Renal transplantation in children less than 5 years of age

The evolving ethics of infant dialysis

In this paper, we review ethical issues that arise when families and doctors face clinical decisions about renal replacement therapy for an infant with end-stage renal disease (ESRD). Over the last 20 years, many centers have begun to routinely offer renal replacement therapy. However, doctors and nurses both continue to view such therapy as optional, rather than mandatory. We speculate that the burdens of therapy on the family, and the uncertainties about satisfactory outcomes have led to a situation in which renal replacement therapy remains desirable, but non-obligatory. We discuss the reasons why this is likely to remain so, and the ways in which renal replacement therapy for infants with ESRD is similar to, or different from, other clinical situations in pediatrics. Finally, we propose a research agenda to answer questions that are crucial to making good ethical decisions about infant dialysis.

Current status of kidney transplant: update 2003

Pediatric transplantation has seen remarkable advances over the past two decades with reduced morbidity and mortality, reduced rejection rates, and improved long-term patient and allograft survival. Infants currently have short-term patient and allograft survival rates better than any other age group; short-term allograft survival rates in CD recipients are equal to those in LD recipients. With decreased rejection, long-term allograft survival is improving dramatically. Transplantation allows for much reduced risks and improved metabolic status, growth and development, and more normal social interactions. The future of transplantation continues to be exciting, with opportunities for reduced immunosuppressive medications and their side effects, and the elusive goal of transplantation tolerance seems within reach.

Outcome of reaching end stage renal failure in children under 2 years of age

AIMS

To determine the outcome of children who reach end stage renal failure before the age of 2 years.

METHODS

Using a retrospective questionnaire, 10 years' data were collected from the paediatric nephrology units in Britain and Ireland (1988 to 1997, follow up 1.3-11.5 years).

RESULTS

A total of 192 children were identified; 0.31/million/year. Most had congenital or inherited conditions, and there were more boys. Latterly, half were diagnosed antenatally. Ninety per cent were dialysed initially, most using home peritoneal cyclers, some by haemodialysis through central lines. Five per cent recovered sufficient function to come off dialysis. Most required tube feeding (often gastrostomy) and erythropoietin; some needed growth hormone. A total of 56% received a transplant (2% without prior dialysis) at (medians) 2.6 years and 12.3 kg. The 2 and 10 year survival of first kidneys was 78%. Growth improved following transplantation. Fourteen per cent died because treatment was not started or was withdrawn. Most had particularly complex renal conditions, or additional major non-renal diagnoses. Typically, decisions not to treat were made mutually between clinicians and families. When treatment was continued, 71% survived, and few had serious non-renal conditions. Most attended normal schools, and by 6 years of age, less than 10% still required dialysis. Infants starting treatment under and over 1 month of age fared equally well.

CONCLUSIONS

By school age, most infants treated for end stage renal failure will have a functioning transplant, reasonable growth, and will attend a normal class, regardless of the age at which they commence treatment. Treatment is seldom sustained in children who have serious additional medical conditions. It is reasonable to treat infants with uncomplicated renal failure.

Kidney transplant in children weighing less than 15 kg: donor selection and technical considerations

BACKGROUND

Small children represent a challenging patient group in kidney transplantation (KTx). The aim of this study was to analyze patient and donor data influencing outcome in children that weighed <15 kg.

METHODS

Sixty-eight kidneys were transplanted in 64 children that weighed <15 kg. In 44 cases, kidneys came from cadaveric donors (CAD) and in 24 cases from living-related donors (LRD). Grafts were placed transperitoneally via midline incision (n=16) or extraperitoneally to the iliac fossa (n=52). Vascular anastomoses were routinely performed to the aorta and vena cava even when the extraperitoneal approach was used.

RESULTS

Vascular thrombosis was observed in two (3%), urinary leaks in five (7%), and stenosis in four (6%) patients. In six children receiving organs from adults to the iliac fossa, wound closure was performed using an absorbable mesh to avoid organ compression. Initial graft function occurred in 60 cases (88%). Frequency of initial graft function was significantly higher after KTx from LRD (100%) compared with CAD (82%). The 1-, 5-, and 10-year patient survival was 93%, 91%, and 91%, respectively, and the 1-, 5-, and 10-year graft survival was 92%, 85%, and 85%, respectively. There was no significant difference in patient and graft survival when KTx from LRD and CAD were compared. Within the CAD group, graft survival was improved using kidneys from donors >12 years compared with younger donors.

