Living‐related pediatric renal transplants: 
A single‐center experience from a developing country

Abstract

We retrospectively analyzed the results of 75 living-related pediatric renal transplants performed at our center between January 1986 and December 1999. The major causes of end-stage renal disease (ESRD) were glomerulonephritis (26%) and nephrolithiasis (16%), while the etiology was unknown in 50%. The mean age of the recipients was 12 yr (range 6-17 yr) and that of the donors was 39 yr (range 20-65 yr). The majority (73%) of donors were parents. Eighty five per cent of donors were one-haplotype matched and the rest identical. Immunosuppression was based on a triple drug regimen. Thirty per cent of recipients were rapid metabolizers of cyclosporin A (CsA) (area under the curve [AUC]: < 6,000 ng/mL/h), while 16% were slow metabolizers (AUC: > 8,000 ng/mL/h). Forty three (57%) children encountered 59 rejection episodes, the majority of which (59%) were recorded in the first month post-transplant. Seventy-four per cent of the rejection episodes were steroid sensitive and the rest, except two, were resolved by therapy with antithymocyte globulin (ATG) or orthoclone thymocyte 3 (OKT3). After a mean follow-up of 37 months, 17 (22%) grafts had chronic rejection and 76% of these recipients had previously experienced acute rejection episodes. The overall infection rate was high, necessitating two hospital admissions/patient/year. The majority (53%) of the infections were bacterial. Urinary tract infections (UTIs) were seen in 17 (23%) recipients. Twelve of these had ESRD as a result of stone disease and eight grafts were lost because of UTIs. Eight per cent of recipients developed tuberculosis (TB), and extra-pulmonary lesions were seen in 50%. Surgical complications were encountered in eight patients. Free medication to all recipients and parental support ensured a compliance rate of 93%. Baseline growth deficit was seen in children of the two groups studied (the 6-12 yr and 13-17 yr age-groups), with Z-scores of - 2.39 and - 2.12, respectively. No growth catch-up was observed at 12 and 24 months in either group. Post-donation complications were seen most commonly in donors > 50 yr of age and included: proteinuria (> 300 mg/24 h, four patients), hypertension (three patients), and diabetes (one patient). Twenty-four grafts were lost, 54% as a result of immunological and the rest as a result of non-immunological causes, and 17 recipients died during the follow-up period. Infections were the main cause of patient and graft loss. Overall 1- and 5-yr graft and patient survival rates were 88% and 65%, and 90% and 75%, respectively.

Pediatric Kidney Transplantation in the Developing World: Challenges and Solutions

“…Our data of 801 biopsies in children showed primary GN in 87% and secondary GN in 6% of the patients (16) as compared to our earlier findings of 26% (11). Establishment of pediatric nephrology services in Turkey, Saudi Arabia and Kuwait have improved the care of children with CKD and ESRD (13)(14)(15).…”

“…A challenge in many countries is to convince the parents that transplantation is a successful mode of therapy, as there are apprehensions on long-term graft and patient survival (11). In a low socioeconomic backdrop kidney donors have fears of postdonation medical problems and compromised ability to earn a livelihood (33).…”

“…The etiology of ESRD shows wide variations, glomerulonephritis in 8-40% and congenital urologic/cystic diseases in 8-80% of the cases. In some countries neglected and misdiagnosed stone disease lead to ESRD where rates vary from 2.6% in Turkey, 9% in Sudan, to 16% in Pakistan (6,10,11).…”

The risk of tuberculosis in transplant candidates and recipients: a TBNET consensus statement

“…However, published reports of small numbers of cases from single institutions suggest that rates of TB following liver transplantation in children range from 2.4% in non-endemic areas to 3.6% in highly endemic areas [140,141] while rates following renal transplantation of 8-9.7% have been reported from highly endemic areas [142,143]. In agreement with reports in adults, the incidence of TB following bone marrow transplantation is lower than that observed with SOT, with rates of 1.7% reported in a retrospective study in India [144].…”

“…Children, particularly of very young age, who develop TB are more prone to present with extrapulmonary and disseminated forms compared to adults, a risk that is also reflected in the presence of immunosuppression [147]. Whilst the majority of reported cases of TB in paediatric transplant recipients are pulmonary, some case series report frequencies of disseminated disease and extrapulmonary disease in excess of 50% [141][142][143][144]148]. Compared to the adult population, children who develop TB have an increased risk of death.…”