Management of sensitized pediatric patients prior to renal transplantation

Pirojsakul, Kwanchai; Desai, Dev M.; Lacelle, Chantale; Seikaly, Mouin G.

doi:10.1007/s00467-015-3295-z

Cited by 17 publications

(9 citation statements)

References 31 publications

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“…In the United States, approximately 3% of pediatric first‐time renal transplant recipients are already sensitized with PRA >80%, due to prior exposure to blood transfusions or other organ transplants. This increases their risk of hyperacute and acute rejection following subsequent solid organ transplantation . Single small pediatric kidneys may be particularly susceptible to this phenomenon, as well as medication noncompliance, which is known to occur commonly in adolescence …”

Section: Discussionmentioning

confidence: 99%

“…This increases their risk of hyperacute and acute rejection following subsequent solid organ transplantation. 28 Single small pediatric kidneys may be particularly susceptible to this phenomenon, as well as medication noncompliance, which is known to occur commonly in adolescence. 29 Our results are subject to the limitations inherent in observational data.…”

Section: Discussionmentioning

confidence: 99%

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Very small pediatric donor kidney transplantation in pediatric recipients

Yaffe

Friedmann

Kayler

2017

Pediatric Transplantation

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Kidneys from very small pediatric donors (age <5 years, weight <21 kg) may be a means to increase the donor pool for pediatric recipients. Transplantation of small pediatric kidneys is more commonly performed in adult recipients due to the increased risks of technical complications, thrombosis, and early graft failure. While these risks are abrogated in adult recipients by limiting the donor weight to ≥10 kg and using the EB technique, it is unknown whether pediatric recipients achieve comparable results. US national data were assessed for all first-time, deceased-donor, kidney-only pediatric recipients, 1/1996-10/2013, who received very small pediatric donor grafts or grafts from ideal adult donors. We identified 57 pediatric EB, 110 pediatric SK, and 2350 adult transplants. The primary outcome was 3-year all-cause graft survival. Kaplan-Meier curves showed worse outcomes for pediatric grafts compared to adult ideal grafts (P=.042). On multivariate analysis, pediatric recipients of SK grafts had significantly higher HRs (aHR 2.01, 95% CI 1.34-3.00) and pediatric recipients of EB grafts had somewhat higher non-significant HRs (1.57; 95% CI 0.88-2.79) for graft survival. These results suggest cautionary use of very small pediatric donors as a source to expand the donor pool for pediatric candidates.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Very small pediatric donor kidney transplantation in pediatric recipients

Yaffe

Friedmann

Kayler

2017

Pediatric Transplantation

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“…In kidney paired donation (KPD) programs, this allows access to better HLA‐ or blood group–matched living donors, and in the Eurotransplant Acceptable Mismatch Program, highly sensitized patients are given priority for organs from deceased donors with HLA alleles that are at low risk of producing a positive crossmatch . While both desensitization and ABO‐mismatched transplantations have been successfully performed for children , KPD offers access to LDKT without the associated higher immunosuppression required to overcome these immune barriers.…”

Section: Introductionmentioning

confidence: 99%

Optimizing Outcomes in Pediatric Renal Transplantation Through the Australian Paired Kidney Exchange Program

Sypek

Schmeißer

Cantwell³

et al. 2017

American Journal of Transplantation

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Kidney paired donation (KPD) programs offer the opportunity to enable living kidney donation when immunological and other barriers prevent safe directed donation. Children are likely to require multiple transplants during their lifetime; therefore, high-level histocompatibility and organ quality matching are key priorities. Details are given for a cohort of seven pediatric renal transplantations performed through the Australian Kidney Exchange (AKX), including barriers to alternative transplantation and outcomes after KPD. Reasons for entering the KPD program were preformed donor-specific antibodies to their registered donor in five cases, ABO mismatch, and avoidance of the risk of exposure to hepatitis B virus. Four recipients were highly sensitized. All patients received transplants with organs of lower immunological risk compared with their registered donors. HLA eplet mismatch scores were calculated for donor-recipient pairs; three patients had improved eplet mismatch load with AKX donor compared with their registered donor. All grafts are functioning, with a mean estimated glomerular filtration rate of 77 mL/min/1.73 m (range 46-94 mL) and a follow-up range of 8-54 months, and no patient experienced clinical or histological rejection. KPD is a viable strategy to overcome many barriers to living donation for pediatric patients who have an otherwise suitable donor and provides an opportunity to minimize immunological risks.

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“…The manuscript by Priojsakul et al [4] is therefore a welcome addition to the literature. Unfortunately, there are a number of concerns with this paper.…”

Section: Desensitization Protocolsmentioning

confidence: 92%

“…Priojsakul and colleagues [4] describe four cases, of which two were living donors: one had a positive cross-match with a low level of DSA and one a negative baseline cross-match and no significant DSA. It is unclear whether a subsequent positive B cell flow cytometric cross-match could have been due to autoreactivity or administration of intravenous immunoglobulin (IVIg).…”

Section: Desensitization Protocolsmentioning

confidence: 99%

Desensitization protocols for prospective pediatric renal transplant recipients

Mamode

Marks

2016

Pediatr Nephrol

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Desensitization protocols should be considered for children with positive crossmatches awaiting renal transplantation. Children are sensitized usually due to previous renal (and/or other solid-organ) transplants but can be from administration of blood and/or platelet transfusions, infections, and immunizations (as sensitization from pregnancy is a rare occurrence in pediatric patients). However, the definition of HLA-incompatible (HLAi) renal transplantation in the literature varies and is best considered only when there is a positive cross-match (positive baseline flow cytometric cross-match or positive complement-dependent cytotoxic cross-match). Renal transplantation where the recipient has donor-specific antibodies (DSA) but a negative cross-match should not fall into this category, although they are higher risk.

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Management of sensitized pediatric patients prior to renal transplantation

Abstract: The four sensitized patients reported here who received desensitization therapy had successful renal transplants with a low risk of immediate post-transplant rejection. Overall, long-term allograft functions and complications from immunosuppression were encouraging.

Cited by 17 publications

References 31 publications

Very small pediatric donor kidney transplantation in pediatric recipients

Very small pediatric donor kidney transplantation in pediatric recipients

Optimizing Outcomes in Pediatric Renal Transplantation Through the Australian Paired Kidney Exchange Program

Desensitization protocols for prospective pediatric renal transplant recipients

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