Pearls and Pitfalls in Pediatric Kidney Transplantation After 5 Decades

Abstract

Worldwide, over 1,300 pediatric kidney transplantations are performed every year. Since the first transplantation in 1959, healthcare has evolved dramatically. Pre-emptive transplantations with grafts from living donors have become more common. Despite a subsequent improvement in graft survival, there are still challenges to face. This study attempts to summarize how our understanding of pediatric kidney transplantation has developed and improved since its beginnings, whilst also highlighting those areas where future research should concentrate in order to help resolve as yet unanswered questions. Existing literature was compared to our own data of 411 single-center pediatric kidney transplantations between 1968 and 2020, in order to find discrepancies and allow identification of future challenges. Important issues for future care are innovations in immunosuppressive medication, improving medication adherence, careful donor selection with regard to characteristics of both donor and recipient, improvement of surgical techniques and increased attention for lower urinary tract dysfunction and voiding behavior in all patients.

Approach to acute kidney injury following paediatric kidney transplant

“…Vascular causes that lead to graft dysfunction are transplant renal artery stenosis (TRAS) and renal vascular thrombosis. TRAS is an increasingly recognized cause of graft dysfunction and has been reported in 3–15% of paediatric transplant recipients [28 ▪ ,29]. This condition is typically diagnosed between 3 months and 2 years after transplantation.…”

“…The diagnosis is made by renal ultrasound with doppler. Anticoagulation therapy can be considered, with risks and benefits of this therapy weighed individually for each patient [28 ▪ ,31].…”

“…TRAS may be suspected in the setting of worsening or hard to manage hypertension in a patient with graft dysfunction [28 ▪ ]. Transplant renal ultrasound with doppler will support the clinical suspicion, and confirmation is with imaging, either computed tomography angiography or magnetic resonance angiography, or with arteriography.…”

Changes in graft outcomes in recipients <10 kg over 25 years of pediatric kidney transplantation in the United States

“…2 This was primarily due to challenges in donor-recipient size matching, a higher risk of surgical and infectious complications, and peri-transplant difficulties with fluid management and hemodynamics. [3][4][5] Pediatric transplantation has evolved considerably when compared to the earlier era of kidney transplantation, including changes in organ allocation policy, rates of living donor transplantation, surgical technique, and immunosuppression. 2,4,6 In more recent years, potential kidney recipients have been considered transplantable from weights as small as 7-8 kg depending on the surgical experience of the transplant surgeon.…”

“…However, the advent of pediatric kidney transplants was initially associated with poor outcomes, especially in smaller recipients 2 . This was primarily due to challenges in donor‐recipient size matching, a higher risk of surgical and infectious complications, and peri‐transplant difficulties with fluid management and hemodynamics 3–5 . Pediatric transplantation has evolved considerably when compared to the earlier era of kidney transplantation, including changes in organ allocation policy, rates of living donor transplantation, surgical technique, and immunosuppression 2,4,6 …”