Native nephrectomy prior to pediatric kidney transplantation: biological and clinical aspects

Assisted single port bilateral nephrectomy for management of refractory hypertension: A case report

INTRODUCTION AND IMPORTANCE

In children, refractory hypertension presents a complex medical challenge that is, characterized by consistently high blood pressure levels despite the administration of numerous antihypertensive drugs. Bilateral nephrectomy has been reported as a potential treatment option for children with refractory hypertension who have not responded to medical management.

CASE PRESENTATION

In this report, we describe the outcomes of an assisted single-port laparoscopic bilateral nephrectomy in a 7-year-old girl with refractory hypertension after other treatment modalities had been exhausted.

CLINICAL DISCUSSION

Single-port laparoscopic surgery is a minimally invasive technique with potential benefits, including shorter recovery times and improved cosmetic outcomes, which are especially relevant in pediatric patients.

CONCLUSION

This case report demonstrates the successful use of single-port laparoscopic bilateral nephrectomy as a treatment for refractory hypertension in pediatric patients.

Features of Kidney Transplant in Pediatric Recipients: Experience of a Single Center

OBJECTIVES

Congenital abnormalities of the kidneys and the urinary tract are common reasons for endstage renal disease in children. We studied the features of postoperative management and possible complications after pediatric kidney transplant.

MATERIALS AND METHODS

We retrospectively analyzed 29 children aged from 9 to 18 years who underwent kidney transplants from April 2018 to December 2013 (17 boys and 12 girls). All recipients were on hemodialysis for 3 to 18 months (mean of 10.17 ± 4.52 mo). Etiology of end-stage kidney disease included chronic glomerulonephritis (n = 12 [41.4%]), urolithiasis (n = 3 [10.3%]), and congenital abnormalities of the kidneys and the urinary tract (n =14 [48.3%]), including urinary reflux (n = 5 [17.2%]). Donors were parents in 16 cases, siblings in 5, uncles in 5, and aunts in 3 cases. HLA mismatching ranged from 2 to 5 (mean of 2.93 ± 1.39). Three patients had intraoperative nephrectomy, and 2 patients had hydronephrosis and urethroplasty with megaureter to prevent urinary tract infection.

RESULTS

Six patients (20.6%) had early postoperative complications: 2 with delayed graft function, 1 with venous anastomosis thrombosis, 2 with hematoma around the graft, and 1 with lymphocele. Venous anastomosis thrombosis was eliminated by open thrombectomy, with graft function restored on postoperative day 17. The lymphocele was eliminated by puncture and drainage. Hematomas did not require surgical correction and blood transfusion. Ten patients (34.4%) had late postoperative complications: 1 with stricture of vesicoureteral anastomosis, 3 with vesicoureteral reflux, and 5 with urinary tract infection (3 with bacterial culture). Stricture of vesicoureteral anastomosis was successfully resolved by open surgery. Vesicoureteral reflux was eliminated with hydrogel. One patient developed chronic kidney rejection within 6 months because of noncompliance with posttransplant regimen and required transplantectomy.

CONCLUSIONS

A major factor in reducing frequency of infections after surgery is the recipient's nephrectomy.

[Kidney transplantation in children with complex urogenital malformations-what should be considered?]

BACKGROUND

Congenital anomalies of the kidneys and urinary tract (CAKUT) are the most common cause of end-stage renal disease (ESRD) in children. Approximately one third of children with CAKUT have lower urinary tract dysfunction (LUTD).

AIM

This article highlights the important aspects that need to be considered in kidney transplantation of children with complex urogenital malformations.

MATERIALS AND METHODS

The paper reviews the existing literature regarding the evaluation, preparation, perioperative management, and follow-up of children with complex urogenital malformations and ESRD undergoing renal transplantation.

RESULTS

Comprehensive diagnostics are required before any pediatric kidney transplantation. If LUTD is suspected, voiding cystourethrography and a urodynamic examination should be performed. Treatment of symptomatic vesicoureterorenal reflux and LUTD is mandatory prior to pediatric kidney transplantation. Following successful kidney transplantation of children with congenital urogenital malformations, lifelong follow-up is required. Regular reevaluations of the bladder by means of urodynamic examinations are necessary. In patients following bladder augmentation with intestinal segments or urinary diversions in childhood, regular endoscopic examinations of the urinary tract are recommended to rule out secondary malignancy.

CONCLUSION

Treatment of children with complex urogenital malformations should be carried out in centers with appropriate expertise.