CONCLUSION

Despite size discrepancy between recipients and grafts, KTx is feasible in children that weigh <15 kg by using an improved surgical technique even when adult organs are placed to the iliac fossa.

Renal transplantation in children less than two years old

Twenty-one infants, 2 years old or younger, received 21 renal transplants between 1983 and 1995. Six of the transplantations were performed from 1983 to 1989, and the remaining 15 were performed from 1990 to 1995. The median age at transplantation was 16.0 months and the median body weight was 9.0 kg. Living-related donor kidneys were used in 15 cases, an adult cadaveric donor kidney was used in one case, and pediatric cadaveric donor kidneys were used in five cases. All grafts were placed intra-abdominally. The immunosuppressive therapy consisted of cyclosporine, azathioprine, and prednisolone. No prophylactic antithymocyte globulins were used. Five infants have died, one with a functioning graft and four after loss of graft function. All graft losses and deaths occurred during the first 6 months after transplantation. The 5-year patient survival and graft survival rates were 87% for recipients of living donor grafts and 44% for recipients of cadaveric grafts. The median height SD score increased from -3.7 before operation to -1.9 at 1 year, -0.7 at 3 years, and -1.1 at 5 years. The glomerular filtration rate in absolute values remained stable in all infants, whereas a reduction in glomerular filtration rate related to body surface area was seen at follow-up, 5 years after transplantation. We conclude that renal transplantation can be performed with good long-term results in children less than 2 years old.

Renal transplantation in very young children

Results of renal transplantation in very young children with end-stage chronic renal failure have been poor compared with those in older children and adults. Consequently small children either may not be treated or may be placed on chronic dialysis programmes. Between 1988 and 1992, six children under the age of 5 years received seven renal transplants at the Royal Children's Hospital, Parkville, Victoria, Australia; five from live donors and two from cadaver donors. All children were treated with peritoneal dialysis before transplantation, and immunosuppressed with a standardized regimen of cyclosporine, azathioprine and prednisolone. An extraperitoneal incision was used, and the donor renal vessels were anastomosed to the lower abdominal aorta and inferior vena cava or the common iliac vein. All children received intensive monitoring and fluid replacement during the peri-operative period. Patient survival was 100%. One cadaver graft failed 1 week after transplantation because of irreversible acute rejection. This child subsequently received a successful second transplant. Two children developed postoperative urinary fistulae which were treated successfully by further operation. Current renal function in all children is excellent. The success of this programme has led us to review our attitude towards renal transplantation in this age group and to advocate live donor renal transplantation as the treatment of choice in very young children with end-stage chronic renal failure whenever possible.

Outcome of renal transplantation in children less than two years of age

Twenty-two renal transplants were performed in 21 children less than two years of age at Children's Hospital. Fourteen were from living related donors and eight were from cadaveric donors. The five year patient and graft survivals of these recipients were compared to all other pediatric recipients between two and 18 years of age who received renal transplants over the same time period. Five year graft survival for recipients less than two years of age was 86% following living-related donor transplantation and 38% following cadaver donor transplantation. Older pediatric recipients aged between two and 18 years had a five year graft survival of 73% following living-related donor renal transplantation, which was similar to that for recipients less than two years of age. Although older cadaveric recipients had a comparable five year graft survival to younger recipients, at 42%, the patterns of graft loss were different. Graft failures in young recipients occurred within the first seven months post-transplant, whereas the older recipient's grafts failed more gradually. Actuarial five-year patient survival in recipients less than two years of age was 86% following living-related donor renal transplantation and 70% following cadaver-donor renal transplantation. Recipients less than two years of age had a poorer patient survival than older recipients following both living-related donor renal transplantation (P = 0.06) and cadaver-donor renal transplantation (P less than 0.05). These findings suggest that the graft survival of living-related donor renal transplantation in recipients less than two years of age is better than that of cadaver-donor renal transplantation.(ABSTRACT TRUNCATED AT 250 WORDS)

Paediatric renal transplantation in Ireland: 1980-1990

Between 1980 and 1990, 862 renal transplants were performed at our unit. Forty-six of these were given to 38 children. The mean age of the children was 8.6 years. Reflux nephropathy accounted for 39% of the primary renal diseases, followed by congenital disorders (30%), and glomerulonephritis (16%). Seventy percent of the grafts were from cadaveric donors. The one year patient survival was 90%, and the one year graft survival 61%. Seven children received a second graft with a one year graft survival of 71%.

