Transplantation of adult‐size kidneys in small pediatric recipients: A single‐center experience

Abstract

RTx of adult‐size kidneys presents a size mismatch in small pediatric recipients, and there are potential surgical complications. This study reveals the outcomes of intra‐ and extraperitoneal RTx in low‐weight (less than 15 kg) pediatric recipients. We studied 51 pediatric patients weighing less than 15 kg who received a living‐related donor renal transplant between 2009 and 2017. The intraperitoneal (group A, n = 24) and extraperitoneal (group B, n = 27) approaches were compared. In group A, the mean age, Ht, and weight were 3.8 ± 1.6 years, 83.7 ± 6.5 cm, 10.5 ± 1.8 kg; in group B, 5.0 ± 1.9 years, 95.3 ± 7.3 cm, and 13.0 ± 1.4 kg. Single renal artery grafts (21 in group A and 16 in group B) and double renal artery grafts (three in group A and 11 in group B) were performed. Of the patients with double renal artery transplants, one in group A and six in group B underwent ex vivo arterial reconstruction. The eGFR (mL/min/1.73 m2) at 1‐week post‐transplant in group A was significantly higher than that in group B; the eGFRs at 4 weeks post‐transplant did not differ. One graft was lost in group B because of vascular thrombosis. Post‐transplant complications included ileus and transplant ureteral stenosis. There was no significant difference in 5‐year graft survival rate (group A 100%, group B 91.7%). Both transplant approaches are feasible to adapt to a size mismatch between the adult‐size donor kidney and low‐weight pediatric recipients.

Extraperitoneal kidney transplantation: a comparison between children weighting ≤15 kg and >15 kg. Experience of a single institution

“…A comparison between the intraperitoneal and extraperitoneal techniques reported similar long‐term outcomes in graft function and survival [ 28 ]. It is relevant to highlight, however, that the extraperitoneal approach may avoid episodes of intestinal obstruction or twisting of the allograft on its vascular pedicle, as reported in other series, in which the intraperitoneal implantation was the preferred choice [ 7 , 8 ].…”

Good outcomes after pediatric intraperitoneal kidney transplant

“…When possible, the extraperitoneal approach is preferred as it decreases the risk for peritoneal disruption, avoids previous intra‐abdominal adhesions and the formation of new ones, while decreasing the risk of a prolonged post‐operative ileus 16,17 . However, in our small patients, the intra‐abdominal approach provides the necessary inflow and outflow pressures to accommodate the adult donor graft as well as allows for larger capacity to prevent compression of the allograft, theoretically improving patency of the allograft vasculature, which is widely reported in pediatric patients 18 . Many of our patients have urinary diversions that are more accessible from an intraperitoneal approach, which also leaves the iliac vessels available for anastomosis for future re‐transplant, as pediatric patients often require multiple transplants in a lifetime 18 .…”

“…16,17 However, in our small patients, the intra-abdominal approach provides the necessary inflow and outflow pressures to accommodate the adult donor graft as well as allows for larger capacity to prevent compression of the allograft, theoretically improving patency of the allograft vasculature, which is widely reported in pediatric patients. 18 Many of our patients have urinary diversions that are more accessible from an intraperitoneal approach, which also leaves the iliac vessels available for anastomosis for future re-transplant, as pediatric patients often require multiple transplants in a lifetime. 18 Ultimately, the approach for kidney transplantation is up to the surgeon's discretion with consideration of the recipient's needs.…”

Pearls and Pitfalls in Pediatric Kidney Transplantation After 5 Decades

“…Currently, there is no consensus on a minimal age or weight for transplantation. Whereas, some centers perform transplantations in children above 6 kg, others use a minimum age of 2 years (69,72,87). Further work is required to determine optimal timing with regard to long term outcome.…”