Native nephrectomy in advanced pediatric kidney disease: indications, timing, and surgical approaches

In pediatric kidney failure, native kidneys may pose a risk to successful transplant outcomes. The indications and timing of native nephrectomy represent a controversial management decision. A lack of high-quality, outcomes-based data has prevented development of evidence-based guidelines for intervention. In this article, we review the published literature on medical indications for native nephrectomy and current knowledge gaps. In addition, we provide a surgical perspective regarding timing and approach.

Hospital admissions associated with dehydration in childhood kidney transplantation

BACKGROUND

Paediatric kidney transplant recipients may be at a particular risk of dehydration due to poor kidney concentrating capacity and illness associated with poor fluid intake or losses. In this population, creatinine rise may be more likely with relatively mild dehydration, which may trigger hospital admission. This study describes hospital admissions in the first 12 months after transplantation with diagnosis of graft dysfunction associated with dehydration due to illness or poor fluid intake. We assess risk factors for these admissions.

METHODS

Data was extracted from medical records of patients transplanted in two tertiary children hospitals. Following descriptive analysis, multiple failure regression analyses were used to identify factors associated with admission for acute kidney allograft dysfunction associated with dehydration.

RESULTS

Of 92 children, 42% had at least 1 dehydration admission in the 12 months following transplantation. Almost half of the dehydration admissions were due to poor fluid intake, which accounted for 1/5 of all unplanned hospital admissions. Target fluid intake at first discharge of > 100 ml/kg/day was associated with dehydration admissions of all types (hazard ratio (HR) 2.04 (95% CI 1.13-3.68)). Teen age was associated with poor fluid intake dehydration admissions (HR 4.87 (95% CI 1.19-19.86)), which were more frequent in mid-summer. Use of enteric feeding tube, which correlated with age under 4, associated with contributing illness dehydration admissions (HR 2.18 (95% CI 1.08-4.41)).

CONCLUSIONS

Dehydration admissions in the 12 months following childhood kidney transplantation are common. Highlighted admission risk factors should prompt further study into optimal fluid intake prescription and hydration advice given to children, teenagers, and their carers following kidney transplantation. Use of an enteric feeding tube may not protect patients from admission with dehydration associated with contributing illness. A highger resolution version of the Graphical abstract is available as Supplementary information.

Shift from severe hypotension to salt-dependent hypertension in a child with autosomal recessive polycystic kidney disease after bilateral nephrectomies: a case report

BACKGROUND

Autosomal recessive polycystic kidney disease (ARPKD) is a significant cause of morbidity and mortality in infants and children. In severe cases bilateral nephrectomies are considered but may be associated with significant neurological complications and life-threatening hypotension.

CASE PRESENTATION

We describe a case of a 17 months old boy with genetically confirmed ARPKD who underwent sequential bilateral nephrectomies at the age of 4 and 10 months. Following the second nephrectomy the boy was started on continuous cycling peritoneal dialysis with blood pressure on the lower range. At the age of 12 months after a few days of poor feeding at home the boy experienced a severe episode of hypotension and coma of Glasgow Come Scale of three. Brain magnetic-resonance imaging (MRI) showed signs of hemorrhage, cytotoxic cerebral edema and diffuse cerebral atrophy. During the subsequent 72 h he developed seizures requiring anti-epileptic drug therapy, gradually regained consciousness but remained significantly hypotensive after discontinuation of vasopressors. Thus, he received high doses of sodium chloride orally and intraperitoneally as well as midodrine hydrochloride. His ultrafiltration (UF) was targeted to keep him in mild-to-moderate fluid overload. After two months of stable condition the patient started to develop hypertension requiring four antihypertensive medications. After optimizing peritoneal dialysis to avoid fluid overload and discontinuation of sodium chloride the antihypertensives were discontinued, but hyponatremia with hypotensive episodes reoccurred. Sodium chloride was reintroduced resulting in recurrent salt-dependent hypertension.

CONCLUSIONS

Our case report illustrates an unusual course of blood pressure changes following bilateral nephrectomies in an infant with ARPKD and the particular importance of tight regulation of sodium chloride supplementation. The case adds to the scarce literature about clinical sequences of bilateral nephrectomies in infants, and as well highlights the challenge of managing blood pressure in these patients. Further research on the mechanisms and management of blood pressure control is clearly needed.

Renal transplantation in pediatric recipients: Considerations and preoperative assessment strategies

INTRODUCTION AND OBJECTIVE

Renal transplantation in the pediatric population differs from adults in many aspects. This review will focus on the unique issues of the pediatric recipient.