Cadaveric renal transplantation in children under 5 years of age

From March 1987 to August 1990 23 cadaveric renal transplants were performed in 19 children under the age of 5 years at the time of transplantation. The mean age of the recipients was 3.3 years (range 1.3-4.7) and the mean weight 13.0 kg (range 9.3-19.2). The mean donor age was 7.8 years (range 1.5-25). All children received triple immunosuppression with prednisolone, cyclosporin A and azathioprine, and 4 who had 2 grafts during this period also received antithymocyte globulin at the time of the second transplant. Patient survival is 100%. Actuarial first cadaveric graft survival was 57% at 1 year and remains unchanged at 3 years. There were 10 graft losses, 4 were associated with renal venous thrombosis without apparent rejection. Two were lost due to acute vascular rejection with associated renal venous thrombosis, and the remaining 4 losses followed cellular or chronic vascular rejection. The mean glomerular filtration rate +/- SD was 51.4 +/- 23.6 ml/min per 1.73 m2 (n = 11) at 1 year and 43.5 +/- 25.3 at 2 years (n = 6). The mean height standard deviation score improved from -2.2 +/- 1.1 at the time of transplantation to -1.3 +/- 1.0 1 year post transplant (n = 11). The immunosuppression was well tolerated with a low incidence of side effects. Cadaveric renal transplantation remains a difficult but rewarding undertaking in children under 5 years of age.

Growth after renal transplantation: correlation with immunosuppressive therapy

The growth data for children transplanted between 1973 and 1987 were analysed according to their immunosuppressive regimen. All patients treated before 1985 received conventional treatment (prednisone, azathioprine); 37% of the prepubertal children with a follow-up of longer than 2 years showed catch-up growth, and 30% of the pubertal children exhibited a normal adolescent growth spurt. Reduced renal function and corticosteroid treatment are the two main causes of growth delay. The children transplanted between January 1985 and September 1987 were given either triple therapy [cyclosporine (CsA), prednisone, azathioprine] or conventional treatment after randomisation. Growth data were significantly better with CsA. The mean height gain for prepubertal children was +0.24 SD/year on triple therapy and +0.14 SD/year on conventional therapy during the 1st year after transplantation; and 0.4 SD/year and 0 SD/year during the 2nd year (P less than 0.05). The mean height gain for pubertal children was 5.6 cm/year on triple therapy and 3.6 cm/year on conventional therapy (P less than 0.005). The patients on triple therapy also received a significantly lower cumulative dose of prednisone. Some selected patients on triple therapy were taken off prednisone 12 months after transplantation. All patients showed catch-up growth (+0.83 SD/year in prepubertal children, 7.2 cm/year in pubertal children). In conclusion, protocols including CsA and the lowest cumulative dose of steroid (with alternate-day or even steroid withdrawal) allow the best restoration of growth.

