ± 49.7 months. DISCUSSION The main finding of this retrospective study was that pediatric donor kidneys from donors aged ≤6 years could safely be used in pediatric recipients without an increased risk of surgical and urological complications or graft loss. Nevertheless, KT with small donor kidneys is challenging and should be performed at experienced pediatric centers. CONCLUSION In line with these results, the outcomes of KT using donors aged ≤6 years were encouraging and similar to those obtained with older donors. Thus, this study supported using kidney grafts from young donors, given the organ shortage and potential high mortality risk while awaiting KT.
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Affiliation(s)
- R Gander
- Department of Pediatric Surgery, Pediatric Urology and Renal Transplant Unit, University Hospital Vall d'Hebron, Barcelona, Spain.
| | - M Asensio
- Department of Pediatric Surgery, Pediatric Urology and Renal Transplant Unit, University Hospital Vall d'Hebron, Barcelona, Spain
| | - J A Molino
- Department of Pediatric Surgery, Pediatric Urology and Renal Transplant Unit, University Hospital Vall d'Hebron, Barcelona, Spain
| | - G F Royo
- Department of Pediatric Surgery, Pediatric Urology and Renal Transplant Unit, University Hospital Vall d'Hebron, Barcelona, Spain
| | - G Ariceta
- Department of Pediatric Nephrology, University Hospital Vall d'Hebron, Barcelona, Spain; Department of Pediatrics, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - M Muñoz
- Department of Pediatric Nephrology, University Hospital Vall d'Hebron, Barcelona, Spain
| | - M López
- Department of Pediatric Surgery, University Hospital Vall d'Hebron, Barcelona, Spain
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Hebert SA, Swinford RD, Hall DR, Au JK, Bynon JS. Special Considerations in Pediatric Kidney Transplantation. Adv Chronic Kidney Dis 2017; 24:398-404. [PMID: 29229171 DOI: 10.1053/j.ackd.2017.09.009] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Universally accepted as the treatment of choice for children needing renal replacement therapy, kidney transplantation affords children the opportunity for an improved quality of life over dialysis therapy. Immunologic and surgical advances over the last 15 years have improved the pediatric patient and kidney graft survival. Unique to pediatrics, congenital genitourinary anomalies are the most common primary diseases leading to kidney failure, many with urological issues. Early urological evaluation for post-transplant bladder dysfunction and emphasis on immunization adherence are the mainstays of pediatric pretransplant and post-transplant evaluations. A child's height can be challenging, sometimes requiring an intra-abdominally placed graft, particularly if the patient is <20 kg. Maintenance immunosuppression regimens are similar to adult kidney graft recipients, although distinctive pharmacokinetics may change dosing intervals in children from twice a day to thrice a day. Viral infections and secondary malignancies are problematic for children relative to adults. Current trends to reduce/remove corticosteroid therapy from post-transplant protocols have produced improved linear growth with less steroid toxicity; although these studies are still ongoing, graft function and survival are considered acceptable. Finally, all children with a kidney transplant need a smooth transition to adult clinics. Future research in pertinent psychosocial aspects and continued technological advances will only serve to optimize the transition process. Although some aspects of kidney transplantation are similar in children and adults, for instance immunosuppression and immunosuppressive regimens, and rejection mechanisms and their diagnosis using the Banff criteria, there are important differences this review will focus on and which continue to drive innovation.