MATERIAL AND METHODS

A narrative review on the scarce literature regarding preoperative evaluation before kidney transplantation of the paediatric recipient with an educational focus was conducted. The literature search allowed for identification of publications in English from January 2000 to October 2022. Published studies were identified by searching the following electronic databases: PubMed (MEDLINE), WHO/UNAIDS, Google-Scholar, Semantic-Scholar and Research Gate. For efficiency and reliability, recent randomized controlled trials, meta-analyses, high quality systematic reviews and large well-designed studies were used if available. Internet searches were conducted for other relevant information (definitions, policies or guidelines).

RESULTS

Management of congenital urogenital anomalies and lower urinary tract dysfunction along with optimal pediatric urological preoperative assessment for renal transplantation in children is addressed in the light of the available literature. Furthermore, particular considerations including pre-emptive transplantation, transplantation of an adult-size kidney into an infant or small child is discussed.

CONCLUSIONS

Outcomes of RT in children have shown progressive improvement over the past 15 years. Transplantation with living related donor gives the best results and pre-emptive transplantation provides with benefits of avoiding dialysis. Surgical and medical considerations in both the pre-transplant and post-transplant management of the pediatric kidney recipient are extremely crucial in order to achieve better short and long-term results.

Paediatric kidney transplantation: Towards a framework for pretransplant urological evaluation

The role of the urologist in paediatric kidney transplantation has evolved alongside advances in management for the various causes of end-stage kidney disease. Improvements in antenatal intervention and postnatal care have seen children with increasingly complex urological anomalies survive until transplant. Once solely responsible for the oversight of a child's surgical care, the paediatric urologist now works within a multidisciplinary transplant team, alongside transplant surgeons, paediatric nephrologists, transplant coordinators, psychologists, social workers, and transitional care specialists. We sought to identify available pretransplant evaluation frameworks to guide urological preparation and decision-making. Drawing from available evidence and reflecting on multi-institutional experience, we propose a streamlined approach to urologic assessment, which recognises that optimal transplant outcomes in this heterogenous cohort require lower urinary tract dysfunction to be carefully defined preoperatively.

MEDIUM AND LONG-TERM CLINICAL OUTCOMES OF KIDNEY TRANSPLANTATION IN PATIENTS WITH PRUNE BELLY SYNDROME: A SINGLE-CENTRE EXPERIENCE

OBJECTIVES

To present the medium and long-term outcomes of kidney transplantation performed in patients with Prune Belly Syndrome (PBS) which is one of the congenital anomalies of the kidney and urinary tract (CAKUT).

METHODS

Thirteen kidney transplantations were performed in nine patients with PBS from January 1994 to December 2020. Demographics, surgical features, graft and patient survival rates were analysed. Survival outcomes was compared with 106 age- and donor-type matched controls who underwent transplantation because of non-urological causes.

RESULTS

The median ages of PBS patients at the time of first and second transplantation were 19 and 34 years old, respectively. One patient had postoperative Clavien grade 3a complication. Eight of 13 transplants are still functional at the last follow-up. Eight patients underwent pre-transplant urological operations in preparation for kidney transplantation, while four patients underwent urological operations in the post-transplant period. Graft survival for PBS transplants at 5, 10 and 15 years were 90.9%, 57.7% and 38.5%, respectively. Graft survival for control cohort at 5, 10 and 15 years were 89.9%, 80% and 74%, respectively. The patient and graft survival rates were similar between PBS and control groups (p=0.449, p=0.134, respectively).

CONCLUSION

This single-centre study showed that the medium term graft survival rates in patients with PBS are encouraging and comparible to non-CAKUT transplant patients, however long-term graft survival rates were found to be proportionally inferior. To help determine the reasons for long-term transplant kidney function deterioration and how to improve them we suggest that multi-centre international collaboration will be needed.

Pearls and Pitfalls in Pediatric Kidney Transplantation After 5 Decades

Worldwide, over 1,300 pediatric kidney transplantations are performed every year. Since the first transplantation in 1959, healthcare has evolved dramatically. Pre-emptive transplantations with grafts from living donors have become more common. Despite a subsequent improvement in graft survival, there are still challenges to face. This study attempts to summarize how our understanding of pediatric kidney transplantation has developed and improved since its beginnings, whilst also highlighting those areas where future research should concentrate in order to help resolve as yet unanswered questions. Existing literature was compared to our own data of 411 single-center pediatric kidney transplantations between 1968 and 2020, in order to find discrepancies and allow identification of future challenges. Important issues for future care are innovations in immunosuppressive medication, improving medication adherence, careful donor selection with regard to characteristics of both donor and recipient, improvement of surgical techniques and increased attention for lower urinary tract dysfunction and voiding behavior in all patients.

