Pediatric Renal Transplantation: 13 Years of Experience—Report From The Chilean Cooperative Multicenter Group

Paediatric kidney transplantation in under-resourced regions-a panoramic view

Kidney transplantation is the ideal choice of kidney replacement therapy in children as it offers a low risk of mortality and a better quality of life. A wide variance in the access to kidney replacement therapies exists across the world with only 21% of low- and low-middle income countries (LLMIC) undertaking kidney transplantation. Pediatric kidney transplantation rates in these under-resourced regions are reported to be as low as < 4 pmcp [per million child population]. A robust kidney failure care program forms the cornerstone of a transplant program. Even the smallest transplant program entails a multidisciplinary workforce and expertise besides ensuring family commitment towards long-term care and economic burden. In general, the short-term graft survival rates from under-resourced regions are comparable to most high-income countries (HIC) and the challenge lies in the long-term outcomes. This review focuses on specific issues relevant to kidney transplants in children in under-resourced regions by highlighting limitations in the capacity and health workforce, regulatory norms, medical issues, economic burden, factors beyond financial hardship and ethical considerations relevant to these regions. Finally, the perspective of strengthening transplant programs in these regions should factor in the bigger challenges that exist in achieving the health-related sustainable development goals by 2030.

Ten-year appraisal of pediatric renal allograft biopsies: Points to ponder

There is paucity of literature on pediatric renal allograft biopsy (RAB) evaluation. We present RAB findings of pediatric renal transplantation (RT) and correlate with outcome. This is a 10-year retrospective study of diagnostic RAB of children <12 years divided in to three groups: Group 1 (n = 9): less than haplo-match living donor RT (LDRT), Group 2 (n = 32): greater than or equal to haplo-match LDRT, and Group 3 (n = 7): deceased donor RT. Demographics, biopsy findings, survival, and serum creatinine (SCr) were evaluated. Statistical analysis was performed using IBM SPSS Statistics version 20.0. The most common findings were antibody-mediated rejection (ABMR) observed in 77.7%, 45%, and 71.5% and T-cell-mediated rejections (TCMRs) in 33.3%, 52.5%, and 42.9% in Groups 1, 2, and 3, respectively. Recurrent oxalosis was seen in 5% in Group 2. Death-censored graft survival was 100% at 1 year and 43.8% from 5 to 9 years in Group 1; 93.5%, 76.6%, 56.5%, and 14.4% at 1, 5, 10, and 15 years in Group 2; 100% at one year; and 71.4% from 5 to 12 years in Group 3. No patient appeared after 9 years in Group 1 and after 12 years in Group 3. In Group 1, the mean SCr (mg/dL) was 1.06 ± 0.45, 2.12 ± 1.87, and 1.39 at 1, 5, and 9 years; 1.35 ± 0.97, 1.73 ± 1.15, and 2.49 ± 1.64 in Group 2; and 1.15 ± 1.24, 1.43 ± 0.1, and 1.18 ± 0.06, respectively, in Group 3 at 1, 5, and 10 years posttransplant. ABMR followed by TCMR was the most common injury in all the groups. Group 1 had more rejections than others.

Outcome and complications of living donor pediatric renal transplantation: Experience from a tertiary care center

Introduction:

We retrospectively reviewed the patient characteristics, outcome, and complications of renal transplantation in pediatric age group performed at our center and compared the results with various centers in India and other developed countries.

Materials and Methods:

Patients younger than eighteen years of age who underwent renal transplantation from 2003 to 2014 at our institute were reviewed. Demographic data of the transplant recipients and donors, etiology of ESRD, mode of dialysis, surgical details of renal transplantation, immunosuppression, medical and surgical complications, and post-transplant follow-up were assessed. Graft survival was determined at 1, 3 and 5 years post-transplant. All data collected were entered into Microsoft excel program and analyzed using SPSS 20. Kaplan–Meier method was applied to determine the graft survival at 1, 3, and 5 years. The log-rank test was applied to test the statistical significance of the difference in survival between groups.

Results:

Thirty-two children underwent transplantation comprising of 18 females and 14 males. The mean age was 14.5 years (range 10–17 years). The primary cause of renal failure was glomerular diseases in 53% (17/32) of patients. Seventeen postsurgical complications were noted in our series. Two grafts were lost over a follow-up of 5 years. The 1, 3, and 5 year graft survival rates were 96.7%, 92.9%, and 85%, respectively. There was no mortality.

Conclusion:

The etiology of ESRD in our region is different from that of developed countries. The mean age at which children undergo renal transplantation is higher. Graft survival at our center is comparable to that of developed nations. Renal transplantation can be safely performed in children with ESRD.

