Kidney Transplantation Without Prior Dialysis in Children: The Eurotransplant Experience

Abstract

Kidney transplantation without prior dialysis may prevent dialysis-associated morbidity. We analyzed the outcome of 1113 first kidney transplants in children performed between 1990 and 2000 in the Eurotransplant community. Enlistment for a deceased donor kidney before start of dialysis (127/895, 14%) made dialysis redundant in 55% of cases. Mean residual creatinine clearance at transplantation of these patients was 8 mL/min/1.73 m 2 . Pre-emptive transplantations of deceased donor kidneys showed less acute rejections (52% vs. 37% rejection-free at 3 years, p = 0.039), compared to transplantations following dialysis. The difference in graft survival between non-dialyzed and dialyzed patients (82% vs. 69% at 6 year) did not reach statistical significance (p = 0.055). No differences were noted after living donor transplantation. Multivariate analysis showed that the period of transplantation was the strongest predictor of graft survival (p < 0.001). Congenital structural abnormalities such as primary kidney disease predominated in nondialyzed patients as compared to dialyzed patients (p < 0.001); this factor did not influence graft survival. Based on our conclusion that pre-emptive transplantation is at least as good as post-dialysis transplantation, as well as on quality of life arguments, we recommend to consider pre-emptive transplantation in children with end-stage renal failure.

Determinants of eGFR at start of renal replacement therapy in paediatric patients

“…We hypothesize that patients who have a suitable donor are likely to have their transplant timed early enough to avoid dialysis [21] and therefore at a higher GFR than that at which they would commence dialysis. Nevertheless, a previous study found no differences in eGFR levels between pre-emptive and post-dialysis transplant patients [13]. However, their eGFR levels were much lower than those reported in our study.…”

“…The main determinants of eGFR at start were age, gender, treatment modality at start as well as time between the first visit to a PN and start of RRT. We found slightly higher median eGFR levels at start compared with US dialysis patients [5,12] and patients from the Eurotransplant registry [13]. However, these studies took place at an earlier period in slightly younger patients.…”

Renal Replacement Therapy in Infants with Chronic Renal Failure in the First Year of Life

“…A younger age at the start of RRT, especially for infants who are younger than 1 yr, has been a risk factor for mortality (15,16,20); however, early transplantation, in particular preemptive transplantation, has been shown to improve survival and reduce mortality in children who have CRF and are younger than 5 yr (7,22). Patients who underwent preemptive RTx showed better graft survival (23), probably because the donor was living related and because of shorter cold ischemia time (24). Survival of infants who underwent RTx was comparable to that of older children.…”

Renal transplantation in infants

“…According to a NAPRTCS report from the US, a living donor (LD) kidney was used in about 50 % of all pediatric RTx and in 74 % of infant RTx [5]. In the Eurotransplant region, the percentage of LD in pediatric RTx was much less (20 %), but no exact figures were available for infant RTx [16]. The use of either of the parents as an LD brings several advantages: timing of the operation is feasible, RTx can be performed pre-emptively, immunological matching is at least satisfactory (one haplotype), the donor age is often low (<35 years), and the cold-ischemia time is very short.…”