| Abstract|| |
To evaluate our experience with pediatric renal transplantation at King Hussein Medical Center, the medical records of 71 pediatric patients who underwent a renal transplantation procedure between the years 2004 and 2010 or started follow-up at our center within one week of transplantation done elsewhere were reviewed. Over the seven-year period, 71 children under the age of 14 years who received their first renal transplant were studied. About 56% (40) were males. The mean age was 9.44 ± 2.86 years. Dysplastic kidney was the most common cause of end-stage renal failure in our group, followed by glomerulonephritis. Mothers were the donors in 39.4% of the cases, followed by fathers. Twenty-three patients (32.4%) were transplanted preemptively. The overall one-year graft survival was 96%, three-year survival was 95%, and the five-year survival was 88%. Prednisone, tacrolimus, and mycophenolate mofetil formed the main-stay of immunosuppressive agents. We have developed a successful live donor program for renal transplantation in children at King Hussein Medical Center in Amman. Although our experience is still short, the graft survival is similar to that achieved in the developed world, especially with preemptive transplant.
|How to cite this article:|
Hazza I, Al-Mardini R, Salaita G. Pediatric renal transplantation: Jordan's experience. Saudi J Kidney Dis Transpl 2013;24:157-61
|How to cite this URL:|
Hazza I, Al-Mardini R, Salaita G. Pediatric renal transplantation: Jordan's experience. Saudi J Kidney Dis Transpl [serial online] 2013 [cited 2020 Jun 6];24:157-61. Available from: http://www.sjkdt.org/text.asp?2013/24/1/157/106361
| Introduction|| |
Renal replacement therapy (RRT) in the pediatric population is provided through hemodialysis, peritoneal dialysis, and renal transplantation. Among these, renal transplantation remains the choice of RRT for children with end-stage renal failure (ESRF). , It provides a higher quality of life, improves the potential for growth, neurodevelopment, and school performance than with any form of dialysis therapy. , It is also cost effective.
Jordan is a country with a population of 6.13 million, with 37.3% below the age of 15.  King Hussein Medical Center (KHMC) is the only hospital in Jordan where renal transplant is performed for pediatric patients. This study was conducted to evaluate the Jordanian experience of pediatric renal transplantation at KHMC.
| Patients and Methods|| |
This retrospective study was done with the aim to document and evaluate our results and compare them with the international experience. Medical records of all pediatric patients below the age of 14 (totally 71), who underwent renal transplantation and were being followed up at the Pediatric Nephrology Unit at KHMC between January 2004 and July 2011, were reviewed and the demographic characteristics, etiology of ESRF, immunosuppressant drugs used, rejection episodes, surgical and other complications, recurrence of primary disease, and graft survival rates were recorded. Statistical methods used were simple descriptive studies in addition to Kaplan-Meier method for measuring graft survival analysis.
| Results|| |
A total of 71 patients were followed up in the period between January 2004 and July 2011; 62 patients were transplanted at KHMC and nine patients were those who started their follow-up at our center within one week of their transplantation done outside Jordan.
Forty patients (56.4%) were males, while 31 (43.6%) were females; 46.5% were between ten and 12 years of age and 42.2.1% were between four and nine years of age [Figure 1]. The mean age was 9.44 ± 2.86 years. The youngest was aged four years with a weight of 12 kg. As shown in [Figure 2], the highest number of transplants was in the year 2008.
The causes of chronic kidney disease (CKD), shown in [Figure 3], were multicystic dyplastic kidney disease in 21 patients (29.7%), reflux nephropathy in ten cases (14%), and focal segmental glomerulosclerosis (FSGS) in ten (14.8%).
Sixty-nine kidneys were donated from living donors. Twenty-eight (39.4%) were mothers and 22 (31%) were fathers; ten (14.1 %) donors were second-degree relatives, while nine (12.7%) of the donors were non-related where kidney transplantation was done outside Jordan. It is illegal in Jordan to accept and transplant kidney from a non-related donor. Two (2.8%) brothers with ESRF secondary to familial-type FSGS received pediatric cadaveric renal transplant done for the first time to children in Jordan. Pre-emptive kidney transplant was performed in 23 cases (32.4%) and all pre-emptive renal transplants were performed at glomerular filtration rate (GFR) of 10-15 mL/ 1.73 m 2 /min. Prednisone, tacrolimus, and mycophenolate mofetil were the main immunosuppressive agents.
The one-year graft survival was 96%, the three-year survival was 95%, and the five-year survival was 88% [Figure 4].
Forty-two patients (59%) had no complications. Cytomegalovirus (CMV) infection due to reactivation occurred in eight patients. Prophylactic gancyclovir was given for high-risk patients where the donor was CMV positive and the recipient was negative, and also for patients who received Antithymoglobuline. Diabetes mellitus occurred in four patients, and surgical complications occurred in five patients as four patients developed ureteric stenosis during the first six months post-transplantation and needed ureteric reimplantation and one patient had a flap dissection [Figure 5].
