Immunologic and Patient Selection Strategies for Successful Utilization of Less Than 15 Kg Pediatric Donor Kidneys-Long Term Experiences With 40 Transplants1

Abstract

Renal transplantation using infant donors is associated with significantly less graft survival (GS) and increased morbidity, especially from very young and small donors. We report our results using specific strategies to determine which age and size donor require en bloc renal transplant reconstruction and associated immunologic protocols for optimization of subsequent GS. Forty cadaveric pediatric en bloc renal transplants were performed. Mean donor age was 23.6+/-18.4 months with subgroups: 2-12 months, n=14; 13-24 months, n=19; and 25-60 months, n=7. Mean donor weight was 14.4+/-4.5 kg. All kidneys were placed in primary, nonsensitized (peak PRA = 7.9+/-5.6%) adult (41.6+/-16 years) recipients. Low weight was preferred (62.4+/-12.8 kg). Mean cold ischemia time was 26.9+/-8.6 hr. Immunosuppression consisted of quadruple immunosuppression (QI) with OKT3 induction. All patients had ureteral stents placed intraoperatively. Mean follow-up was 16.9 months. Actuarial GS at 12, 24, and 33 months were 100% (n=13), 85% (n=20), and 71% (n=7), respectively. Total GS was 35/40=88%. All grafts functioned immediately and there were no technical losses. Biopsy proven rejections occurred in 12 (30%) patients, developing at 16-167 days postoperatively (mean = 50.3 days). Mean serum creatinine at one week and 1, 6, 12, and 18 months were 2.1+/-2.0, 1.5+/-0.8, 1.3+/-0.5, 1.1+/-0.4, and 0.9+/-0.4 mg/dl, respectively. Functional isotopic renography, as well as sonographic monitoring reflected rapid initial and continued growth in these kidneys. Mean BP at 12 and 24 months postoperatively were 145/83+/-18/13 and 122/76+/-20/10 mmHg, respectively, with no significant proteinuria noted. Excellent results with minimal complications utilizing very small and young infant donors can be achieved with QI immunosuppression, and selection of low immune reactive and noncomplicated adult recipients. Additionally, maximal renal dosing by minimizing recipient weight may prevent future hyperfiltration damage.

Single Kidney Transplantation from Young Pediatric Donors in the United States

“…Because of the ongoing discrepancy between the organ supply and demand, kidneys are being transplanted from increasingly smaller pediatric donors (1)(2)(3)(4)(5)(6)(7)(8)(9)(10). Kidneys from small pediatric donors are often transplanted en bloc primarily to avoid small anastomotic vessel size and potentially limit thrombotic complications; however, some are transplanted as single kidneys to increase organ utilization.…”

Single Center Experience of En Bloc Kidney Transplantation and Review of Literature

“…In their series of 40, Bretan et al 5 had one urinary leak (2.5%), and one dehiscence (2.5%). Both were repaired surgically.…”

“…In their series, Bretan et al 5 documented one graft loss (2.5%) of venous thrombosis due to hypercoagulable state. In their series of 22 en bloc kidney transplants, Satterthwaite et al 1 reported one venous thrombosis (4.5%) and two arterial thrombosis (9%), and all three grafts were lost.…”

“…Merkel et al 4 in a series of 20 en bloc kidney transplants reported 19 (95%) primary function. In their series of 40 en bloc renal transplants, Bretan et al 5 reported that all grafts functioned immediately. In their series of 13 en bloc transplants, Kirste et al 6 reported a primary function rate of 92%.…”

Dual renal grafts: expansion of the donor pool from an overlooked source

“…Since the 1970s, pediatric donors ranging in age from 12 months to 5 years have provided both kidneys for transplantation into a single recipient. Advocates of this technically demanding approach have reported satisfactory outcomes despite the higher risks of surgical complications such as thrombosis and ureteral leak [4,22]. It has been said that pediatric grafts are resilient, with the potential for lifetime function.…”