Kidney transplant in pediatric patients with severe bladder pathology

The aim of the current study was to compare results in pediatric renal transplantation of patients with and without SBP. Between 2001 and 2013, a total of 168 kidney transplants were performed at our center. A retrospective analysis was performed and recipients were divided into two groups: NB and SBP. Incidence of surgical complications after procedure, and graft and patient survival were evaluated. A total of 155 recipients (92%) with complete data were analyzed, and 13 recipients that had had previous bladder surgeries were excluded (11 with VUR surgery and two with previous kidney transplants), of the 155 recipients: 123 (79%) patients had NB, and 32 (21%) patients had SBP, with a median follow-up of 60 (1-137) and 52 (1-144) months, respectively. Among post-transplant complications, UTI (68.8% vs. 23%, p < 0.0001) and symptomatic VUR to the graft (40.6% vs. 7.3%, p < 0.0001) were significantly higher in the SBP group. There was no significant difference in overall graft and patient survival between groups. Renal transplantation is safe in pediatric recipients with SBP; however, urologic complications such as UTI and VUR were significantly higher in this group. Graft and patient survival was similar in SBP and NB groups.

The challenges and outcomes of living donor kidney transplantation in pediatric and adolescent age group in a developing country: A critical analysis from a single center of north India

Introduction:

Renal transplantation is the treatment of choice for children with end-stage renal disease (ESRD). We evaluated the outcome of renal transplantation in the pediatric and adolescent age groups in the perspective of a developing country as compared with developed nations while highlighting the challenges we have faced in a pediatric transplant programme.

Materials and Methods:

Seventy live related pediatric and adolescent renal transplantations were reviewed retrospectively. Variables analyzed were etiology of ESRD, pre-transplant renal replacement modality, donor relationship, surgical complications, rejection episodes, immuno-suppression regimens, compliance to immunosuppression, graft survival and overall survival.

Results:

The cohort consisted of 13 (18%) female and 57 male (82%) recipients. The mean age was 14 ± 1.4 years. The etiology of ESRD was chronic glomerulonephritis (n = 43), chronic interstitial nephritis (n = 26) and Alport's syndrome (n = 1). Fifty-six (80%) children were on hemo-dialysis and 10 (14%) on peritoneal dialysis prior to transplantation. 80.5% and 61% patients were strictly compliant to immunosuppresant medications at 1 and 5 years. The 1, 3 and 5 year graft survival rates were 94.3%, 89.2% and 66.8%, respectively. The overall survival rates were 95.7%, 96.4% and 94.1% for 1, 3 and 5 years, respectively.

Conclusions:

The spectrum of etiology of ESRD differs in our patients from the west, with chronic glomerulonephritis being the most common etiology. Early graft survival is comparable, but the 5-year graft survival is clearly inferior as compared with developed countries.

Pediatric kidney transplantation in the developing world: challenges and solutions

The prevalence of pediatric RRT and transplantation are low in developing countries, 6-12 and <1 to 5 per million child population (pmcp), respectively. This is due to low GDP/capita of <$10 000, government expenditure on health of <2.6-9% of GDP and paucity of facilities. The reported incidence of pediatric CKD and ESRD is <1.0-8 and 3.4-35 pmcp, respectively. RRT and transplantation are offered mostly in private centers in cities where HD costs $20-100/session and transplants $10 000-20 000. High costs and long distance to centers results in treatment refusal in up to 35% of the cases. In this backdrop 75-85% of children with ESRD are disfranchised from RRT and transplantation. Our center initiated an integrated dialysis-transplant program funded by a community-government partnership where RRT and transplantation was provided "free of cost" with life long follow-up and medication. Access to free RRT at doorsteps and transplantation lead to societal acceptance of transplantation as the therapy of choice for ESRD. This enabled us to perform 475 pediatric transplants in 25 years with 1- and 5-year graft survival of 96% and 81%, respectively. Our model shows that pediatric transplantation is possible in developing countries when freely available and accessible to all who need it in the public sector.