Renal transplantation in infants

The timing of renal transplantation in infants is controversial. Between 1965 and 1989, 79 transplants in 75 infants less than 2 years old were performed: 23 who were 12 months or younger, 52 who were older than 12 months; 63 donors were living related, 1 was living unrelated, and 15 were cadaver donors; 75 were primary transplants and 4 were retransplants. Infants were considered for transplantation when they were on, or about to begin, dialysis. All had intra-abdominal transplants with arterial anastomosis to the distal aorta. Sixty-four per cent are alive with functioning grafts. The most frequent etiologies of renal failure were hypoplasia (32%) and obstructive uropathy (20%); oxalosis was the etiology in 11%. Since 1983 patient survival has been 95% and 91% at 1 and 5 years; graft survival has been 86% and 73% at 1 and 5 years. For cyclosporine immunosuppressed patients, patient survival is 100% at 1 and 5 years; graft survival is 96% and 82% at 1 and 5 years. There was no difference in outcome between infants who were 12 months or younger versus those who were aged 12 to 24 months; similarly there was no difference between infants and older children. Sixteen (21%) patients died: 5 after operation from coagulopathy (1) and infection (4); and 11 late from postsplenectomy sepsis (4), recurrent oxalosis (3), infection (2), and other causes (2). Routine splenectomy is no longer done. There has not been a death from infection in patients transplanted since 1983. Rejection was the most common cause of graft loss (in 15 patients); other causes included death (with function) (7), recurrent oxalosis (3), and technical complications (3). Overall 52% of patients have not had a rejection episode; mean creatinine level in patients with functioning grafts is 0.8 +/- 0.2 mg/dL. Common postoperative problems include fever, atelectasis, and ileus. At the time of their transplants, the infants were small for age; but with a successful transplant, their growth, head circumference, and development have improved. Transplantation in infants requires an intensive multidisciplinary approach but yields excellent short- and long-term survival rates that are no different from those seen in older children or adults. Living donors should be used whenever possible. Patients with a successful transplantation experience improved growth and development, with excellent rehabilitation.

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.

The influence of donor age on graft survival in renal transplantation

The current supply of kidneys from cadaver and living related donor sources is not sufficient to meet the demand. As a result, alternative sources of renal allografts are being explored, including very young donors and anencephalic newborns. However, data on the success of transplanting kidneys from very young donors are limited and conflicting. The purpose of this study was to determine whether the function and survival of renal grafts obtained from newborns and very young donors is different from that for grafts obtained from older donors. Thirty-six cadaveric donors under the age of 3 years, including seven anencephalic newborns, were evaluated. Allograft recipients ranged in age from 12 months to 57 years. The clinical outcome for these donor organs was compared with the graft survival for 136 kidneys transplanted from cadaver donors over age 3 years at our institution. There was a 65% 6-month and 64% 1-year graft survival in recipients of kidneys from donors greater than or equal to 3 years. Survival of grafts from donors under 12 months of age (n = 16) was significantly decreased compared with donors age 3 years and older, with a 31% 6-month (P less than .01) and 19% 12-month survival (P less than .001). Grafts obtained from anencephalic donors did not differ in survival or function from kidneys obtained from other donors less than 12 months of age. Survival for renal allografts from donors age 13 months to 3 years was also decreased relative to older donors: 55% at 6 months (P greater than .1) and 40% at 1 year (P less than .05).(ABSTRACT TRUNCATED AT 250 WORDS)

Experience with anencephalic infants as prospective organ donors

Recent advances have made organ transplantation in newborns feasible, but the paucity of organs small enough for this age group remains a major limitation. Because anencephalic infants can survive for no more than a few weeks, they have been considered as possible organ donors for other infants. Under current law, however, they cannot be used as donors until their brain-stem activity ceases and the criteria for total brain death are thereby met. If anencephalic infants receive customary care, their solid organs usually undergo irreversible hypoxic injury during the process of dying and become unsuitable for donation by the time of death. We modified the medical care of 12 live-born anencephalic infants for one week to determine whether organ viability could be maintained and whether the criteria of total brain death could be met. Six received intensive care from birth, and six only when signs of imminent death developed. Only two infants met the criteria for total brain death within one week, and no solid organs were procured. Most organs were suitable for transplantation at birth. When intensive care was provided from birth, organ function was maintained; however, brain-stem activity ceased in only one infant within the first week. When intensive care was delayed until death was imminent, most organs were damaged to an extent that made them no longer suitable for transplantation. Our findings suggest that it is usually not feasible, with the restrictions of current law, to procure solid organs for transplantation from anencephalic infants.

