Kidney transplantation in a child with posterior urethral valve from a hepatitis B virus-carrier mother. Report of a case with special reference to urinary tract reconstruction for dysfunctionalized uropathies and seroimmunological preparation against viral transmission

Outcomes Among Children Who Received a Kidney Transplant in the United States From a Hepatitis B Core Antibody-Positive Donor, 1995-2010

BACKGROUND

Accepting kidneys for transplant from donors with a history of hepatitis B virus infection may increase the availability of organs for those with end-stage kidney disease. In adult recipients, kidney transplants from hepatitis B virus core antibody-positive donors have resulted in favorable graft and patient survival rates. However, pediatric organ transplant recipients have developing immune systems and a higher risk of infectious complications than adults. Accordingly, little is known about the outcomes of children who have received a kidney transplant from a hepatitis B virus core antibody-positive donor.

METHODS

We included 11 898 children ≤18 years of age who received a first kidney transplant in the United States between January 1, 1995, and December 31, 2010, and who were recorded in the Scientific Registry of Transplant Recipients. We examined differences in graft and patient survival rates among children who received a kidney transplant from a hepatitis B virus core antibody-positive donor.

RESULTS

There were 199 children (1.7%) who received a kidney transplant from a hepatitis B virus core antibody-positive donor. More than 80% of these transplants occurred in recipients who were hepatitis B virus core antibody and surface antigen negative. After a median follow-up of 7.9 years, there were no significant differences in the adjusted graft (hazard ratio [HR], 1.03 [95% confidence interval (CI), 0.80-1.31]) or patient (HR, 1.12 [95% CI, 0.73-1.73]) survival rates according to donor core antibody status.

CONCLUSIONS

It may be acceptable, on a case-by-case basis, to consider hepatitis B virus core antibody-positive donors for kidney transplants to seroprotected children with end-stage kidney disease.

Solid organ transplantation from hepatitis B virus-positive donors: consensus guidelines for recipient management

Use of organs from donors testing positive for hepatitis B virus (HBV) may safely expand the donor pool. The American Society of Transplantation convened a multidisciplinary expert panel that reviewed the existing literature and developed consensus recommendations for recipient management following the use of organs from HBV positive donors. Transmission risk is highest with liver donors and significantly lower with non-liver (kidney and thoracic) donors. Antiviral prophylaxis significantly reduces the rate of transmission to liver recipients from isolated HBV core antibody positive (anti-HBc+) donors. Organs from anti-HBc+ donors should be considered for all adult transplant candidates after an individualized assessment of the risks and benefits and appropriate patient consent. Indefinite antiviral prophylaxis is recommended in liver recipients with no immunity or vaccine immunity but not in liver recipients with natural immunity. Antiviral prophylaxis may be considered for up to 1 year in susceptible non-liver recipients but is not recommended in immune non-liver recipients. Although no longer the treatment of choice in patients with chronic HBV, lamivudine remains the most cost-effective choice for prophylaxis in this setting. Hepatitis B immunoglobulin is not recommended.

The effect of HBsAg-positivity of kidney donors on long-term patient and graft outcome

The number of patients on the kidney waiting list is increasing, creating a shortage of donor organs. To solve this problem, there is an interest in transplanting organs formerly considered marginal or undesirable. We performed seven (four living related, three cadaveric) kidney transplants from hepatitis B surface antigen (HBsAg)-positive donors. Hepatitis B e antigen (HBeAg) and hepatitis B virus (HBV) DNA were negative in the living donors and were unknown in cadaveric donors. Liver function tests were in the normal range in all of the donors. All of the recipients were HBsAg-negative and hepatitis B surface antibody (anti-HBs)-positive. Recipients receiving kidneys from cadaveric donors were given prophylactic lamivudine treatment postoperatively. Anti-HBs remained positive throughout the follow-up period in all but one patient with a cadaveric graft. None of the patients receiving a kidney from an HBsAg-positive donor developed clinical HBV infection in a mean follow-up period of 42.6 +/- 36.8 months (range: 16 to 121 months, median 30 months). Liver function tests remained in the normal ranges in all patients. All the grafts are still functioning with a mean serum creatinine level of 1.6 +/- 0.85 mg/dL. In conclusion, transplants from HBsAg-positive and HBeAg-/HBV DNA-negative donors seem to carry no risk to the recipients who are immune to HBV. Even cadaveric donors with HBsAg-positivity and unknown HBeAg/HBV DNA status can be used with caution in selected recipients without significantly affecting graft and patient outcome.

Pre-emptive renal transplantation in children

BACKGROUND

Renal transplantation is a definitive therapeutic modality in end-stage renal disease (ESRD). Most ESRD patients in Japan experience dialysis prior to renal transplantation. The present study was undertaken to examine the usefulness of pre-emptive renal transplantation (PET).

METHODS

Between 1987 and 1998, 255 renal transplantations were carried out by the authors. Among those consecutive cases, 10 were cases of PET. In nine pediatric cases, demographics, graft and patient survival, height growth and benefits from successful transplantation were studied and compared with age-matched dialyzed transplantation controls.

RESULTS

All transplantation was living-related. There was a disparity of causes of ESRD between the two groups. In PET, acquired renal deterioration due to a congenital lower urinary tract disorder was the major cause. Graft and patient prognosis was favorable in both groups. Growth retardation in PET patients under 15 years of age was significantly less apparent at the time of transplantation and after 3 years compared to the control. The benefits from transplantation were different in the two groups. Most PET patients felt an improvement of their physical condition; however, all of the control patients felt that the major boon was the freedom from the restriction of the daily diet and time for dialysis.

CONCLUSION

In pediatric renal transplantation, short-term preceding dialysis does not have a detrimental effect, but PET could benefit ESRD patients by maintaining their quality of life. Moreover, PET minimizes the production of renal dwarfism in prepubertal children. Thus, PET should be taken into consideration in the choice of renal replacement therapy.