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
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 1st 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 1st KTx has been also elevated. In US, survival
rate with a functioning graft in children received 1st 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 1st 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.
COMMENTS