One-Year Follow-up of En Bloc Renal Transplants from Pediatric Donors in Adult Recipients

Effect of donor body weight on en bloc pediatric kidney transplantation in adults: A systematic review and meta-analysis

BACKGROUND

The shortage of donor grafts for kidney transplantation remains a critical challenge. En bloc kidney transplantation (EBKT) using small deceased pediatric donors has the potential to expand the donor pool. This review aimed to investigate the outcomes of pediatric-donor EBKT in adults compared with standard single kidney transplantation (SKT).

METHODS

Relevant databases, including Ovid, Web of Knowledge, Google Scholar, Wiley, and Embase, were searched for eligible studies. Demographic data and transplant outcomes were extracted from the included studies. The primary outcome was graft survival. A random-effects model was used for the meta-analysis.

RESULTS

Thirteen studies were included. The median 1-year graft survival rates were 83.8 % and 89.2 % for EBKT and SKT, respectively (risk ratio [RR], 0.97; 95 % confidence interval [CI], 0.93-1.01). The median 5-year graft survival rates were 78.7 % and 72.7 % for EBKT and SKT, respectively (RR, 1.05; 95 % CI, 0.93-1.19). For donors with a body weight > 10 kg (EBKT >10 kg) and ≤ 10 kg (EBKT ≤10 kg), the median 1-year graft survival rates were 100.0 % and 90.0 %, respectively (RR, 1.08; 95 % CI, 1.05-1.12). Vascular complications were identified as the primary cause of graft loss.

CONCLUSIONS

Pediatric-donor EBKT in adults is a safe approach with excellent long-term functional outcomes comparable to those of SKT. EBKT represents an effective option to further utilizing pediatric donor kidneys. Outcomes of EBKT vary based on donor body weight. EBKT ≤10 kg was associated with higher short-term graft failure rates despite long-term performance being comparable to EBKT >10 kg.

Technical Feasibility of Renal Artery Embolization on a Transplanted Kidney Due to Intractable Unilateral Hydronephrosis After En Bloc Kidney Transplantation: Case Report

INTRODUCTION

En bloc kidney transplantation (EBKT) is a technique used to transplant pediatric kidneys to adult recipients, but can lead to certain complications seldom found in single-kidney transplantation. We report a case of renal artery embolization after EBKT due to intractable unilateral hydronephrosis and highlight the technical details and challenges of the procedure.

CASE

An 18-year-old female with MELAS syndrome underwent EBKT from a 10-month-old male baby. Two months later, the patient developed unilateral hydronephrosis and recurrent urinary tract infections, which was intractable to conventional therapy. Therefore, we underwent embolization of the problematic transplanted left kidney. Owing to the complicated anatomy and multiple angulations, multiple microcatheters, wires and support catheters were needed to select the renal arteries. Repeated procedures were required due to remnant flow from small branches and accessory renal arteries that were not easily visualized by conventional angiography, which were eventually detected by adjunctive use of 3-dimensional rotational angiography.

CONCLUSIONS

Selective renal artery embolization after EBKT is challenging due to the short renal artery length and multiple angulations, yet it can still be performed safely and effectively by use of meticulous catheter-wire interactions and adjunctive intraoperative imaging techniques to delineate the precise anatomy of the target arteries.

CLINICAL IMPACT

Selective renal artery embolization, which is less invasive than nephrectomy, can be considered if the culprit kidney must inevitably be sacrificed in en bloc kidney transplantation.

Successful Pediatric Kidney Transplantation Into an Adult Recipient: A Case Report

BACKGROUND

The constant shortage of kidney donors prompts exploration into new strategies of transplantation. One of these strategies is the use of pediatric donors aged up to 5 years whose kidneys can be transplanted into adult recipients, mainly en bloc. This involves retrieving kidneys en bloc with aorta and inferior vena cava and anastomosing them to the recipient's external iliac vessels.