Impact of native nephrectomy on hypertension outcomes in pediatric kidney transplant recipients: a 10-year institutional experience

OBJECTIVE

To assess the role native nephrectomy (NN) in hypertension-related outcomes for pediatric patients undergoing renal transplantation (RT).

METHODS

Renal transplants (RT) performed at our institution between 2006 and 2015 were reviewed. RT recipients who underwent NN were compared to those who did not. Primary outcomes were hypertension-related: use/number of medications pre-/post-transplant and hypertension-related readmissions. Secondary outcomes were 1-year outcomes of: readmissions, eGFR, Clavien-Dindo classification ≥ 3 complications, and graft loss.

RESULTS

135 patients were evaluated. 24 underwent NN (Group 1) and 111 did not (Group 2). Baseline characteristics were similar between Groups 1 and 2. The majority of NN indications were hypertension (10/39 kidneys) and proteinuria (12/39 kidneys). There were no differences in use/number of anti-hypertensive medications pre- or post-transplant. However, between Group 2 and subgroup of patients who underwent NN for hypertension, a significant difference was seen in medication use/numbers but not post-transplant. Number of readmissions due to hypertension was similar (7.2% vs. 12.5%). The only difference in secondary outcomes was higher readmission rates with bacterial infections for group 1 (45.8% vs. 23.4%, p = 0.041).

CONCLUSION

NN, when offered to patients at higher risk of post-RT hypertension, may allow high-risk patients to achieve similar hypertension outcomes as those at lower risk.

Surgical considerations in paediatric kidney transplantation: an update

Background

Kidney transplantation has established itself as the most appropriate mode of renal replacement therapy for the majority with end-stage kidney disease. Although at present this is applicable for children as well as adults, a few decades back kidney transplantation was not considered a first-line option in children. This was due to inferior outcomes following transplantation in this age group compared to that of adults. These poor results were attributed to challenges in paediatric transplantation such as the shortage of suitable donors, technical difficulties in performing a sound vascular anastomosis and the adverse effects of immunosuppressive medication on growth and development. However, current patient and graft-centred outcomes after paediatric transplantation equal or surpass that of adults. The advances in evaluation and management of specific surgical concerns in children who undergo transplantation, such as pre-transplant native nephrectomy, correction of congenital anomalies of the urinary tract, placement of an adult-sized kidney in a small child and minimizing the risk of allograft thrombosis, have contributed immensely for these remarkable outcomes.

Conclusions

In this review, we aim to discuss surgical factors that can be considered unique for children undergoing kidney transplantation. We believe that an updated knowledge on these issues will be invaluable for transplant clinicians, who are dealing with paediatric kidney transplantation.

Timing of native nephrectomy and kidney transplant outcomes in children

BACKGROUND

No consensus exists on the optimal timing for native nephrectomy in pediatric kidney transplant recipients. Data comparing outcomes between recipients undergoing pretransplant nephrectomy (staged nephrectomy with subsequent transplant) and those undergoing nephrectomy simultaneously with the transplant are lacking.

METHOD

We studied 32 pediatric kidney transplant recipients who underwent native nephrectomy at a single center from 01/01/2011 to 12/31/2016. We divided recipients into two groups based on the nephrectomy timing (simultaneous nephrectomy/transplant and staged nephrectomy). We used Wilcoxon rank-sum test, Fisher's exact test, and Kaplan-Meier methods to compare outcomes.

RESULTS

Of 32 recipients, 20 underwent simultaneous and 12 underwent staged nephrectomy. Simultaneous recipients were younger (median (years): 2.0 vs 7.0; P = .049). Staged recipients were more likely to have proteinuria/hypoalbuminemia, whereas simultaneous recipients were more likely to have hydronephrosis/vesicoureteral reflux/urinary infections as nephrectomy indications (P = .06). Median prenephrectomy albumin for patients with nephrotic syndrome was significantly lower in staged recipients (median g/dL: 1.9 vs 3.8; P = .02). Total number of hospital days (including both procedures) was higher for staged recipients compared with simultaneous (one procedure) recipients (median (days): 17.0 vs 11.5; P = .05). We observed no difference in 5-year graft survival between the groups (95.0% vs 91.7%, P = .73). Patient survival was 100% in both groups over a median follow-up of 44.2 months. Surgical complications were similar between the groups.

CONCLUSION

Staged and simultaneous native nephrectomy in pediatric kidney transplant recipients are associated with comparable outcomes.