Early outcome in renal transplantation from large donors to small and size-matched recipients - a porcine experimental model

Kidney transplantation from a large donor to a small recipient, as in pediatric transplantation, is associated with an increased risk of thrombosis and DGF. We established a porcine model for renal transplantation from an adult donor to a small or size-matched recipient with a high risk of DGF and studied GFR, RPP using MRI, and markers of kidney injury within 10 h after transplantation. After induction of BD, kidneys were removed from ∼63-kg donors and kept in cold storage for ∼22 h until transplanted into small (∼15 kg, n = 8) or size-matched (n = 8) recipients. A reduction in GFR was observed in small recipients within 60 min after reperfusion. Interestingly, this was associated with a significant reduction in medullary RPP, while there was no significant change in the size-matched recipients. No difference was observed in urinary NGAL excretion between the groups. A significant higher level of HO-1 mRNA was observed in small recipients than in donors and size-matched recipients indicating cortical injury. Improvement in early graft perfusion may be a goal to improve short- and long-term GFR and avoid graft thrombosis in pediatric recipients.

Early steroid withdrawal in pediatric renal transplant: five years of follow-up

This prospective, comparative trial investigated the impact on mean change in height standard deviation score (SDS), acute rejection rate, and renal function of early steroid withdrawal in 96 recipients with 5 years of follow-up. Recipients under basiliximab induction and steroid withdrawal (SW: TAC/MMF; n = 55) were compared with a matched steroid control group (SC: TAC/MMF/STEROID, n = 41). SW received steroids until Day 6, SC decreased to 10 mg/m(2) within 2 months post-transplant. Five years after SW, the longitudinal growth (SDS) gain was 1.4 ± 0.4 vs. 1.1 ± 0.3 for SC group (p < 0.02). Height benefits in prepubertal and pubertal status in both groups were demonstrated in the delta growth trends (mixed model; p < 0.01). Biopsy-proven acute rejection in SW was 11% and 17.5%, SC (p: ns). Mean eGFR (ml/min/1.73 m(2)) at 5 years post-transplant was SW 80.6 ± 27.8 vs. 82.6 ± 25.1 for SC (p: ns). The death-censored graft survival rate at 1 and 5 years was 99 and 90% for SW; 98 and 96% for SC (p = ns). PTLD incidence in SW 3.3 vs. 2.5% in SC (p: ns). Five years post-transplant, early steroid withdrawal showed positive impacts on growth, stable renal function without increased acute rejection risk, and PTLD incidence.

Outcome of renal transplantation in children: a multi-center national report from Iran

The outcome of pediatric renal transplantation was previously reported by a single-center study at the year 2006. Therefore, we aimed to evaluate and report the characteristics and outcome of renal pediatric renal transplantation in a multi-center nationwide study. In this nationwide report, medical records of 907 children (≤18yr) with renal transplantation in eight major pediatric transplant centers of Iran were recorded. These 907 patients received a total of 922 transplants. All children who failed to follow-up were excluded. Rather than baseline characteristics, graft and patient outcomes were considered for survival analysis. For further analysis, they were divided into two groups: patients who had graft survival time more than 10yr (n=91) and the ones with graft survival time of equal or less than 10yr (n=831). Of 922 recipients, 515 (55.8%) were boys and 407 (44.2%) were girls with the mean age of 13.10 (s.d.=3.54) yr. DGF and AR were occurred in 10% and 39.5% of the transplanted children, respectively. Transplantation year, dialyzing status before transplantation, DGF, and AR were significant enough to predict graft survival in cox regression model (overall model: p<0.001). Nowadays, there is a successful live donor pediatric renal transplantation in Iran. Graft survival has improved in our recipients and now the graft survival rates are near to international standards.

Latin American Registry of Pediatric Renal Transplantation 2004-2008

The Latin American Pediatric Nephrology Association (ALANEPE) reports the first regional kidney transplant registry in Latin America. A mean range of 75%, 30% to 100% renal transplant recipients under 21 yr old were included. Out of 20 countries invited to participate, 14 performed renal transplant, 11 had universal financial support from their governments. The centers included: Brazil (9), Argentina (4), Chile (4), Venezuela (3), Mexico (2), and one in: Cuba, Colombia, Costa Rica, Nicaragua, Guatemala, Ecuador, Honduras, Paraguay and Peru. The registry included 1458 patients, average of 291 per year, 55% male. Mean follow-up 23.4+/-17 months; mean age was 11.7+/-4.3 yr (1-21), 11% under five yr of age.

ETIOLOGY

uropathy/ reflux nephropathy 27%, glomerulopathies 24% (included 12% FSGS), hypo/dysplasia (11%), vascular (6%), congenital/hereditary (5%), unknown (19%). Induction therapy: 71% anti-IL2RAb, 13% ATG/TIMO, 14% non-induction. Maintenance therapy: Tacrolimus 64%, Cyclosporine 32%, MMF 54%, MPS 20%, noTORi 96%, steroids 90%, withdrawal or steroid avoidance 10%. Loss of graft 155/1458 (11%), death with functioning graft (3.4%), vascular thrombosis (2.8%), acute rejection (2.8%), recurrence of disease (1%). Forty-eight patients died (3.3%); infection was the main cause 23 (2.1%). Global patient survival rate at one, three, and five yr was 97%, 96%, and 96%. Graft survival rate at one, three, and five yr LRD was 96%, 93% and 89%; for DD 92%, 86% and 76% respectively. Both survival rates were higher in LRD (p<0.008 and p<0.001). A pediatric renal transplant study has started, making information available to be shared between the centers and the world.

