Successful pediatric kidney transplantation from pediatric non-heart-beating donors

Survival Benefit of Donation After Circulatory Death Kidney Transplantation in Children Compared With Remaining on the Waiting List for a Kidney Donated After Brain Death

BACKGROUND

Kidneys donated after circulatory death (DCD) are increasingly being used for transplantation in adults to alleviate organ shortage. Pediatric data on survival benefits of DCD transplantation compared with remaining on the waitlist for a kidney donated after brain death (DBD) offer are lacking.

METHODS

We used Scientific Registry of Transplant Recipients to identify 285 pediatric (<18 y) DCD kidney transplants performed between 1987 and 2017. Propensity score matching was used to create a comparison group of 1132 DBD transplants. We used sequential Cox analysis to evaluate survival benefit of DCD transplantation versus remaining on the waitlist and Cox regression to evaluate patient and graft survival.

RESULTS

DCD transplantation was associated with a higher incidence of delayed graft function (adjusted odds ratio: 3.0; P < 0.001). The risks of graft failure (adjusted hazard ratio [aHR], 0.89; P = 0.46) and death (aHR, 1.2; P = 0.67) were similar between DCD and DBD recipients. We found a significant survival benefit of DCD transplantation compared with remaining on the waitlist awaiting a DBD kidney (aHR, 0.44; P = 0.03).

CONCLUSIONS

Despite a higher incidence of delayed graft function, long-term patient and graft survival are similar between pediatric DCD and DBD kidney transplant recipients. DCD transplantation in children is associated with a survival benefit, despite pediatric priority for organ allocation, compared with remaining on the waitlist.

Late graft loss among pediatric recipients of DCD kidneys

BACKGROUND AND OBJECTIVES

Kidney transplantation from donors after cardiac death (DCD) provides similar graft survival to donors after brain death (DBD) in adult recipients. However, outcomes of DCD kidneys in pediatric recipients remain unclear, primarily because of limited sample sizes.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We identified 137 pediatric (<18 years old) recipients of DCD kidneys between 1994 and 2010 using Scientific Registry of Transplant Recipients data and compared outcomes with 6059 pediatric recipients of DBD kidneys during the same time period, accounting for donor, recipient, and transplant characteristics using time-varying Cox regression and matched controls. Long-term follow-up (4 years or beyond) was available for 31 DCD recipients.

RESULTS

Pediatric recipients of DCD kidneys experienced a significantly higher rate of delayed graft function (22.0% versus 12.3%; P = 0.001), although lower than reported delayed graft function rates of DCD grafts in adults. Although DCD and DBD graft survival was equal in the early postoperative period, graft loss among pediatric recipients of DCD kidneys exceeded their DBD counterparts starting 4 years after transplantation. This effect was statistically significant in a multivariate Cox model (hazard ratio = 2.03; 95% confidence interval, 1.21 to 3.39; P = 0.007) and matched-controls analysis (hazard ratio = 2.36; 95% confidence interval, 1.11 to 5.03; P = 0.03).

CONCLUSIONS

A significant increase in DCD graft loss starting 4 years after transplantation motivates a cautious approach to the use of DCD kidneys in children, in whom long-term graft survival is of utmost importance.

Kidney transplantation in children and adolescents

Worldwide, specific pediatric allocation schemes successfully try to minimize waiting time for children with end-stage renal disease (ESRD). The article is a review of current issues in pediatric kidney transplantation. The procedure is the treatment of choice for children and adolescents with ESRD, with 1- and 3-year graft survival rates of 95% and 90% and recipient survival after 5 and 10 years of 95% and 90%. Preoperative surgery is often necessary to minimize negative effects of congenital anomalies. No minimum age exists for pediatric transplantation, but most often the recipient body weight is ideally above 10 to 15 kg. Technical concepts should include extravesical anastomosis, stenting of the ureter, and potentially intraperitoneal placement of the graft. Immunosuppression has constantly improved. The aim is a tailored regimen to reduce side effects and improve compliance, which necessitates intense counseling of the child and the parents prior to, during, and after transplantation as many adolescents lose their graft due to noncompliance. Intense follow-up must also exclude infections, especially with herpes and polyoma viruses. For the future, age matching may be only one promising concept to improve results. As only a small number of children require the procedure in each country, multinational studies should be initiated to optimize outcomes in children and adolescents.

Segmental liver transplantation from non-heart beating donors--an early experience with implications for the future

We report our experience of pediatric liver transplantation with partial grafts from non-heart beating donors (NHBD). Controlled donors less than 40 years of age with a warm ischemia time (WI) of less than 30 min were considered for pediatric recipients. Death was declared 5 min after asystole. A super-rapid recovery technique with aortic and portal perfusion was utilized. Mean donor age was 29 years and WI 14.6 min (range 11-18). Seven children, mean age 4.9 years (0.7-11), median weight 20 kg (8.4-53) received NHBD segmental liver grafts. Diagnoses included seronegative hepatitis, neonatal sclerosing cholangitis, familial intrahepatic cholestasis, hepatoblastoma, primary hyperoxaluria and factor VII deficiency (n=2). The grafts included four reduced and one split left lateral segments, one left lobe and one right auxiliary graft. Mean cold ischemia was 7.3 h (6.2-8.8). Complications included one pleural effusion and one biliary collection drained percutaneously. At 20 months (10-36) follow-up all children are alive and well with functioning grafts. Donation after cardiac death is a significant source of liver grafts for adults and children with careful donor selection and short cold ischemic times.