Renal transplantation

Outcomes of pediatric living donor kidney transplantation: A single-center experience

Renal transplantation is the treatment of choice for children with ESRD offering advantages of improved survival, growth potential, cognitive development, and quality of life. The aim of our study was to compare the outcomes of LDKT vs DDKT performed in children at a single center. Retrospective chart review of pediatric patients who underwent kidney transplantation from 2005 to 2014 was performed. Ninety-one renal transplants were accomplished, and 31 cases (38.27%) were LDKT, and in 96.7% of the cases, the graft was obtained through laparoscopy. Thirty-four receptors weighted <25 kg. LDKT group had statistically significant lower cold ischemia times than DDKT one. Complication rate was 9.67% for LDKT and 18.33% for DDKT. eGFR was better in LDKT. Patient survival rate was 100% for LDKT and 98.3% for DDKT, and graft survival rate was 96.7% for LDKT and 88.33%-80% for DDKT at a year and 5 years. Our program of pediatric kidney transplantation has achieved optimal patient and graft survival rates with low rate of complications. Living donor pediatric kidney transplants have higher patient and better graft survival rates than deceased donor kidney transplants.

Preliminary Results of a Newly Established Organ Transplantation Program in a Teaching Hospital

OBJECTIVES

End-stage renal disease is the complete failure of kidney function; kidney transplant offers the best survival advantage. We analyzed data from Al-Basheer Hospital's newly established transplant program and present our kidney transplant results from the first year of operation.

MATERIALS AND METHODS

Between April 2015 and June 2016, 20 kidney transplants were performed (19 living-related donors and 1 deceased donor). We assessed the demographic data, surgical techniques employed, complications, immunosuppressive drugs used, and graft and patient survival rates. The mean recipient age was 32.8 years. There were 10 male and 10 female patients. Two patients underwent preemptive transplant, and 18 were on hemodialysis. Preparation of the donor and recipient employed an established transplant protocol. Induction immunosuppression therapy was used in 13.65% of patients. The left kidney was used from all living donors, and the right kidney was harvested from the deceased donor. The total ischemia time in the living-donor grafts ranged from 30 to 53 minutes; in the deceased donor, the ischemia time was 90 minutes. Intraoperative Doppler ultrasonography was used in most cases.

RESULTS

There was no donor mortality, and no significant donor complications occurred, either intraoperatively or postoperatively. There was no recipient mortality, but there were complications in 6 patients. Intraoperative complications were reported in 2 patients: 1 with renal artery thrombosis and the other with external iliac artery dissection. Postoperative complications were reported in 4 patients: slow graft function in 1 patient with thrombotic thrombocytopenic purpura, 1 patient with acute cellular rejection treated with intravenous immunoglobulin, 1 patient with cytomegalovirus gastroenteritis, and 1 patient treated for varicella pneumonitis. The follow-up ranged from 1 week to 13 months.

CONCLUSIONS

The first-year outcomes for our newly established transplant program at Al-Basheer Hospital are comparable to those of well-established programs.

Strategies to optimize kidney recovery and preservation in transplantation: specific aspects in pediatric transplantation

In renal transplantation, live donor kidney grafts are associated with optimum success rates due to the shorter period of ischemia during the surgical procedure. The current shortage of donor organs for adult patients has caused a shift towards deceased donors, often with co-morbidity factors, whose organs are more sensitive to ischemia-reperfusion injury, which is unavoidable during transplantation. Donor management is pivotal to kidney graft survival through the control of the ischemia-reperfusion sequence, which is known to stimulate numerous deleterious or regenerative pathways. Although the key role of endothelial cells has been established, the complexity of the injury, associated with stimulation of different cell signaling pathways, such as unfolded protein response and cell death, prevents the definition of a unique therapeutic target. Preclinical transplant models in large animals are necessary to establish relationships and kinetics and have already contributed to the improvement of organ preservation. Therapeutic strategies using mesenchymal stem cells to induce allograft tolerance are promising advances in the treatment of the pediatric recipient in terms of reducing/withdrawing immunosuppressive therapy. In this review we focus on the different donor management strategies in kidney graft conditioning and on graft preservation consequences by highlighting the role of endothelial cells. We also propose strategies for preventing ischemia-reperfusion, such as cell therapy.

Quality of life of adolescents with end-stage renal disease and kidney transplant

The health-related quality of life (HRQOL) of adolescents with end-stage renal disease (ESRD) is an important marker of disease burden. Our aims were to investigate HRQOL in a group of children and adolescents with ESRD and to compare them with the reference population norms. Ours was a cross-sectional study of 81 patients aged 10 years to 21 years with ESRD (68 with kidney transplants and 13 on dialysis) at five Spanish paediatric nephrology centres. HRQOL was investigated with the Spanish version of the child health and illness profile, adolescent edition (CHIP-AE). Clinical variables such as underlying diagnosis, number of rejection episodes, pre-emptive transplantation, anaemia and height were also analysed. No differences were found between patients with kidney transplants and their healthy peers in any domain or sub-domain of CHIP-AE. The group on dialysis scored lower than healthy controls and patients with transplants for satisfaction with health. Discomfort was higher in patients with transplants who had suffered one rejection episode. Physical discomfort was increased in anaemic patients with transplants. Short patients scored less in the satisfaction domain, with lower self-esteem and lower satisfaction with health. Adolescents with kidney transplants had better satisfaction with health than the group on dialysis, which matched the level of a healthy population. Further long-term prospective research is warranted.