Minimal-invasive management of urological complications after kidney transplantation

Kidney transplantation represents the gold standard treatment option for patients with end-stage renal disease. Improvements in surgical technique and pharmacologic treatment have continuously prolonged allograft survival in recent years. However, urological complications are frequently observed, leading to both postoperative morbidity and putative deterioration of allograft function. While open redo surgery in these patients is often accompanied by elevated surgical risk, endoscopic management of urological complications is an alternative, minimal-invasive option. In the present article, we reviewed the literature on relevant urological postoperative complications after kidney transplantation and describe preventive approaches during the pre-transplantation assessment and their management using minimal-invasive approaches.

Preparing for a kidney transplant: Medical nephrectomy in children with nephrotic syndrome

Nephrotic syndrome is characterized by proteinuria, hypoalbuminemia, and general edema. These symptoms may persist in children who reach ESRD, which is unfavorable for the patient's allograft outcome. In addition, this may hamper early diagnosis of a relapse after transplantation. Surgical bilateral nephrectomy is often considered for that reason, but medical nephrectomy may be a less invasive alternative. In this retrospective single-center case series, we identified all children on dialysis with ESRD due to nephrotic syndrome in which a medical nephrectomy was attempted before kidney transplantation between 2013 and 2018. Outcome was measured by urine output and serum albumin levels. Eight patients with either congenital nephrotic syndrome or focal segmental glomerular sclerosis were included in the study. All patients received an ACE inhibitor as drug of first choice for medical nephrectomy, to which 5 patients responded with oligoanuria and a significant rise in serum albumin, and 3 patients responded insufficiently. In 1 of these 3 patients, diclofenac was added to the ACE inhibitor, with good result. In the other 2 patients, indomethacin was initiated without success, and surgical bilateral nephrectomy was performed. Overall, 6/8 patients had a successful medical nephrectomy and did not need surgical nephrectomy. No recurrence of nephrotic syndrome was found after kidney transplantation in all but one. Medical nephrectomy with ACE inhibitors and/or non-steroidal anti-inflammatory drugs is a safe and non-invasive therapy to minimize proteinuria in children with ESRD due to nephrotic syndrome before kidney transplantation. We suggest that this strategy should be considered as therapy before proceeding with surgical nephrectomy.

KDIGO Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation

The 2020 Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation is intended to assist health care professionals worldwide who evaluate and manage potential candidates for deceased or living donor kidney transplantation. This guideline addresses general candidacy issues such as access to transplantation, patient demographic and health status factors, and immunological and psychosocial assessment. The roles of various risk factors and comorbid conditions governing an individual's suitability for transplantation such as adherence, tobacco use, diabetes, obesity, perioperative issues, causes of kidney failure, infections, malignancy, pulmonary disease, cardiac and peripheral arterial disease, neurologic disease, gastrointestinal and liver disease, hematologic disease, and bone and mineral disorder are also addressed. This guideline provides recommendations for evaluation of individual aspects of a candidate's profile such that each risk factor and comorbidity are considered separately. The goal is to assist the clinical team to assimilate all data relevant to an individual, consider this within their local health context, and make an overall judgment on candidacy for transplantation. The guideline development process followed the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) approach. Guideline recommendations are primarily based on systematic reviews of relevant studies and our assessment of the quality of that evidence, and the strengths of recommendations are provided. Limitations of the evidence are discussed with differences from previous guidelines noted and suggestions for future research are also provided.

Diagnostic and Management Challenges in Congenital Nephrotic Syndrome

Congenital Nephrotic Syndrome (CNS) is defined as nephrotic range proteinuria, hypoalbuminaemia and edema in the first three months of life. CNS is most commonly genetic in cause, with international variance in the incidence of causative mutations. Initially defined by the histopathological appearance, increasingly sophisticated and accessible genetic analyses now provide a body of evidence to suggest that there is a disparity between the histological appearance, the genotype of individuals and the severity of the clinical disease. Through the evolution of management approaches CNS has changed from being an invariably fatal condition to one with appreciable ongoing morbidity and mortality but comparably good outcomes to other causes of paediatric end-stage renal disease, especially following transplantation. This review briefly summarises the more commonly recognised genetic mutations leading to CNS, addresses common management decisions, and concludes with potential therapies for the future.

