Transplantation of the adult kidney into the very small child

Miller, Laurie C.; Lum, Caliann T.; Bock, Glenn H.; Simmons, Richard L.; Najarían, John S.; Mauer, S. Michael

doi:10.1016/0002-9610(83)90071-5

Cited by 40 publications

(10 citation statements)

References 3 publications

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“…A few years later organ procurement from a brain-dead heart-beating donor was performed (2,3). While some aspects of kidney transplantation were similar for children and adults, the surgical approach varied and technical challenges were great in small children (4)(5)(6). Prolonged pediatric dialysis was fraught with issues related to dialysis access, nutrition, growth, bone disease, and developmental and neuro-cognitive delays (7)(8)(9).…”

Section: Surgical and Medical Considerations Before And During Transpmentioning

confidence: 99%

Pediatric kidney transplantation: a historical review

Verghese

2016

Pediatr Res

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Successful renal transplantation is the optimal treatment for chronic kidney failure, but this was not always so for children. Beginning with the first kidney transplants in the 1950s, children experienced poorer patient and graft survival rates than adult patients. But over the last 6 decades, an improved understanding of the immune system which has steered pediatric multi-center clinical/pharmacokinetic and mechanistic studies that have sculpted our immunosuppression with markedly better patient and graft survivals. In addition, uniquely pediatric issues related to growth, development, neurocognitive maturation, increased complications from primary viral infections, and comorbid congenital/inherited disorders, are now diagnosed and effectively managed in these children. Refined pretransplant preparation (vaccinations for preventable diseases, attention to cognitive delays, effective dialysis and nutrition) improved donor selection, and more potent immunosuppression have all contributed to enhanced outcomes. Similarly, improvements in pediatric surgical techniques, postoperative care and better antiviral prophylaxis have all shortened hospitalizations and reduced morbidity. Today pediatric kidney transplant outcomes are markedly improved and younger children today experience better long-term graft survival than adults! While difficult problems remain, we have made tremendous progress and anticipate even more advances in the future of pediatric kidney transplantation.

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Section: Surgical and Medical Considerations Before And During Transpmentioning

confidence: 99%

Pediatric kidney transplantation: a historical review

Verghese

2016

Pediatr Res

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“…The initial nephrostogram showed no obstruction or urine leak, indicating that the drainage procedure was unnecessary. Thus, DARF has to be differentiated from technical complications such as vascular or urinary tract obstruction or urinary leak [7,8]. These clinical errors are less likely if alternate explanations fitting the patients clinical features are considered.…”

Section: Discussionmentioning

confidence: 99%

“…Acute renal failure (ARF) is one such serious complication requiring effective management. The differential diagnosis of ARF developing after initial good graft function during the first 2 weeks after Tx include: acute rejection (AR) [4 -6], acute tubular necrosis (ATN) [6], technical complications [7,8], recurrence of primary disease [9,10], drug toxicity [11], and systemic infections with hemodynamic instability [12,13]. Renal ultrasound (US), renogram, voiding cystourethrogram, and a thorough evaluation for infection may be required to differentiate between these conditions [14].…”

Section: Introductionmentioning

confidence: 99%

Delayed acute renal failure in post-transplant period in young children from unexplained etiology

