Kidney transplantation in children.

Kidney transplantation (KTx) is the ttt (treatment) of choice for children with ESRD owing to its superior ptn survival rate as compared to maintainan

 

General principles Kidney transplantation in children.

Allograft - Renal transplantation

Kidney transplantation (KTx) is the ttt (treatment) of choice for children with ESRD owing to its

superior ptn survival rate as compared to maintainance DX. Moreover, it provides a better growth & developmental outcomes.

The most common cause of ESKD in pediatrics undergoing KTx is congenital anomalies of the kidney & UT (40 %), followed by glomerulopathies (25 %) & hereditary/genetic kidney disorders (15 %), FSGS in black ptns in particular. It still uncertain if preemptive KTx can provide better long-term outcome in comparison to Tx while maintained on DX, children frequently undergo preemptive Tx, in which Tx is the 1^st module of therapy for ESKD. This approach most commonly include a living donor who is highly related to the recipient. It happened mostly in children than adults as parents’ & patients’ desire to avoid DX with an available living donation.

 

One preferable approach is to offer preemptive KTx to suitable Tx recipient if there is a readily available living donor. If there’s NOT an available living donor, ptn should be placed on the deceased donor waitlist in a trial they may find a Tx before the need for DX. There’re few CI (contraindications) for KTx as the best modality for RRT in pediatric ESRD. They include:

1)    Evident sepsis,

2)    Uncontrolled extra renal Cancer,

3)    Irreversible MOF (multiorgan damage),

4)    Intense cardiac/pulmonary malfunction not corrected by organ tx,

5)    Underlying life-threatening disease cannot corrected by KTx,

6)    High levels of anti-glomerular BM AB disease, &

7)    Past history of non-compliance to medical care advice.

Allograft survival is much superior with living donor vs deceased donor grafts.  

 

Pre-tx evaluation is a key element for successful transplant in pediatrics:  

1)    Detection of donor HLA AB

2)    Correction of any associated UT abnormality

3)    Detection & ttt of any infection before Tx.

4)    Completion of ALL current pediatric immunizations

5)    Recognition of Nc (nephrectomy) benefits on the long-run.

 

PATIENT SURVIVAL 👉

Ptn survival is better in pediatric KTx recipients than in adults, and mortality has decreased in recent years. Centers from US and other countries reported similar results of improved ptn MR in young children. Survival with a functioning graft in children receiving 1^st KTx has been also elevated. In US, survival rate with a functioning graft in children received 1^st renal allograft from 1990-2010 was 82 % over 8.4 ys. Mortality (MR) still higher for infants as compared to older children. An illustration provided by the 3-y survival rates of the NAPRTCS database children registry who transplanted 1996-2013:

Living donor: 👉

1)    AL: ptns: 98 %

2)    Ptns ≤1 y of age: 96 %

3)    Ptns: 2-5 ys of age: 98 %

4)    Ptns: 6-12 ys of age: 98 %

5)    Ptns >12 ys of age: 98 %

Deceased donor: 👉

1)    All ptns: 98 %

2)    Ptns ≤1 y of age: 95 %

3)    Ptns: 2-5 ys of age: 96 %

4)    Ptns: 6-12 years of age: 99 %

5)    Ptns >12 ys of age: 98 %

As seen in adults, survival is 👍 superior in pediatrics with KTx compared to ptns maintained on DX. Observational study: 6000 ptns < 19 ys placed on KTx waiting list. Compared with ptns still on the list, a significant lower MR was observed in ptns commenced tx (13.1 vs 17.6 deaths/1000 ptn-ys). Survival benefit has been observed 6 mo post-tx. Generally, major causes of MR include CVS, infection, & malignancy. Major causes of death within 1^st 3 mo are infection (mainly CMV) & bleeding. However, incidence of cancer & CVS are less than those in adults. Non-renal findings of the underlying disease may have an impact upon child survival.

 

CHILD GROWTH AFTER KIDNEY TRANSPLANTATION

Although most children have improved statural growth after successful KTx; about 50% would achieve normal height. Factors accompanied with perfect catch-up growth include:

1)      Living donation KTx.

2)      Steroid-free im/m. regimen,

3)      Young aged recipient (<6 ys), &

4)      Excellent graft function at time of Tx (normal/near normal GFR),  

-       GH therapy: Recombinant growth hormone therapy may be beneficial in enhancing growth in a pre-pubertal child with growth retardation after KTx.