The World's Youngest Cadaveric Kidney Transplant: Medical, Surgical and Ethical Issues

Abstract

BackgroundWe report here the first successful transplant from a preterm cadaveric donor. This was performed in November 1994. The donor, who had been born at about 33 weeks of gestation, was diagnosed as having agenesis of the corpus callosum. The transplant was carried out 10 days after the donor's birth. The recipient was a 17-month-old boy with a diagnosis of Denys-Drash syndrome (WT1 mutation).MethodWe describe and analyze the ethical, social, cultural, medical and surgical issues encountered and how these were addressed. The major issue of determining death in a beating heart, very young donor was dealt with in the absence of worldwide experience and guidelines.ResultsThe transplanted recipient has lived with the grafted pair of kidneys for more then 22 years. He has led a relatively normal life.ConclusionsIt is possible for immature preterm deceased donor kidneys to be transplanted into a 17-month-old recipient and for the grafted kidneys to grow with the recipient and function for 22 years. There were challenges in ethically determining the death of the donor, in surgical techniques to obviate potential surgical complications, and in postoperative care of the recipient, but these were managed successfully.

Kidney transplantation with allografts from infant donors—Small organs, big value

“…In addition to that, a recent case report demonstrated excellent long‐term graft survival 22 years after transplantation of a kidney from a 33 weeks gestational age donor 18 . Analysis of nephrogenesis in human fetal kidneys shows that the development of glomeruli within the fetal kidneys is directly proportional to the gestational age and is ongoing up to the 37th gestation week 18 . The concept of immature kidney allografts from infant donors should be abandoned, as actual clinical data no longer support such a hypothesis.…”

“…This result is in contrasts to historical data that attributed inferior results to infant donor kidneys 17 . In addition to that, a recent case report demonstrated excellent long‐term graft survival 22 years after transplantation of a kidney from a 33 weeks gestational age donor 18 . Analysis of nephrogenesis in human fetal kidneys shows that the development of glomeruli within the fetal kidneys is directly proportional to the gestational age and is ongoing up to the 37th gestation week 18 .…”

Kidney transplantation outcomes for adult recipients of pediatric donor kidneys

“…The increased filtration rate, when sustained over a long period of time, leads to compensatory glomerular hypertrophy and eventual global sclerosis and allograft dysfunction. However, separate analysis has shown the number of nephrons in a kidney is finalized by 36 weeks of gestation; hence, a baby born at term has the same number of nephrons as an adult kidney 3 . Furthermore, studies exploring the impact of this “hyperfiltration hypothesis” in adults have found no significant difference in long‐term outcomes when donor mass is greater or smaller than to the recipient 13,14 .…”

“…Operative difficulties and the smaller vessel size lead to increases in the incidence of transplant renal artery stenosis, which is reported in approximately 30% of recipients of pediatric donor kidneys, compared with 2‐5% in recipients of adult kidneys 1 . Furthermore, adult recipients of pediatric donor kidneys are noted to have an increased risk of hemorrhage, vessel angulation, and graft thrombosis 2‐4 . In addition to these surgical factors, the “hyperfiltration hypothesis” proposes that decreased nephron mass from pediatric donors may result in nephron exhaustion, due to size mismatch.…”