Vats

Mauer

Burke

et al. 1997

Pediatric Nephrology

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This report describes six young children (5 male) who developed delayed acute renal failure (DARF) in the early post-kidney-transplant (Tx) period in the absence of acute rejection (AR) or other diagnosable conditions. These young children, aged 16.5 +/- 3.1 (12-21) months [mean +/- SD, (range)] and weighing 8.5 +/- 1.7 (7.1-11.4) kg received a primary renal Tx (5 living-related donor, 1 cadaver) between 1984 and 1992. Immunosuppression included prednisone, azathioprine, and Minnesota antilymphocyte globulin (MALG, n = 5); one patient received cyclosporine and no MALG. Initially, all patients had good urine output (UO). They became systemically ill and abruptly developed diminished UO on post-operative day (POD) 6.5 +/- 1 (4-8). DARF was accompanied by fever (39.1-40.4 degrees C, n = 6), thrombocytopenia (platelets < 100,000/mm3, n = 6), leukocytosis, or leukopenia (white cell count > 20,000/mm3, n = 4 or < 1,000/mm3, n = 1). Four patients had diarrhea. Three had ascites and one was surgically explored for suspected urinary leak. None showed significant urinary obstruction by renal ultrasound. Renograms showed intact blood flow. Renal biopsy showed tubular ectasia (n = 6), vascular congestion (n = 5), focal glomerular endothelial swelling (n = 4), and capillary thrombi (n = 3). None showed AR. Five patients required dialysis for 11 +/- 4 (7-15) days. All patients survived. One patient, treated for suspected AR with the monoclonal antibody OKT3, developed shock and lost her graft on POD 12 due to vascular thrombosis. Renal functional recovery in the remaining five patients took 14 +/- 5 (6-20) days and their serum creatinine at discharge was 0.7 +/- 0.5 (0.3-1.6) mg/dl. We report DARF from undetermined etiology occurring in the first 2 weeks of renal Tx in young children. Treatment is supportive care including dialysis. Recognition of this complication will help avoid risky investigations or unnecessary treatment for rejection.

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“…These are fundamental techniques that have been well described by others. 11,15,16 Expansion of recipient intravascular volume is also critical to a prompt complete reperfusion of the donor kidney. We routinely set a target recipient CVP measurement of 16 to 20 mm Hg to expand the intravascular space and to increase perfusion pressure.…”

Section: Commentmentioning

confidence: 99%

“…As already noted, there was a significant size mismatch between the donor and recipient, and we have found that wide mobilization of the peritoneum to develop a retroperitoneal space allows easy and direct access to the aorta and IVC. Classically, these large adult kidneys have been placed intraperitoneally, 15,16 so as to avoid additional compression by the peritoneal contents that may contribute to the risk of vascular thrombosis. We have found the exposure excellent for vascular anastomoses, and believe that the peritoneum helps to maintain the kidney in a more stable position with a lower risk of unwanted twisting or shifting of the kidney that could lead to vascular compromise.…”

Section: Commentmentioning

confidence: 99%

Transplantation of Adult Living Donor Kidneys Into Infants and Small Children

Healey¹,

McDonald²,

Waldhausen³

et al. 2000

Archives of Surgery

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We hypothesized that improved outcomes following renal transplantation in high-risk infants and small children primarily are due to advances in immunosuppression and accurate diagnosis of rejection. Optimizing renal allograft perfusion is critical to achieving good early graft function and decreasing early graft loss. Design: Twenty-eight consecutive recipients (weighing Ͻ20 kg) of adult living donor kidneys transplanted at our center from 1984 to 1999 were reviewed. Two groups were identified based on differing immunosuppression protocols and clinical surveillance. Actuarial graft and patient survival reported at 1, 3, and 5 years were compared for group 1 (1984-1991) and group 2 (1992-1999). Graft losses, categorized as immunologic or nonimmunologic, and the incidences of delayed graft function, vascular thrombosis, and rejection were compared. Results: Graft and patient survival in group 1 (n=13) at 1, 3, and 5 years was 77% and 92%, 54% and 85%, and 54% and 85%, respectively. In group 2, all 15 patients are alive with functioning grafts to date. Immunologic graft loss occurred in 5 of 13 patients in group 1 who developed chronic rejection. Nonimmunologic causes (vascular thrombosis [2 patients]) and patient death [1]) resulted in early graft failure within 2 weeks in 3 of 13 patients in group 1. The overall incidences of delayed graft function (10.7%) and thrombosis (7.1%) were low and did not differ between groups. Percutaneous renal biopsy was used more frequently in group 2 to evaluate graft dysfunction and guide treatment. Conclusions: We conclude that improved overall graft and patient survival in group 2 is owing to advances in immunosuppression and better treatment of rejection. Percutaneous renal biopsy allows prompt and accurate histological diagnosis of graft dysfunction. Surgical technique and aggressive fluid management aimed at maximizing renal allograft perfusion is critical in optimizing early graft function and decreasing vascular complications.

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Transplantation of the adult kidney into the very small child

Cited by 40 publications

References 3 publications

Pediatric kidney transplantation: a historical review

Pediatric kidney transplantation: a historical review

Delayed acute renal failure in post-transplant period in young children from unexplained etiology

Transplantation of Adult Living Donor Kidneys Into Infants and Small Children

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