Renal transplantation of the infant and young child and the use of pediatric cadaver kidneys for transplantation in pediatric and adult recipients

Transplantation of infants less than 1 year of age with kidneys from live-related parental donors has recently led to good results, whereas cadaver donor renal transplantation in this recipient age group has led to a high mortality rate (11/13). Similarly, the results of cadaver donor renal transplantation in infants and young children less than 5 years of age has been suboptimal in the past, although recent data are more encouraging. With recent availability of long-term peritoneal dialysis for the infant and young child with end-stage renal disease (ESRD), it is possible to defer transplantation until an optimal donor becomes available. Because of the possible immunologic hyperactivity of such recipients, the immunosuppressive regimen may need to be modified if improved cadaver donor survival rates are to be obtained. The use of anencephalic kidneys for transplantation has been associated with a high incidence of primary nonfunction and few recipients with long-term functioning grafts. Harvesting of kidneys from anencephalic donors declared "brain-dead" at birth may reduce the incidence of primary nonfunction and increase the availability of anencephalic kidneys for transplantation. Reports of the use of pediatric cadaver kidneys for transplantation into pediatric and adult recipients yields discrepant results. Analysis of the data indicates that if pediatric cadaver kidneys from donors less than 6 years of age are used, the potential for decreased graft survival rates and an increased incidence of technical complications exists. However, the use of pediatric cadaver kidneys can provide adequate graft function in both pediatric and adult recipients and the use of such kidneys should increase the number of kidneys available for transplantation.

The pediatric nephrologist's dilemma: growth after renal transplantation and its interaction with age as a possible immunologic variable

Two important criteria for successful end-stage renal disease therapy in children are achievement of optimal growth and possession of a well-functioning renal transplant. We describe eight children with accelerated post-transplant growth. Accelerated and even catch-up growth was achievable if the transplant occurred at an early age (less than 9 years), the daily dose of prednisone was low (less than or equal to 0.24 mg/kg/d), and renal function was excellent (creatinine clearance greater than or equal to 89 mL/min/1.73 m2). However, the benefit to growth of transplanting a kidney in young children may be offset by reduced cadaver graft survival in children younger than 6 years. To study whether the less favorable graft survival was attributable to an increased immunologic responsiveness in the younger child, we examined three tests of nonspecific immune responsiveness, each of which, when increased, may indicate a propensity toward rejection: total T cell absolute number, T helper/suppressor ratio, and spontaneous blastogenesis. Each measurement was significantly increased in 20 uremic children 5 years old or younger, compared with 81 children 6 to 23 years of age. These data suggest that improved growth may be attained by transplanting a kidney in the young child with end-stage renal disease, but the young child may be at increased risk for rejection. This hypothesis suggests that for optimal rehabilitation, strategies should take into account the unique needs of the young child.

The therapeutic approach to the infant, child, and adolescent with end-stage renal disease

Factors involved in choosing a treatment modality for the infant, child, and adolescent with ESRD differ from those used when counseling an adult patient. Age at the time ESRD develops, mental status, psychosocial status, and the primary renal disease must be taken into consideration when contemplating the optimal therapeutic modality for the pediatric patient with ESRD. The ideal approach to optimize growth in the pediatric patient with ESRD remains to be delineated.

Transplantation in infants less than 1 year of age

Thirteen infants received their first renal transplant at the University of Minnesota from 1978 through 1985. Nine of the originally transplanted kidneys are still functioning and only two patients have died. These results are similar to those obtained in larger groups of children either less than 2 years of age or less than 5 years of age at the time of transplantation. Successfully transplanted infants experience accelerated growth and development, frequently reaching the normal range for their age. Since both chronic uremia and dialysis carry special risks in infancy, the option of earlier transplantation should be considered in any infant with end-stage renal failure.

The outcome of 304 primary renal transplants in children (1968-1985)