Towards adulthood with a solitary kidney

Around 1/1000 people have a solitary kidney. Congenital conditions mainly include multicystic dysplastic kidney and unilateral renal aplasia/agenesis; acquired conditions are secondary to nephrectomy performed because of urologic structural abnormalities, severe parenchymal infection, renal trauma, and renal or pararenal tumors. Children born with congenital solitary kidney have a better long-term glomerular filtration rate than those with solitary kidney secondary to nephrectomy later in life. Acute and chronic adaptation processes lead to hyperfiltration followed by fibrosis in the remnant kidney, with further risk of albuminuria, arterial hypertension, and impaired renal function. Protective measures rely on non-pharmacological renoprotection (controlled protein and sodium intake, avoidance/limitation of nephrotoxic agents, keeping normal body mass index, and limitation of tobacco exposure). Lifelong monitoring should include blood pressure and albuminuria assessment, completed by glomerular filtration rate (GFR) estimation in case of abnormal values. In the absence of additional risk factors to solitary kidney, such assessment can be proposed every 5 years. There is no current consensus for indication and timing of pharmacological intervention.

Left lateral retroperitoneoscopic total nephrectomy of a horseshoe kidney in a 3-year-old boy

The unilateral or bilateral approach for nephrectomy in horseshoe kidney by minimally invasive surgery has been described. A total binephrectomy by a unilateral retroperitoneoscopic approach was performed for congenital nephrotic syndrome. A unilateral retroperitoneoscopic approach was planned in a 3-year-old boy (13 kg) with congenital nephrotic syndrome resistant to steroids with massive protein loss. The operative time was 160 min. The postoperative course was uneventful with continued hemodialysis until renal transplant 18 months later. The unilateral retroperitoneal approach allows total nephrectomy to be completed safely in horseshoe kidney for benign disease. The retroperitoneal access preserves the abdominal cavity, should peritoneal dialysis be required.

Superior Hypertension Management in Pediatric Kidney Transplant Patients After Native Nephrectomy

BACKGROUND

Native nephrectomy in pediatric kidney transplant recipients is performed for multiple indications. Posttransplant hypertension requiring medical management is common, and the effect of native nephrectomy on posttransplant hypertension is poorly studied. Our aim is to evaluate the impact of native nephrectomy on posttransplant hypertension.

METHODS

One hundred thirty-six consecutive pediatric kidney transplant recipients from 2007 to 2012 were studied at a single institution and divided into 2 groups: no nephrectomy and native nephrectomy (unilateral and bilateral nephrectomy). Antihypertensive medication use was evaluated before nephrectomy/transplant, at discharge from transplant and at 1, 3, and 5 years posttransplant.

RESULTS

In a bivariate analysis, nephrectomy was associated with a significant reduction in the percentage of patients requiring antihypertensive medication at the time of discharge (27.3%) and 1 year posttransplant (10.7%) as compared with patients without nephrectomy (71.7%, and 50%, respectively, P < 0.05). This trend toward reduction in antihypertensive medication in the nephrectomy group as compared with the no nephrectomy group persisted at 3 (18.6% versus 43.2%) and 5 years (19.7% versus 37.5%) posttransplant. Multivariable logistic regression demonstrated that patients without native nephrectomy had higher odds of requiring antihypertensive medication at the time of discharge (3.3) and 1 year (5.2) as compared with patients who underwent native nephrectomy (P = 0.036 and P = 0.013, respectively).

CONCLUSIONS

Native nephrectomy reduces the odds of needing antihypertensive medication after transplant. The impact of native nephrectomy is crucial to the comprehensive management of pediatric transplant recipients where medication compliance is challenging and lifelong hypertension is known to negatively impact cardiovascular health.

Special Considerations in Pediatric Kidney Transplantation

Universally accepted as the treatment of choice for children needing renal replacement therapy, kidney transplantation affords children the opportunity for an improved quality of life over dialysis therapy. Immunologic and surgical advances over the last 15 years have improved the pediatric patient and kidney graft survival. Unique to pediatrics, congenital genitourinary anomalies are the most common primary diseases leading to kidney failure, many with urological issues. Early urological evaluation for post-transplant bladder dysfunction and emphasis on immunization adherence are the mainstays of pediatric pretransplant and post-transplant evaluations. A child's height can be challenging, sometimes requiring an intra-abdominally placed graft, particularly if the patient is <20 kg. Maintenance immunosuppression regimens are similar to adult kidney graft recipients, although distinctive pharmacokinetics may change dosing intervals in children from twice a day to thrice a day. Viral infections and secondary malignancies are problematic for children relative to adults. Current trends to reduce/remove corticosteroid therapy from post-transplant protocols have produced improved linear growth with less steroid toxicity; although these studies are still ongoing, graft function and survival are considered acceptable. Finally, all children with a kidney transplant need a smooth transition to adult clinics. Future research in pertinent psychosocial aspects and continued technological advances will only serve to optimize the transition process. Although some aspects of kidney transplantation are similar in children and adults, for instance immunosuppression and immunosuppressive regimens, and rejection mechanisms and their diagnosis using the Banff criteria, there are important differences this review will focus on and which continue to drive innovation.