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13
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Desensitization protocol enabling pediatric crossmatch-positive renal transplantation: successful HLA-antibody-incompatible renal transplantation of two highly sensitized children. Pediatr Nephrol 2017; 32:359-364. [PMID: 27585679 PMCID: PMC5203834 DOI: 10.1007/s00467-016-3489-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Revised: 07/31/2016] [Accepted: 08/05/2016] [Indexed: 12/27/2022]
Abstract
BACKGROUND Renal transplantation improves quality of life (QoL) and survival in children requiring renal replacement therapy (RRT). Sensitization with development of a broad-spectrum of anti-HLA antibodies as a result of previous transplantation or after receiving blood products is an increasing problem. There are no published reports of desensitization protocols in children allowing renal transplantation from HLA-antibody-incompatible living donors. METHODS We adopted our well-established adult desensitization protocol for this purpose and undertook HLA antibody-incompatible living donor renal transplants in two children: a 14-year-old girl and a 13-year-old boy. RESULTS After 2 and 1.5 years of follow-up, respectively, both patients have stable renal allograft function despite a rise in donor-specific antibodies in one case. CONCLUSIONS HLA-incompatible transplantation should be considered in selected cases for sensitized children.
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14
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Graves RC, Fine RN. Kidney retransplantation in children following rejection and recurrent disease. Pediatr Nephrol 2016; 31:2235-2247. [PMID: 27048230 DOI: 10.1007/s00467-016-3346-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Revised: 01/08/2016] [Accepted: 01/11/2016] [Indexed: 11/27/2022]
Abstract
Retransplantation accounts for approximately 15 % of the annual transplants performed in the USA, and in the recent International Collaborative Transplant Study report on pediatric patients 15.2 % of the 9209 patients included in the report were retransplant recipients. Although the significant advances in clinical management and newer immunosuppressive agents have had a significant impact on improving short-term allograft function, it is apparent that long-term allograft function remains suboptimal. Therefore, it is likely that the majority of pediatric renal allograft recipients will require one or more retransplants during their lifetime. Unfortunately, a second or subsequent graft in pediatric recipients has inferior long-term graft survival rates compared to initial grafts, with decreasing rates with each subsequent graft. Multiple issues influence the outcome of retransplantation, with the most significant being the cause of the prior transplant failure. Non-adherence-associated graft loss poses unresolved ethical issues that may impact access to retransplantation. Graft nephrectomy prior to retransplantation may benefit selected patients, but the impact of an in situ failed graft on the development of panel-reactive antibodies remains to be definitively determined. It is important that these and other factors discussed in this review be taken into consideration during the counseling of families on the optimal approach for their child who requires a retransplant.
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Affiliation(s)
- Rebecca C Graves
- Pediatric Residency Program, Los Angeles County + University of Southern California (LAC+USC) Medical Center, Los Angeles, CA, USA.
| | - Richard N Fine
- Department of Pediatrics, Stony Brook University School of Medicine, Stony Brook, NY, USA.,Department of Pediatrics, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
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15
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EXP CLIN TRANSPLANTExp Clin Transplant 2016; 14. [DOI: 10.6002/ect.tondtdtd2016.l26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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16
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Adler JT, Markmann JF, Yeh H. Renal allograft thrombosis after living donor transplantation: risk factors and obstacles to retransplantation. Clin Transplant 2016; 30:864-71. [DOI: 10.1111/ctr.12750] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/10/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Joel T. Adler
- Division of Transplant Surgery; Department of Surgery; Massachusetts General Hospital; Boston MA USA
- Center for Surgery and Public Health; Brigham and Women's Hospital; Boston MA USA
| | - James F. Markmann
- Division of Transplant Surgery; Department of Surgery; Massachusetts General Hospital; Boston MA USA
| | - Heidi Yeh
- Division of Transplant Surgery; Department of Surgery; Massachusetts General Hospital; Boston MA USA
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17
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Abstract
Renal transplantation in paediatric patients usually provides excellent short-term and medium-term results. Early diagnosis of chronic kidney disease and active therapy of end-stage renal disease before and after transplantation enables the majority of children to grow and develop normally. The adverse effects of immunosuppressive medication and reduced graft function might, however, hamper long-term outcomes in these patients and can lead to metabolic complications, cardiovascular disease, reduced bone health, and malignancies. The neurocognitive development and quality of life of paediatric transplant recipients largely depend on the primary diagnosis and on graft function. Poor adherence to immunosuppression is an important risk factor for graft loss in adolescents, and controlled transition to adult care is of utmost importance to ensure a continued normal life. In this Review, we discuss the outcomes and long-term effects of renal transplantation in paediatric recipients, including consequences on growth, development, bone, metabolic, and cardiovascular disorders. We discuss the key problems in the care of paediatric renal transplant recipients and the remaining challenges that should be the focus of future research.