CASE PRESENTATION

In our hospital, kidneys from a 3-year-old child were transplanted to a 30-year-old man. The recipient with end-stage renal failure, due to glomerular nephritis, was dialyzed for 12 years and had 1 failed transplantation with consequent graftectomy. In 2009, kidneys were transplanted to the external iliac artery and vein with reconstruction of the renal vessels. Shortly after transplantation the patient had normal renal measures. Three months later a critical stenosis of 1 renal artery was detected. Angioplasty was performed but technical reasons did not allow for effective dilatation of the vessel. Further, 6 months after kidney transplantation (KTx) nephrotic proteinuria appeared and features of membranous nephropathy were detected in a renal biopsy. The proteinuria subsided after administration of ramipril and losartan. Doppler ultrasound revealed that 1 artery remained 90% stenotic with a peak systolic velocity of 377 cm/sec. Despite reported complications, renal function appeared normal over 7 years of observation.

CONCLUSIONS

A transplantation of 2 pediatric kidneys into an adult recipient has very high efficacy. The survival of both graft and recipient is similar to the results obtained after living donor kidney transplantation.

Unusual Bilateral Renal Parenchymal Urine Leak After Pediatric En Bloc Kidney Transplantation: First Case Study Report

Kidney transplantation is usually the best course of treatment for patients with end-stage renal disease. En bloc kidney transplantation (EBKT) is a surgical treatment option that increases available donor organs with excellent graft survival for patients with end-stage renal disease. Herein, we report a case of an unusual bilateral renal parenchymal urine leak after EBKT leading to removal of both moieties of the EBKT. This unfortunate complication after EBKT, to our knowledge, is the only reported of its kind. We explore the possible causes of the bilateral parenchymal urine leaks and suggest preventive strategies to avoid urological complications after EBKT.

Organ Donation Following Neurologic and Circulatory Determination of Death

OBJECTIVES

To describe important considerations during the process of caring for critically ill children who may be potential organ donors and supporting the family during the death of their child.

DESIGN

Literature review and expert commentary.

MEASUREMENT AND MAIN RESULTS

Medical literature focusing on pediatric donation, best pediatric donation practices, donor management, and factors influencing donation were reviewed. Additional pediatric data were obtained and reviewed from the U.S. Organ Procurement and Transplantation Network. Achieving successful organ donation requires the coordinated efforts of the critical care team, organ donation organization, and transplant team to effectively manage a potential donor and recover suitable organs for transplantation. Collaboration between these teams is essential to ensure that all potential organs are recovered in optimal condition, to reduce death and morbidity in children on transplantation waiting lists as well as fulfilling the family's wishes for their dying child to become a donor.

CONCLUSIONS

Organ donation is an important component of end-of-life care and can help the healing process for families and medical staff following the death of a child. The process of pediatric organ donation requires healthcare providers to actively work to preserve the option of donation before the death of the child and ensure donation occurs after consent/authorization has been obtained from the family. Medical management of the pediatric organ donor requires the expertise of a multidisciplinary medical team skilled in the unique needs of caring for children after neurologic determination of death and those who become donors following circulatory death after withdrawal of life-sustaining medical therapies.

Graft arterial stenosis in kidney en bloc grafts from very small pediatric donors: incidence, timing, and role of ultrasound in screening

In previous studies with different donor selection criteria and noncontemporary surgical techniques, graft arterial stenosis (GAS) has been reported to occur more frequently in adult recipients of pediatric en bloc renal allografts (EBKT) as compared to single adult donor allografts. The purpose of our study was to evaluate the incidence of GAS within our EBKT recipient population and to evaluate clinical and imaging features of those cases with GAS. In a retrospective cohort study, we analyzed 182 EBKT performed at a single institution. We identified cases of suspected GAS based on clinical factors, lab results, and noninvasive imaging. Diagnosis of GAS was confirmed by digital subtraction angiography. Two EBKT recipients (1.1% of 182) had angiographically confirmed GAS at 2.5 and 4.5 months after transplant. In both cases, the stenoses were short segment within the proximal (perianastomotic) donor aorta, color Doppler ultrasound demonstrated peak systolic velocities of >400 cm/s, and poststenotic parvus tardus waveforms were present. Both patients underwent angioplasty and demonstrated postintervention improvement in renal function and blood pressure. Restenosis did not occur during follow up. In conclusion, recipients of EBKT have a low incidence of GAS, similar to the lowest reported for adult single allografts.