Combined epidural and general anesthesia for paediatric renal transplantation-a single center experience

BACKGROUND

Appropriate anesthesia for pediatric renal transplantation requires stable intraoperative hemodynamics, optimal perfusion of the newly transplanted kidney and good analgesia during recovery. The aim of this study was to assess the preliminary application, success and safety of combined epidural and general anesthesia in pediatric renal transplantation in a small cohort.

METHODS

We retrospectively reviewed the anesthesia records of 46 consecutive pediatric patients who received renal transplantation under combined epidural and general anesthesia from January 2003-2007.

RESULTS

The mean patient age and weight were 13.2 +/- 2.4 years and 25.7 +/- 5.46 kg, respectively. The infused crystalloids, 20% albumin and red blood cell concentrates were 120 +/- 2 mL/kg to achieve a CVP of 13 to 15 mm Hg. Brisk diuresis was observed in all patients. Epidural tramadol (2 mg/kg) provided good postoperative analgesia in 89% patients. 15% patients developed radiological evidence of pulmonary edema, only one required mechanical ventilation for hypoxemia. Minor adverse effects were nausea and vomiting (17.5%) and convulsions (8.5%). No perioperative mortality or major morbidity was recorded.

CONCLUSION

Epidural anesthesia is a useful adjunct to general anesthesia due to stable intraoperative haemodynamics and good postoperative analgesia.

A drug transporter for all ages? ABCB1 and the developmental pharmacogenetics of cyclosporine

Evaluation of: Fanta S, Niemi M, Jönsson S et al.: Pharmacogenetics of cyclosporine in children suggests an age-dependent influence of ABCB1polymorphisms. Pharmacogenet. Genomics 18(2), 77-90 (2008). The clinical use of the immunosuppressive agent cyclosporine is complicated by its toxicity, narrow therapeutic window and highly variable pharmacokinetics between individuals. In adults, genetic polymorphisms in the genes encoding the cyclosporine-metabolizing enzymes CYP3A4 and CYP3A5, as well as the ABCB1 gene, which encodes the efflux-pump P-glycoprotein, seem to have a limited effect, if any, on cyclosporine pharmacokinetics. However, the authors have now reported for the first time an association between cyclosporine oral bioavailability and the ABCB1 c.1236C>T and c.2677G>T polymorphisms, as well as the related haplotype c.1199G-c.1236C-c.2677G-c.3435C, in children with end-stage renal disease older than 8 years of age. Carriers of the variant alleles had a cyclosporine oral bioavailability that was around 1.5-times higher compared with noncarriers. This association was not observed in children younger than 8 years of age. In addition, no relation between cyclosporine disposition and genetic variation in the CYP3A4, CYP3A5, ABCC2, SLCO1B1 and NR1I2 genes was observed. These data suggest that the effect of ABCB1 polymorphisms on cyclosporine pharmacokinetics is related to age, and thus developmental stage. Although further study is necessary to establish the predictive value of ABCB1 genotyping for individualization of cyclosporine therapy in children older than 8 years, an important step towards further personalized immunosuppressive drug therapy has been made.

First experiences of pediatric kidney transplantation in Sri Lanka

KT is the most effective therapeutic option for ESRF. We present our first experiences in a developing country. All children who underwent kidney transplantation since the inception of this program in July 2004 until 30 September 2005 were studied. Their demographic data, operative and peri-operative details, graft and host survival, and drug compliance are described here. Data were collected from patient records and nursing observation records. Eleven children were transplanted during this period (median recipient age 10.75 yr, range: 8-16). The median age of the donors was 41 yr (range: 38-45) and was the mother in eight, father in two and uncle in one. The median (range) follow-up period following transplantation was 12.5 months (7-12). The vascular anastomotic site was aorta and inferior vena cava in nine patients and the cold ischemia time was mean (s.d.) 1.9 h (0.96). All patients received steroids, cyclosporine and MMF for immunosuppression. Hypotension, heart failure and septicemia were common medical complications. Four were treated for acute rejection. Vascular anastomotic leak, burst abdomen, intestinal obstruction, intra-abdominal leak of supra pubic catheter and vesico-ureteric junction obstruction were surgical complications. There were no graft losses or deaths. Despite limited resources good outcomes are possible following renal transplantation in children in developing countries.

Paediatric kidney transplantation in small children-- a single centre experience

Kidney transplantation (KTx) remains a challenging procedure in small children. This study presents our centre results. From 1983 to 2004, 40 of 442 paediatric KTx were performed in children with a body weight <11 kg. Median body weight was 9.2 kg (range: 7.2-10.9), median age was 2.7 years (range: 0.9-5.9). Preoperative dialysis was performed in 87.5%. In 24 cases (60%) grafts came from cadaveric (CAD) and in 16 cases (40%) from living related donors (LRD). Median donor age of CAD was 8 years (range: 1-40). The overall 1-, 5-, 10-, 15-year patient survival was 93%, 90%, 90% and 87% respectively. The overall 1-, 5-, 10-, 15-year graft survival was 90%, 80%, 66% and 56% respectively. There was no significant difference in survival of CAD or LRD grafts. Median follow-up was 13.7 years. Initial graft function rate was 100% for LRD and 79% for CAD. The relative glomerular filtration rate (GFR) showed no statistical difference between CAD and LRD. Main reasons for graft loss were chronic transplant nephropathy. Paediatric KTx is the treatment of choice even in very small children. Living donor KTx is the preferable donor source in terms of primary graft function and timing to transplantation.