Is Preoperative Preparation Time a Barrier to Small Children Being Ready for Kidney Transplantation?

Abstract

Background. Small children are less frequently transplanted when compared with older. The objective of the present study was to compare the preparation time for transplantation in children of different weights and to identify factors associated with a delay in the workup of small children. Methods. We report on a retrospective cohort comprising all children referred for renal transplantation (RTx) workup between 2009 and 2017. The main outcome was transplantation workup time, defined as the time elapsed between the first consultation and when the child became ready for the surgery. Results. A total of 389 children (63.5% males) were selected, with a median weight of 18 kg (interquartile range, 11–32). Patients were categorized into 2 groups: group A (study group): ≤15 kg (n = 165) and group B (control group): >15 kg (n = 224). The probability of being ready for RTx was comparable between groups A and B. The cumulative incidence rate difference between groups is −0.05 (95% confidence interval, −0.03 to 0.02). The median time for RTx workup was 5.4 (2.4–9.4) in group A and 4.3 (2.2–9.0) months in group B (P = 0.451). Moreover, the presence of urinary tract malformation was associated with the need for longer transplantation workup time (P < 0.001). Conclusions. In children >7 kg, the workup time for transplantation is not related to body weight. In a specialized center, children weighing 7–15 kg became ready within the same timeframe as children weighing >15 kg, despite the smaller children had greater difficulty being nourished, dialyzed, and a greater need for surgical correction of the urinary tract pretransplant.

Kidney Transplantation in Small Children: Association Between Body Weight and Outcome—A Report From the ESPN/ERA-EDTA Registry

“…As failure to thrive is a major complication in the treatment of small children with end-stage kidney disease, [30][31][32][33][34] our findings might suggest that the decision for early Tx and consequently improved patient survival were at least partly influenced by pronounced growth failure or lower weight gain, 13,17,32 and we may speculate that timing of Tx was guided by selecting patients with high need for Tx characterized by intolerance of dialysis treatment and failure to thrive. 17,18 One-year graft survival was significantly lower, with a >2-fold increased risk of graft loss in Tx <10 kg patients. Despite these short-term relative differences, however, even in these patients, a 5-y graft survival of 86% could be achieved.…”

“…As failure to thrive is a major complication in the treatment of small children with end-stage kidney disease, 30-34 our findings might suggest that the decision for early Tx and consequently improved patient survival were at least partly influenced by pronounced growth failure or lower weight gain, 13,17,32 and we may speculate that timing of Tx was guided by selecting patients with high need for Tx characterized by intolerance of dialysis treatment and failure to thrive. 17,18…”

“…Although the ESPN/ERA-EDTA Registry does not allow analysis at the center level, we might speculate that centers performing Tx in patients with a weight <10 kg might present specialized and high-volume care. 18,[36][37][38][39][40][41][42][43] Therefore, the results should be carefully interpreted regarding the generalizability of the 10 kg threshold to the entire European pediatric KRT population.…”

“…Furthermore, small children represent a particularly vulnerable population regarding fluid and blood pressure management and immunosuppressive medication in the first weeks or months after Tx. [13][14][15][16][17][18] Currently, experts generally recommend performing Tx at a minimum weight of 10 kg. 13,15,16,19,20 Recently, Weitz et al 21 showed a 2-y graft survival of 100% for patients who received a Tx <10 kg.…”

“…Furthermore, small children represent a particularly vulnerable population regarding fluid and blood pressure management and immunosuppressive medication in the first weeks or months after Tx. 13-18…”