Pediatric kidney transplantation

Since first performed in 1954, kidney transplantation has evolved as the preferred long-term treatment of children with end stage renal disease (ESRD). The etiology of chronic kidney disease (CKD) and ESRD in children is broad and can be quite complicated, necessitating a multidisciplinary team to adequately care for these patients and their myriad needs. Precise surgical techniques and modern protocols for immunosuppression provide excellent long-term patient and graft survival. This article reviews the many etiologies of renal failure in the pediatric population focusing on those most commonly leading to the need for kidney transplantation. The processes of evaluation, kidney transplantation, short-term and long-term complications, as well as long-term outcomes are also reviewed.

Bilateral native nephrectomy reduces systemic oxalate level after combined liver-kidney transplant: A case report

Primary hyperoxaluria type 1 (PH1) is a rare liver enzymatic defect that causes overproduction of plasma oxalate. Accumulation of oxalate in the kidney and subsequent renal failure are fatal to PH1 patients often in pediatric age. Combined liver and kidney transplantation is the therapy of choice for end-stage renal disease due to PH1. Levels of plasma oxalate remain elevated for several months after liver transplantation, as the residual body oxalate is slowly excreted. Patients with persistent hyperoxaluria after transplant often require hemodialysis, and accumulation of residual oxalate in the kidney can induce graft dysfunction. As the native kidneys are the main target of calcium oxalate accumulation, we postulated that removal of native kidneys could drastically decrease total body oxalate levels after transplantation. Here, we report a case of bilateral nephrectomy at the time of combined liver-kidney transplantation in a pediatric PH1 patient. Bilateral nephrectomy induced a rapid decrease in plasma oxalate to normal levels in less than 20 days, compared to the several months reported in the literature. Our results suggest that removal of native kidneys could be an effective strategy to decrease the need for hemodialysis and the risk of renal dysfunction after combined liver-kidney transplantation in patients with PH1.

Comparison of Native Ureteral Ligation and Open Nephrectomy for Pediatric Renal Transplantation

PURPOSE

In pediatric renal transplant recipients there are some indications for native nephrectomy, which can be performed before, during or after transplantation. Indications include massive proteinuria resistant to therapy, intractable hypertension, polyuria and chronic or recurrent kidney infections. Several scientific studies of adults have demonstrated a minimally invasive alternative to native nephrectomy, which consists of ligation of the native ureter without removing the kidney. We evaluated the safety and efficacy of this minimally invasive technique in pediatric recipients of renal transplantation.

MATERIALS AND METHODS

A total of 29 pediatric kidney transplant recipients underwent unilateral native ureteral ligation during renal transplantation between 2009 and 2013 (group A). In addition, a control group of 21 pediatric renal transplant recipients was enrolled who had undergone unilateral native nephrectomy between January 2005 and December 2008 (group B). Both groups were evaluated preoperatively by Doppler ultrasound of the native kidneys.

RESULTS

Statistical analysis of the 2 groups for the 3 main variables considered (surgical time, intraoperative blood loss and length of surgical scar) revealed a significant difference (Mann-Whitney U test, p <0.001). This finding confirmed the hypothesis that during renal transplantation ligation of the native ureter is less invasive than native nephrectomy.

CONCLUSIONS

Ligation of the native ureter without removal of the ipsilateral kidney is a feasible procedure in pediatric renal transplant recipients. This method is easy to perform and significantly less invasive than surgical nephrectomy.

Review of combined liver and kidney transplantation in children

In this review, we focused on CLKT with regard to indication, results, outcome, and future developments. PH1 is one of the most common diagnoses for adult and pediatric patients qualifying for CLKT. The other major indication for combined transplantation is ARPKD. CLKT appears to be superior to sequential liver and kidney transplantation in the majority of patients and overall results following CLKT are now good, even in small children. Clinical observations suggest that there is an immunological advantage of CLKT in comparison with isolated liver or kidney transplantation. More clinical studies are necessary to identify the best candidates for CLKT while the availability of donor organs is low.

