Peri-operative kidney injury and long-term chronic kidney disease following orthotopic heart transplantation in children

Abstract

Significant advances in cardiac intensive care including extracorporeal life support have enabled children with complex congenital heart disease and end-stage heart failure to be supported while awaiting transplantation. With an increasing number of survivors after heart transplantation in children, the complications from long-term immunosuppression, including renal insufficiency, are becoming more apparent. Severe renal dysfunction after heart transplant is defined by a serum creatinine level >2.5 mg/dL (221 μmol/L), and/or need for dialysis or renal transplant. The degree of renal dysfunction is variable and is progressive over time. About 3–10 % of heart transplant recipients will go on to develop severe renal dysfunction within the first 10 years post-transplantation. Multiple risk factors for chronic kidney disease post-transplant have been identified, which include pre-transplant worsening renal function, recipient demographics and morbidity, peri-transplant haemodynamics and long-term exposure to calcineurin inhibitors. Renal insufficiency increases the risk of post-transplant morbidity and mortality. Hence, screening for renal dysfunction pre-, peri- and post-transplantation is important. Early and timely detection of renal insufficiency may help minimize renal insults, and allow prompt implementation of renoprotective strategies. Close monitoring and pre-emptive management of renal dysfunction is an integral aspect of peri-transplant and subsequent post-transplant long-term care.

A Single-Center Experience of the Optimal Initial Immunosuppressive Strategy for Preventing Early Acute Cellular Rejection in Orthotopic Heart Transplantation Associated With Renal Dysfunction

“…These include the presence of significant renal dysfunction (estimated glomerular filtration rate <50 mL/min or creatinine >150 mmol/L), complex congenital heart disease, ventricular assist device (VAD) patients, or prolonged and/or complex surgery with the potential for destabilizing bleeding. 12 The decision between basiliximab alone and using the combination of ATG plus basiliximab was based on the discretion of treating cardiologist. In these patients either delayed tacrolimus or the CNI-sparing agent everolimus was added within the first week depending on renal function.…”

“…These include the presence of significant renal dysfunction (estimated glomerular filtration rate <50 mL/min or creatinine >150 μmol/L), complex congenital heart disease, ventricular assist device (VAD) patients, or prolonged and/or complex surgery with the potential for destabilizing bleeding. 12…”

Subclinical cardiovascular changes in pediatric solid organ transplant recipients

“…Another common point may be the extent of kidney damage occurring during the transplantation process. It is indeed significant after kidney transplantation due to the ischemia–reperfusion injury, but it may also be important in lung and heart transplant recipients. Even in the case of a given organ, there may be disparities due to the primary disease.…”

Acute Kidney Injury in Pediatric Heart Failure

“…In the patient receiving orthotopic heart transplantation (OHT), there are a myriad of risk factors for developing AKI, including pre-transplant low cardiac output; over diuresis and inability to optimize decongestion in volume overloaded patients prior to OHT; ischemia/reperfusion during transplantation - particularly if the OHT is for failed single ventricle palliation as the duration of CPB may be longer; isolated right heart failure; primary graft failure or delayed function; and the use of calcineurin inhibitors (CNI) amongst other nephrotoxic medications. The CPB induced capillary leak and vasoactive agents commonly used following surgery combined with CNIs could lead to changes in renovascular resistance and therefore alter renal perfusion [ 51 ]. The incidence of AKI in OHT patients varies according to the definitions used.…”