Renal transplantation in children.
H Balaji, S Ballal, X Dominic, S Sunder, UN Talwalkar, K Siddaraju, KD Phadke
Bangalore Kidney Foundation.
Bangalore Kidney Foundation.
|How to cite this article:|
Balaji H, Ballal S, Dominic X, Sunder S, Talwalkar U N, Siddaraju K, Phadke K D. Renal transplantation in children. J Postgrad Med 1994;40:168-9
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Balaji H, Ballal S, Dominic X, Sunder S, Talwalkar U N, Siddaraju K, Phadke K D. Renal transplantation in children. J Postgrad Med [serial online] 1994 [cited 2020 Jul 2 ];40:168-9
Available from: http://www.jpgmonline.com/text.asp?1994/40/3/168/533
Children develop endstage renal disease (ESRD) at an annual rate of 0.5 to 5.5 1 million population. The best rehabilitation of uremic children can be achieved by renal transplantation. The aim of dialysis therefore is to bridge the period of terminal renal insufficiency until transplantation becomes possible.
In the last two decades, transplantation has advanced from an experimental procedure to become the principal goal of pediatric renal programs in the management of children with ESRD. In recent years, a lot of developments in the field of "Pediatric Nephrology" have taken place in our country. The priorities of Pediatric Nephrology" in our country by and large appear to include preventable aspects of Nephrology viz early diagnosis and proper management of urinary tract infections, improving facilities for treatment of acute renal failure and prevention of morbidity and mortality in childhood nephritic syndrome. At the same time, with recent advances in technology and availability of expertise, we should be able to manage children with ESRD and offer them renal transplantation. Because of the small number of transplantation surgeries performed annually at individual centres, data on the outcome of renal transplantation in children at individual centres are sparse.
There is a trend towards pooling of data in this regard e.g.: The Pediatric Registry of the European Dialysis and Transplant Association. The North American Pediatric Renal Transplant Cooperative Study etc. Our pooled experience of 'Pediatric Renal Transplantation" at Bangalore is presented. It is a mixed experience since some centres have been performing predominantly Live Unrelated Transplantation whereas some other centres do not undertake the same. The majority, as also very small children, have been predominantly done at selected centres only.
Over the last five years, thirtythree renal transplants were performed in Bangalore in children below 18 years of age, two being second transplants. Twentyfour were males and nine were females, Five children were below five years of age, nine between 5 10 years and 19 were between 1018 years. The weightwise distribution was 10 children between 1015 kg, 20 children between 1520 kg and 3 children > 25 kg. The kidney donor was the mother in 10 cases, father in 5 cases, brother in 2 cases, aunt in one case and an unrelated donor in the remaining 15cases. Seven children underwent preemptive renal transplantation. Others received intermittent peritoneal dialysis, haemodialysis or a combination of both or CAPD as the modality for dialysis preoperatively. Twentytwo children had underlying glomerular disease as the cause for ESRD the majority belonging to the older age group. Eleven children had tubulointerstitial disease as the cause for ESRD, the majority of them belonged to older age group. All recipients received at least three blood transfusions preoperatively. Bilateral native kidney nephrectomies were performed in nine cases.
A transperitoneal approach was used in smaller children weighing < 15 kg. Arterial anastomosis was performed to the aorta (end to side) in two cases and to the common iliac artery (endto side) or internal iliac artery (endtoend) in the remaining cases. Venous anastomosis was performed lo external iliac or common iliac vein (endtoside) except in one case where it was done to the inferior vena cava. Ureterovesical anastomosis was done using the modified LichGregoir technique. Meticulous monitoring of blood pressure central venous pressure and temperature was done intraoperatively. Blood (10 ml/ kg) was rapidly transfused before release of clamps. Triple immunosuppression (cyclosporine, azathioprine. steroids) was used in all except two cases who did notreceive cyclosporine. The dosage of CyA required was higher compared to their adult recipient counterpart. Azathioprine had to be discontinued in one case due to neutropenia. Acute rejection episodes diagnosis was based on clinical suspicion, elevation of serum creatinine, use of blood CyA levels (to exclude CyA nephrotoxirily), graft Doppler study. FNAC (Fine needle aspiration cytology of graft).
The rejections were treated with intravenous pulse methylprednisoione. The followup period ranged from 4 months 59 months with a mean followup of 22.8 months. Eight episodes of acute rejection were encountered (Two were related to noncompliance: acute withdrawal of cyclosporine). Two acute rejection episodes did not respond to antirejection treatment, the rest did. Two patients developed chronic rejection resulting in graft loss. Due to socio-economic reasons, graft loss and patient loss were one and the same. The other causes of patient mortality in the postoperative period included hypertensive ancephalopathy (3 cases, two in the first week and one after a month), hepatic encephalopathy (one month), ARDS (Ist postoperative day), cortical venous thrombosis (10 days) respiratory infections (3 months), fulminant gastroenteritis (one month). Recurrence of focal segmental glomerulosclerosis was seen in two cases (one week and six months after surgery). Both of them maintained their renal functions. (one year and two years followup). Ureteric leak was encountered in one patient requiring re-exploration. No other surgical complications including vascular thrombosis were encountered in our series.
More than ninety percent of the patients were hypertensive. One year graft and patient survival rate was 80.76%. There was no significant difference between live related (81.25%) and live unrelated (80%) transplants in he one year graft and patient survival. Two years graft and patient survival was 70%. Excellent rehabilitation was obtained. Most of the children with functioning grafts attended school or college. Growth in these children was disappointing. Younger patients had near normal growth acceleration although they did not exhibit catchup growth.
One year graft and patient survival in our series is acceptable although lower compared to other series,. Hypertension, a significant problem in pediatric allograft recipients, was present in most of our patients and was also responsible for increased morbidity and mortality in the postoperative period. Some centres routinely use cyclosporine monotherapy as the preferred form of immunosuppression except in those who have been highly sensitized by blood transfusions or those who have received more than one transplant where they resort to triple immunosuppression. We have however not yet made any attempt to discontinue steroids in any of our patients. From the literature, the response to Growth Hormone (GH) therapy in children with chronic renal failure before and after transplantation is very promising especially in terms of height velocity which increases significantly for all groups. However, due to its exorbitant cost, GH therapy cannot be considered for our patients at the present time. Pediatric transplantation especially for smaller children (< 15 kg) requires social acceptance, specialized services, meticulous approach and adequate infrastructure. Our study validates the concept of Pediatric Renal Transplantation as the optimal therapy for children with ESRD in our setup.
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