Paradoxical increase in blood pressure following bilateral native nephrectomy

Hypertension with Chronic kidney disease is often difficult to control medically. In such patients, nephrectomy can help to control blood pressure (BP). We describe a case of a 6-year-old boy with autosomal recessive polycystic kidney disease who showed a paradoxical increase in BP following bilateral nephrectomy.

Association of Body Mass Index with Patient-Centered Outcomes in Children with ESRD

Obesity is associated with less access to transplantation among adults with ESRD. To examine the association between body mass index at ESRD onset and survival and transplantation in children, we performed a retrospective analysis of children ages 2-19 years old beginning RRT from 1995 to 2011 using the US Renal Data System. Among 13,172 children, prevalence of obesity increased from 14% to 18%, whereas prevalence of underweight decreased from 12% to 9% during this period. Over a median follow-up of 7.0 years, 10,004 children had at least one kidney transplant, and 1675 deaths occurred. Risk of death was higher in obese (hazard ratio [HR], 1.17; 95% confidence interval [95% CI], 1.03 to 1.32) and underweight (HR, 1.26; 95% CI, 1.09 to 1.47) children than children with normal body mass indices. Obese and underweight children were less likely to receive a kidney transplant (HR, 0.92; 95% CI, 0.87 to 0.97; HR, 0.83; 95% CI, 0.78 to 0.89, respectively). Obese children had lower odds of receiving a living donor transplant (odds ratio, 0.85; 95% CI, 0.74 to 0.98) if the transplant occurred within 18 months of ESRD onset. Adjustment for transplant in a time-dependent Cox model attenuated the higher risk of death in obese but not underweight children (HR, 1.09; 95% CI, 0.96 to 1.24). Lower rates of kidney transplantation may, therefore, mediate the higher risk of death in obese children with ESRD. The increasing prevalence of obesity among children starting RRT may impede kidney transplantation, especially from living donors.

Staged Hand-Assisted Bilateral Native Nephrectomy for Management of Posttransplant Polyuria in an Adult with Dent's Disease

Polyuria after kidney transplantation causes graft dysfunction and increased thrombotic risk. We present a case of a polyuric adult with Dent's disease who underwent staged bilateral native nephrectomies, the first operation before transplant and the second four months after transplant. This led to improved allograft function maintained during four years of follow-up. The retroperitoneal laparoscopic approach was well tolerated and allowed continuation of peritoneal dialysis before transplantation. A staged approach helps regulate fluid balance perioperatively and may be tailored to individual need according to posttransplant urine output. This novel approach should be considered for polyuric patients with tubular dysfunction including Dent's disease.

Renal transplantation in children with nephrotic syndrome in the first year of life

OBJECTIVE

The aim of this work was to analyze the evolution of the 1st renal transplantation in children with nephrotic syndrome in the 1st year of life (NSFL).

METHODS

In this retrospective study of 15 patients (8 women and 7 men) with NSFL receiving transplants from 1989 to 2013, 9 had NS of Finnish type, 4 diffuse mesangial sclerosis, 1 minimal changes, and 1 collapsing glomerulopathy. We analyzed the clinical and analytic situation at 4 time points: before dialysis, before transplantation, 3 months after transplantation, and long-term evolution.

RESULTS

Mean follow-up was 72.8 months (range, 1 month to 16.9 years); mean age at diagnosis was 2.21 months (range, 0-8.2 months); mean age at onset of replacement therapy was 22.9 ± 16.4 months (range, 3.8-55.4 months); and mean time on dialysis was 14.9 months (range, 2-44 months). Age at transplantation was 3.1 years (range, 1.8 to 7.7 years), with 6 living-donor transplantations (LDTs) and 9 cadaveric (CDTs). Ten patients required nephrectomy before transplantation (9 bilateral) to control proteinuria after 3.1 ± 3.8 months on dialysis, 1 during transplantation, and 3 after transplantation (2 persistent proteinuria, 1 hypertension). Mean time on dialysis for LDTs was 5.4 ± 2.7 months versus 13.2 ± 6.9 months for CDTs (P < .005). Mean age of cadaveric donors was 6.2 ± 2.4 years and that of living donors 35.5 ± 7.9 years. As complications, there was 1 bleeding from venous anastomosis and 1 urinary leakage after surgery. After 6 ± 5.2 years of evolution, actuarial survival at both 1 and 7 years was 92.9%. One graft was lost owing to acute rejection 1 month after transplantation and 2 others owing to chronic rejection >9 years after transplantation. None had disease recurrence.

CONCLUSIONS

Short-term complications did not differ from the rest of population if transplantation occurred with standard albumin levels, for which most required pre-transplantation nephrectomy because dialysis failed to reduce proteinuria.