Good outcomes after pediatric intraperitoneal kidney transplant

Abstract

Background: Kidney transplantation in small children is technically challenging.Consideration of whether to use intraperitoneal versus extraperitoneal placement of the graft depends on patient size, clinical history, anatomy, and surgical preference.We report a large single-center experience of intraperitoneal kidney transplantation and their outcomes. Methods:We conducted a retrospective review of pediatric patients who underwent kidney transplantation from April 2011 to March 2018 at a single large volume center.We identified those with intraperitoneal placement and assessed their outcomes, including graft and patient survival, rejection episodes, and surgical or non-surgical complications.Results: Forty-six of 168 pediatric kidney transplants (27%) were placed intraperitoneally in children mean age 5.5 ± 2.3 years (range 1.6-10 years) with median body weight 18.2 ± 5 kg (range 11.4-28.6 kg) during the study period. Two patients (4%) had vascular complications; 10 (22%) had urologic complications requiring intervention; all retained graft function. Thirteen patients (28%) had prolonged post-operative ileus. Eight (17%) patients had rejection episodes ≤6 months post-transplant. Only one case resulted in graft loss and was associated with recurrent focal segmental glomerular sclerosis (FSGS). Two patients (4%) had chronic rejection and subsequent graft loss by 5-year follow-up. At 7-year follow-up, graft survival was 93% and patient survival was 98%. Conclusions:The intraperitoneal approach offers access to the great vessels, which allows greater inflow and outflow and more abdominal capacity for an adult donor kidney, which is beneficial in very small patients. Risk of graft failure and surgical Pediatric patients constitute <2% of the kidney transplant recipients in the United States and offer unique surgical challenges for transplant. 1 Historically, matching donor size and age for pediatric patients led to significant graft loss, largely a result of vessel thromboses when small, pediatric kidneys were implanted in small, pediatric recipients. 2 Kidney transplants from larger and older donors are now routinely used in small pediatric patients, necessitating renal artery and vein anastomoses to larger recipient blood vessels, usually the aorta and inferior vena cava (IVC) depending on the recipient size, anatomical limitations and surgeon's preference. 3 In the current era, patient and graft survival for small pediatric patients weighing <30 kg is similar to adult outcomes, though smaller patients may still be at increased risk for vascular complications. [4][5][6][7][8] Several studies indicate that vascular complications are more common in pediatric than adult transplant recipients 7 and may be the most frequent complication in pediatric patients, with one study reporting vascular complication rates as high as 13.8%. 7,9 Additionally, renal vein thrombosis has been a major cause of firstyear graft failure in pediatric patients with increased risk in those <4 years old and those with lower body weight. 10,11 ...

The transplant ureter causing small bowel obstruction following intraperitoneal kidney transplantation: a case report

“…Most kidney transplants are performed using an extraperitoneal approach, this allows for positioning the allograft low in the pelvis and trimming ureteral length to minimize distal ischemia resulting in ureteral stricture. The intraperitoneal space is preferentially utilized in cases of small-sized pediatric recipients, [ 6 ] simultaneous kidney and pancreas transplantation and, to a lesser extent, in certain cases following an extraperitoneal approach followed by an elective opening of the peritoneum due to loss of domain or concerns for vascular compromise of the allograft. The intraperitoneal approach is associated with a higher incidence of post-operative gastrointestinal complications including SBO [ 7 ].…”