Of 304 children who received primary renal transplants at the University of Minnesota between January 1, 1968, and December 31, 1985, 48 (16%) were under the age of 24 months, 60 (20%) were 2-5 years old, and 196 (64%) were 6-17 years old at transplantation. Currently, 254 (84%) are alive at 2 months to 18 years following their first transplants, 77% with functioning grafts (188 first, 45 retransplants) and 7% on dialysis. Overall, patient and graft survival were not significantly different from the primary graft outcome of nondiabetic adults. The actuarial primary graft function rates at 1, 5, and 10 years were 100, 100, and 90% in 16 HLA-identical sibling kidneys; 84, 64, and 52% in 210 mismatched related kidneys; and 72, 54, and 47% in 78 cadaver kidneys (p less than 0.002). The 1-year patient survival and primary graft function rates in 44 mismatched related recipients under the age of 24 months were 92 and 88%. The use of deliberate, pretransplant random blood transfusion since 1979 has been associated with a decreased rejection rate. Primary graft function of mismatched related kidneys in children receiving standard immunosuppression has significantly improved from 78% at 1 year in the pretransfusion era to 91% (p less than 0.01) in the transfusion era. The overall primary cadaver graft function rate, however, did not improve in the transfusion era. Whether cyclosporine use will improve the cadaver renal allograft function in very young recipients remains to be established. However, with the use of related donors, even very young children can be transplanted safely and with excellent results.

Current thinking in transplantation in infants and children

Renal and liver transplantation are now recognized as therapeutic modalities for children with kidney and liver failure. This article reviews the general indications for transplantation, recipient selection, descriptions of the procedures, and the expected outcome of these two procedures in the pediatric setting.

Use of cyclosporine in pediatric renal transplant recipients

Cyclosporine and prednisone were used in combination to produce immunosuppression in 18 pediatric recipients of renal allografts. Ten children received cadaveric kidneys and eight received kidneys from living related donors. With a mean follow-up of 16.5 months (range 7 to 33 months), the patient survival rate is 100% (18 of 18) and the graft survival rate is 83% (15 of 18). Two grafts were lost for nonimmunologic reasons. Currently the group mean (+/- SE) serum creatinine concentration is 1.22 +/- 0.11 mg/dl and creatinine clearance is 69.3 +/- 4.79 ml/min/1.73 m2. Cyclosporine nephrotoxicity has not caused irreversible allograft injury nor led to graft loss in this population. The incidence of treated rejection episodes has been 39% (seven of 18). Only 39% (seven of 18) of children have required hospital readmissions since the initial transplant discharge. There have been no opportunistic infections. In the 15 children with functioning grafts, some linear growth has occurred in 10 of 11 prepubertal and two of four postpubertal patients. Cyclosporine and prednisone have constituted a safe, efficacious immunosuppressive regimen for pediatric renal allograft recipients. Longer follow-up will be necessary to confirm whether these advantages persist beyond 2 years.

Choosing a dialysis therapy for children with end-stage renal disease

Although transplantation is the optimal therapeutic modality for the child with ESRD, it is usual for the child to require short- or long-term dialysis prior to obtaining a successful transplant. Various factors such as age, mental and psychosocial status, and primary renal disease influence the choice of dialysis therapy. The medical and psychosocial benefits of home peritoneal dialysis are the determining factors influencing the increasing use of CAPD/CCPD in children requiring prolonged dialysis therapy.

Paediatric dialysis and transplantation experience in Queensland

Between 1967 and 1981 27 children 6-15 years of age with end stage renal failure were treated in Queensland. The major cause of renal failure was reflux nephropathy (10). Actuarial graft survival was 55%, 50% and 35% at one, two and five years. Patient survival was 88%, 83% and 63% at one, two and five years. Seven deaths occurred, the major cause being hypertension in five children. Since 1978, patient survival has improved with a 93% survival at 3 years. Rehabilitation has been satisfactory with eleven of twelve school-aged children now attending school full time.

Comparison of high-dose intravenous methylprednisolone with low-dose oral prednisolone in acute renal allograft rejection in children

Two corticosteroid regimens were compared in a randomised, prospective study of 48 consecutive acute rejection episodes occurring at least one month after transplantation in 22 children who had received renal allografts. The higher dose schedule (intravenous methylprednisolone 600 mg/m2 daily for three days) was no more effective than the lower (oral prednisolone 3 mg/kg daily for three days) in reversing rejection, being successful in 70% as opposed to 72% of episodes. Few major side effects were seen with either treatment, but unpleasant sensations were reported much more frequently in the group given intravenous methylprednisolone; this regimen was much more disruptive of the patient's life. Oral prednisolone in the dosage described is as effective as about 10 times that dose of intravenous methylprednisolone; it is much cheaper and is viewed as less unpleasant by patients.