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18
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Repeat Kidney Transplantation After Failed First Transplant in Childhood: Past Performance Informs Future Performance. Transplantation 2015; 99:1700-8. [PMID: 25803500 DOI: 10.1097/tp.0000000000000686] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND AND OBJECTIVES Kidney transplant graft survival is almost uniformly superior for initial transplants compared to repeat transplants. We investigate the association between first second kidney transplant graft survival in patients who underwent initial transplant during their pediatric years whether age at second transplant is associated with outcome. DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS This is a retrospective analysis of Organ Procurement and Transplantation Network data from October 1987 to May 2009 examining second kidney graft survival in 2281 patients who received their first transplant at younger than 18 years using Kaplan-Meier statistics. Factors associated with second graft survival were identified using a multivariable Cox proportional hazards model. RESULTS Patients with first kidney graft survival of less than 5 years had better second graft survival compared to patients with first graft survival of 30 days to 5 years (P < 0.01). Patients with first kidney graft survival less than 30 days had similar second kidney graft outcomes(P = 0.50) as those with longer than 5 years first kidney graft survival, demonstrating that very early first graft loss is not associated with poor second transplant outcome. Patients 15 to 20 years of age at second transplant have lower second graft survival compared to other age groups; P less than 0.01, regardless of other recipient/donor characteristics and recurrent disease. CONCLUSIONS Poor second transplant outcomes are identified among patients with previous pediatric kidney transplant with first graft survival longer than 30 days, but shorter than 5 years, and those receiving second transplants at a high-risk age category (15-20 years). These groups may benefit from increased attention both before and after transplantation.
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Van Arendonk KJ, Chow EKH, James NT, Orandi BJ, Ellison TA, Smith JM, Colombani PM, Segev ADL. Choosing the order of deceased donor and living donor kidney transplantation in pediatric recipients: a Markov decision process model. Transplantation 2015; 99:360-6. [PMID: 25594552 DOI: 10.1097/tp.0000000000000588] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Most pediatric kidney transplant recipients eventually require retransplantation, and the most advantageous timing strategy regarding deceased and living donor transplantation in candidates with only 1 living donor remains unclear. METHODS A patient-oriented Markov decision process model was designed to compare, for a given patient with 1 living donor, living-donor-first followed if necessary by deceased donor retransplantation versus deceased-donor-first followed if necessary by living donor (if still able to donate) or deceased donor (if not) retransplantation. Based on Scientific Registry of Transplant Recipients data, the model was designed to account for waitlist, graft, and patient survival, sensitization, increased risk of graft failure seen during late adolescence, and differential deceased donor waiting times based on pediatric priority allocation policies. Based on national cohort data, the model was also designed to account for aging or disease development, leading to ineligibility of the living donor over time. RESULTS Given a set of candidate and living donor characteristics, the Markov model provides the expected patient survival over a time horizon of 20 years. For the most highly sensitized patients (panel reactive antibody > 80%), a deceased-donor-first strategy was advantageous, but for all other patients (panel reactive antibody < 80%), a living-donor-first strategy was recommended. CONCLUSIONS This Markov model illustrates how patients, families, and providers can be provided information and predictions regarding the most advantageous use of deceased donor versus living donor transplantation for pediatric recipients.