Long-term outcome after renal transplantation in childhood

The purpose of this article is to review: 1. Factors influencing long-term outcome data after transplantation 2. Patient survival overall, the effect of recipient age and donor type, causes of death, comparison of mortality after transplantation with that on dialysis, and effect of pre-emptive transplantation and race 3. Transplant survival overall, and the effect of recipient and donor age, donor type, pre-emptive transplantation, recurrent diseases, human leukocyte antigen (HLA) matching, immunosuppression, concordance, hypertension, bladder dynamics and type of donor nephrectomy 4. Final height and obesity 5. Psycho-social outcome.

300 Pediatric Renal Transplantations: A Single-Center Experience

Our objective was to relate the results of 300 consecutive kidney transplants performed in children at a single center.

PATIENTS AND METHODS

An analysis of kidney transplants was performed on patients less than 18 years old engrafted from May 1977 to August 2005.

RESULTS

Among 300 kidney transplants, 48% of the patients were female, 87% were Caucasian, and 13% were African-Brazilian. The mean age at transplant was 11.5 +/- 4.5 years with 39 (13%) less than 6 years of age. The most frequent etiology of renal failure was vesicoureteral reflux/obstructive uropathy (36%) followed by glomerulopathy (27%). The donor was deceased in 32.3% and living related in 77.7% (parents 82%). The mean posttransplant follow-up was 4.8 +/- 4.3 years. The initial immunosuppression was CyA + AZA + PRED in 45%; CyA + MMF + PRED in 9.6%; TAC + AZA + PRED in 7.3%; TAC + MF + PRED in 9.7%; or TAC + MF without PRED in 10%. Sirolimus was employed initially in three cases. Induction with OKT3/ATG occurred in three patients and 112 received an anti-IL2 receptor antibody. The 103 graft losses during 28 years of follow-up were secondary to chronic allograft nephropathy in 51 (49.5%), vascular thrombosis in 5 (4.8%), acute rejection in 12 (11.6%), and recurrence of original disease in 13 (12.6%). Sixteen (15.5%) died with functioning grafts. Graft survival in the first, fifth, and tenth year were 90%, 72%, and 59%, respectively. Patient survival in the first, fifth, and tenth years were 95%, 93%, and 85%, respectively, with infection as the main cause of death.

Pediatric Renal Transplantation: Clinical Analysis of 28 Cases

We performed an outcome analysis of 28 pediatric renal transplant recipients whose mean age at transplantation was 15.2 +/- 2 years (range: 11 to 17 years) and the M/F ratio, 0.75. Four patients received cadaveric grafts. One patient needed retransplantation due to primary nonfunction. Mean HLA match was 3.6 (range: 3 to 5). Immunosuppression was cyclosporine (n = 13) or tacrolimus (n = 11) or sirolimus (n = 4), as well as steroids and azathioprine or mycophenolate mofetil. Delayed graft function occurred in four patients. The main complications were arterial hypertension (n = 11), anemia (n = 4), urinary tract infection (n = 10), hypercholesterolemia (n = 7), and cytomegalovirus infection (n = 1). An acute rejection episode (ARE) occurred in four patients. ARE and hypertension rates were similar between the immunosuppressive drug groups. All the patients with graft failure were on cyclosporine (P = .03). Hemodialysis and peritoneal dialysis (median duration: 6 months) were performed preoperatively in 25 and 3 patients, respectively. The length of pretransplant dialysis was longer among patients with graft failure (P > .05). Noncompliance (10.7%) resulted in an ARE in one patient and graft loss in two patients. One patient died with a functioning graft. Primary disease recurred in one patient. The median follow-up period was 44 months (range: 6 to 157 months). Mean serum creatinine level was 1.35 +/- 0.74 mg/dL at the last follow-up. One- and 3-year graft survival rates were 92% and 86%, respectively, and patient survival was 100%, each. Seventeen patients (60.7%) continued their education after the transplantation; six started working. Successful transplantation in the pediatric age group together with intensive rehabilitation posttransplantation are important to make these children productive individuals to the society.