Surgical complications in pediatric kidney transplantation—Incidence, risk factors, and effects on graft survival: A retrospective single‐center study

Abstract

The field of pediatric kidney transplantation remains challenging due to an ongoing lack of size‐matched grafts and anatomical peculiarities. In the current study, we investigated the incidence of surgical complications in pediatric recipients, with a focus on risk factors and effects on graft outcome. We retrospectively reviewed all 2386 kidney transplantations at our institution from January 2005 until December 2018. Of these, 221 transplants were performed in pediatric recipients, defined as under the age of 18 years. Donor‐recipient body surface area ratios were calculated to evaluate the effects of size mismatching. Regression analyses were performed to identify independent risk factors for surgical complications and graft survival, respectively. Perioperative surgical complications requiring revision were observed in 34 (15.4%) cases. Leading cause for revision were vascular complications such as thrombosis or stenosis (n = 15 [6.8%]), which were significantly more frequent in case of young donors, (ie, donor age <6 years; OR: 4.281; CI‐95%:1.385‐13.226; P = .012), previous nephrectomy (OR: 3.407; CI‐95%:1.019‐11.387; P = .046), and en‐bloc grafts (OR: 4.923; CI‐95%:1.355‐17.884; P = .015), followed by postoperative hemorrhage (n = 10 [4.5%]), ureteral complications (n = 8 [3.6%]), and lymphoceles (n = 7 [3.2%]). Median follow‐up was 84.13 (0.92‐175.72) months. One‐, 5‐, and 10‐year graft survival rates were 97.1%, 88.9%, and 65.1%, respectively. Except for vascular complications (HR: 4.727; CI‐95%:1.363‐16.394; P = .014), none of the analyzed surgical morbidities significantly influenced graft survival. In conclusion, pediatric kidney transplantation achieves excellent long‐term results. However, meticulous surgical technique and continuous postoperative monitoring are imperative for early detection and treatment of imminent vascular complications, especially in case of young donors and en‐bloc grafts.

Pearls and Pitfalls in Pediatric Kidney Transplantation After 5 Decades

“…This might be caused by the mechanical trauma induced by stent placement which activates latent BK virus (148). However, other studies showed ureteral stenting to be protective against urological complications such as stenosis or leakage (149,150). In adults stents are commonly used and associated with a reduction in urological complications from 7 to 1.5% (151).…”

“…A Cochrane Review in the adult population showed that early removal (<15 days) of bladder indwelling and per-urethral stents might decrease the risk on UTI, however differences are small (153). The benefits of stenting in the pediatric populations remain unclear, currently many centers chose early stent removal in order to prevent urological complications and limit the number of infectious events (72,149). The use of suprapubic bladder catheter or transurethral catheter is also based on individual preference and specific patient characteristics.…”

“…Vascular complications are an important cause for early graft loss and include mainly renal thrombosis (3-12%) and arterial stenosis (3-15%) (149,154,155). Venous thrombosis is considered the most common cause of early graft loss and especially small children are at risk for developing thrombotic complications (73,156).…”

“…The most important lymphatic complication after transplantation is lymphocele, which occurs in 0.5-22% of the recipients (149,(160)(161)(162). It is caused by transection of lymphatic vessels of either donor or recipient and develops usually in the 1st week after transplantation.…”

Outcomes of small pediatric donor kidney transplants according to donor weight

“…Small donor arteries and veins, and a delicate vascular anastomosis contribute to increased thrombotic events [2,3]. Other complications, such as postsurgical bleeding because of the use of prophylactic anti-coagulation and urinary leaks, may occur [4]. Moreover, the reduced mass of SPD kidneys may lead to an imbalance between donor and recipient body size, and may be associated with an inadequate kidney function and possibly reduced graft survival because of hyperfiltration injury [5,6].…”