Dual Kidney Transplantation From Pediatric Donors to Adult Recipients

BACKGROUND

The organ shortage is a global problem. A potential approach to expanding the deceased donor pool is to harvest organs from pediatric patients.

METHODS

Seven cases of dual kidney transplantation from pediatric donors to adult recipients were performed between 2012 and 2014 in our center. The proximal end of the donor aorta (AO) was anastomosed to the right common iliac artery or external artery. The proximal end of the donor inferior vena cava (IVC) was anastomosed to the right external iliac vein. Recipients received basiliximab or antithymocyte globulin as induction therapy, followed by tacrolimus, mycophenolate mofetil, and prednisone. Prophylactic anticoagulation was not universal in our study.

RESULTS

During the 21-month study period, both patient and graft survivals were 100%. No patient showed thrombotic complications. Complications included an acute rejection episode in 1 patient, urine leakage in 2, and anticoagulation related hemorrhage in 1. All recipients had excellent graft function with normal serum creatinine ranging from 0.49 to 1.45 mg/dL and estimated glomerular filtration rate ranging from 56.89 to 145.27 mL/min/1.73 m(2).

CONCLUSIONS

Dual kidney transplantation from pediatric donors to adult recipients is a promising way to expand the donor pool. Using the proximal end of the AO/IVC for anastomosis brings satisfactory results.

The potential for neonatal organ donation in a children's hospital

OBJECTIVE

Neonatal organ donation does not occur in the UK. Unlike in other European countries, Australasia and the USA death verification/certification standards effectively prohibit use of neurological criteria for diagnosing death in infants between 37 weeks' gestation and 2 months of age and therefore donation after neurological determination of death. Neonatal donation after circulatory definition of death is also possible but is not currently undertaken. There is currently no specific information about the potential neonatal organ donation in the UK; this study provides this in one tertiary children's hospital.

DESIGN

Retrospective mortality database, clinical document database and patient notes review.

SETTING

Neonatal and Paediatric Intensive Care in a tertiary children's hospital.

PATIENTS

Infants dying between 37 weeks' gestation and 2 months of age between 1 January 2006 and 31 October 2012. Potential assessed using current UK guidelines for older children and neonatal criteria elsewhere.

RESULTS

84 infants died with 45 (54%) identified as potential donors. 34 (40%) were identified as potential donors after circulatory definition of death and 11 (13%) were identified as being theoretical potential donors after neurological determination of death. 10 (12%) were identified as unlikely donors due to relative contraindications and 39 (46%) were definitely not potential donors.

CONCLUSIONS

With around 60 paediatric organ donors in the UK annually, there does appear significant potential for donation within the neonatal population. Reconsideration of current infant brain stem death guidelines is required to allow parents the opportunity of donation after neurological determination of death, together with mandatory training in organ donation for neonatal teams, which will also facilitate donation after circulatory definition of death.

Current status of pediatric donor en bloc kidney transplantation to young adult recipients

CONTEXT AND OBJECTIVES

In recent years, despite the increased number of kidney transplants performed in Spain, we observed a gradual increase in waiting lists. The need to increase the number of transplants performed in our centers, forces us to accept as donors patients previously rejected.

ACQUIRING OF EVIDENCE

We performed a systematic review using PubMed of published articles in the last 10 years, that include the words transplant renal en bloque, "en bloc kidney transplantation" or its initials EBKT.

SYNTHESIS OF EVIDENCE

The pediatric donor to adult recipient has been included in the expanded criteria donors group, being rejected nevertheless such donors in most centers. However, in recent published series comparing the en bloc kidney transplantation from pediatric donor to adult recipients with other transplanted groups, the authors observe similar results between this kind of transplantation and the "optimal" donor group or living kidney donor group, regarding renal function and graft survival, and better results than the transplanted kidneys with expanded criteria donors group.

CONCLUSIONS

The results published in the current series lead us to consider this kind of transplant as an option to increase the number of transplants performed.