Paediatric kidney transplantation in under-resourced regions—a panoramic view

Abstract

Kidney transplantation is the ideal choice of kidney replacement therapy in children as it offers a low risk of mortality and a better quality of life. A wide variance in the access to kidney replacement therapies exists across the world with only 21% of low- and low-middle income countries (LLMIC) undertaking kidney transplantation. Pediatric kidney transplantation rates in these under-resourced regions are reported to be as low as < 4 pmcp [per million child population]. A robust kidney failure care program forms the cornerstone of a transplant program. Even the smallest transplant program entails a multidisciplinary workforce and expertise besides ensuring family commitment towards long-term care and economic burden. In general, the short-term graft survival rates from under-resourced regions are comparable to most high-income countries (HIC) and the challenge lies in the long-term outcomes. This review focuses on specific issues relevant to kidney transplants in children in under-resourced regions by highlighting limitations in the capacity and health workforce, regulatory norms, medical issues, economic burden, factors beyond financial hardship and ethical considerations relevant to these regions. Finally, the perspective of strengthening transplant programs in these regions should factor in the bigger challenges that exist in achieving the health-related sustainable development goals by 2030.

Addressing the Ethical Challenges of Providing Kidney Failure Care for Children: A Global Stance

“…Unfortunately, patient mortality (with a functioning graft) occurs and is usually due to serious infections or sepsis ( 77 , 103 ). Although short term graft outcomes are compatible with HIC, allograft survival at 5 years were consistently <80% and much lower at 10 years, in spite of the predominance of living donor transplants ( 81 ). The most frequently cited causes for graft loss were chronic rejection and infections ( 75 , 78 , 104 ).…”

“…The majority of transplants in LMICs are from living donors ( 81 , 85 ). There is insufficient investment in national deceased donor organ procurement and organ allocation networks in LMICs like India.…”

“…Pediatric kidney transplant centers in LMICs successfully perform transplants, with excellent short term graft survival but access to transplant and transplant centers remains limited (75)(76)(77)(78)(79). There are insufficient pediatric transplant centers and transplant rates for Sub-Saharan Africa and South East Asia remain absent or dismally low (80)(81)(82). Although cost-effective compared to dialysis, transplant is expensive and not a priority for government healthcare spending (83,84).…”

Time from kidney failure onset to transplantation and its impact on growth in pediatric patients

“…Despite this improvement in pediatric transplantations, a significant gap between organ supply and demand remains, representing an ongoing global challenge 20 . This dilemma is further exacerbated by the existence of regional disparities in transplant access both between continents and within countries 21,22 …”

Perspectives: Neonatal acute kidney injury (AKI) in low and middle income countries (LMIC)

“…What is unique about providing cKRT to a neonate is the long ICU stay that will be needed, especially, when morbidity can be significant, and long-term outcomes, including the prospect of transplantation, may well be guarded in this setting ( 30 , 40 ). Perhaps commencing cKRT on neonates is not really a feasible option for most LMICs right now.…”