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Affiliation(s)
- Kyle J Van Arendonk
- 1 Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD. 2 Department of Pediatrics, University of Washington School of Medicine, Seattle, WA. 3 Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
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20
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Ku E, Glidden DV, Hsu CY, Portale AA, Grimes B, Johansen KL. Association of Body Mass Index with Patient-Centered Outcomes in Children with ESRD. J Am Soc Nephrol 2015; 27:551-8. [PMID: 26054540 DOI: 10.1681/asn.2015010008] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Accepted: 04/24/2015] [Indexed: 12/17/2022] Open
Abstract
Obesity is associated with less access to transplantation among adults with ESRD. To examine the association between body mass index at ESRD onset and survival and transplantation in children, we performed a retrospective analysis of children ages 2-19 years old beginning RRT from 1995 to 2011 using the US Renal Data System. Among 13,172 children, prevalence of obesity increased from 14% to 18%, whereas prevalence of underweight decreased from 12% to 9% during this period. Over a median follow-up of 7.0 years, 10,004 children had at least one kidney transplant, and 1675 deaths occurred. Risk of death was higher in obese (hazard ratio [HR], 1.17; 95% confidence interval [95% CI], 1.03 to 1.32) and underweight (HR, 1.26; 95% CI, 1.09 to 1.47) children than children with normal body mass indices. Obese and underweight children were less likely to receive a kidney transplant (HR, 0.92; 95% CI, 0.87 to 0.97; HR, 0.83; 95% CI, 0.78 to 0.89, respectively). Obese children had lower odds of receiving a living donor transplant (odds ratio, 0.85; 95% CI, 0.74 to 0.98) if the transplant occurred within 18 months of ESRD onset. Adjustment for transplant in a time-dependent Cox model attenuated the higher risk of death in obese but not underweight children (HR, 1.09; 95% CI, 0.96 to 1.24). Lower rates of kidney transplantation may, therefore, mediate the higher risk of death in obese children with ESRD. The increasing prevalence of obesity among children starting RRT may impede kidney transplantation, especially from living donors.
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Affiliation(s)
- Elaine Ku
- Division of Nephrology, Department of Medicine, Division of Pediatric Nephrology, Department of Pediatrics, and
| | - David V Glidden
- Department of Biostatistics and Epidemiology, University of California, San Francisco, California
| | | | | | - Barbara Grimes
- Department of Biostatistics and Epidemiology, University of California, San Francisco, California
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21
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Tan JC, Gordon EJ, Dew MA, LaPointe Rudow D, Steiner RW, Woodle ES, Hays R, Rodrigue JR, Segev DL. Living Donor Kidney Transplantation: Facilitating Education about Live Kidney Donation--Recommendations from a Consensus Conference. Clin J Am Soc Nephrol 2015; 10:1670-7. [PMID: 25908792 DOI: 10.2215/cjn.01030115] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The Best Practice in Live Kidney Donation Consensus Conference held in June of 2014 included the Best Practices in Living Donor Education Workgroup, whose charge was to identify best practice strategies in education of living donors, community outreach initiatives, commercial media, solicitation, and state registries. The workgroup's goal was to identify critical content to include in living kidney donor education and best methods to deliver educational content. A detailed summary of considerations regarding educational content issues for potential living kidney donors is presented, including the consensus that was reached. Educational topics that may require updating on the basis of emerging studies on living kidney donor health outcomes are also presented. Enhancing the educational process is important for increasing living donor comprehension to optimize informed decision-making.
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Affiliation(s)
- Jane C Tan
- Department of Medicine, Stanford University School of Medicine, Palo Alto, California;
| | - Elisa J Gordon
- Center for Healthcare Studies and Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Mary Amanda Dew
- Departments of Psychiatry, Psychology, Epidemiology, and Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Dianne LaPointe Rudow
- Recanati Miller Transplantation Institute, Mount Sinai Medical Center, New York, New York
| | - Robert W Steiner
- Department of Medicine, University of California at San Diego, San Diego, California
| | - E Steve Woodle
- Division of Transplantation, Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Rebecca Hays
- Transplant Center, University of Wisconsin Hospital, Madison, Wisconsin
| | - James R Rodrigue
- Transplant Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; and
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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