Graft failure was defined by the need for replacement therapy or death with functioning graft, and was noted in eight (11.3%) patients. Out of five patients who were transplanted with primary diagnosis of FSGS, one case had recurrence, which resulted in graft loss. Other causes of graft loss were vascular thrombosis in one patient, chronic allograft nephropathy in three patients, bleeding due to intimal flap dissection in one patient, and recurrence of the original disease in one patient with primary mesangiocapillary glomerulonephritis.
| Discussion|| |
Epidemiological studies on renal diseases from the Arab countries in North Africa and the Middle East are very scant. They are primarily based on patients referred to tertiary medical centers. There are no regional pediatric nephrology societies in place to collect and publish any valid epidemiological data.  The incidence rates of end-stage renal disease (ESRD) in the developed countries are 6.9 and 21.8 per million population in the 0-4-year-old age group and 15-19-year-old age group, respectively. 
The incidence of ESRD in Jordanian children was calculated to be 14.5 patients per million population among those younger than 14 years of age,  while the prevalence of CKD among Jordanian children in the year 2004 was 75 patients per million child population.  In Jordan, the prevalence of severe CKD (creatinine clearance <30 mL/min/1.73 m 2 ) was calculated to be 51 per most-at-risk populations (MARP), based on Jordan University Hospital admission rate in 2003.  This is somewhat comparable to the incidence and prevalence in other countries such as in Italy (ItalKid Project)  where the mean incidence of pre-terminal CKD (CCr <75 mL/min/1.73 m 2 ) was 12.1 cases per year per million of the age-related MARP, with a point prevalence of 74.7 per MARP in children younger than 20 years of age.  Our results are also comparable to those of other European countries such as Sweden where the annual incidence and prevalence were 7.7 and 21 per MARP, respectively,  as well as France (Lorraine) where the incidence rate of severe pre-terminal CKD has been estimated to be 7.5 per MARP in children younger than 16 years.  The prevalence rate ranged from 29.4 to 54 per MARP. 
Living donor kidney donation has become increasingly the standard and routine procedure for kidney transplantation. An increase in living kidney donation could be observed in some centers over the years and it gives better short- and long-term graft and patient survival. ,, The rate of living donation varies in different countries: in Germany 18%,  North America 60%,  and UK 25%,  and this depends on the cultural and social beliefs as well as the nature of donation in the transplantation programs. In Jordan, all the transplanted kidneys were taken from living donors since there were no available cadaveric kidneys due to cultural beliefs, which, on the other hand, contribute to the good survival rate in our pediatric renal transplants.
The primary renal disease in the recipients is shown in [Figure 2]. Structural diseases such as renal hypoplasia or dysplasia and reflux nephropathy were the most prevalent etiologies in our pediatric patients, followed by glomerulonephritis, mainly FSGS, which is nearly comparable to other countries such as Australia  where 64% was due to congenital and 36% due to acquired diseases, mainly FSGS. In Germany,  the figures were 49.4% for dysplasia and 30% for FSGS.
Preemptive kidney transplantation not only avoids the risks, cost, and inconvenience of dialysis, but is also associated with better graft survival than transplantation after a period of dialysis. Preemptive transplantation has favorable long-term results with better graft function and survival in addition to psychological and financial benefits, compared with transplant performed after a period of dialysis, particularly within the live donor cohort. In children with chronic renal failure, attempt should be made to perform preemptive transplant if a suitable donor is available.  Our data showed that 23 patients (32.4%) were transplanted pre-emptively which improved the outcome and graft survival.
Prednisone, tacrolimus, and mycophenolate mofetil formed the mainstay of immunosuppressive agents used in our patients. Cyclosporine was used in two patients; one was transplanted abroad and the other one was shifted from tacrolimus to cyclosporine due to the development of diabetes mellitus. All patients were kept on low-dose steroids.
The one-year cumulative graft survival was 95.5%, three-year survival was 90.4%, and the five-year survival was 80.2%. Scant data is available for comparison with nearby countries. However, a report from Saudi Arabia shows the 15-year survival rate for grafts from living donors to be 92%.  Another report from Egypt showed the one-, five-, and ten-year graft survival for live related donor recipients to be 94.18%, 76.2%, and 46.6%, respectively. 
We have developed a successful live donor program for renal transplantation in children at the KHMC in Amman. Although our experience is still short, the graft survival is similar to that achieved in the developed world and has reached international standard, especially with preemptive transplant.
| References|| |
|1.||Webb NJ, Johnson R, Postlethwaite RJ. Renal transplantation. Arch Dis Child 2003;88:844-7. |
|2.||Al Akash SI, Ettenger RB, Danovitch GM. Kidney transplantation in children in, Hand book of Kidney Transplantation 3 rd ed. Philadelphia: Lippincott Williams and Wilkins Philadelphia; 2001. p. 332-64. |
|3.||Jordan Statistic Department Report, 13 issue 2010. |
|4.||Coresh J, Astor BC, Greene T, Eknoyan G, Levey AS. Prevalence of chronic kidney disease and decreased kidney function in the adult US population: Third National Health and Nutrition Examination Survey. Am J Kidney Dis 2003;41:1-12. |
|5.||Canadian Institute for Health Information. Health Services Databases. Available from: http://www.cihi.Ca |
|6.||Sacca E, Hazza I. Pediatric End-stage Renal disease: single center analysis. Saudi J Kidney Dis Transpl 2006;17:581-5. |
|7.||Sacca E, Hazza I, Hadidin R, Qsoussous A. Etiology of chronic renal failure in children: Experience at King Hussein Medical Center. J Royal Med Serv 2008;15(11):17-22 |
|8.||Hamed RM. The spectrum of chronic renal failure among Jordanian children. J Nephrol 2002;15:130-5. |
|9.||Ardissino G, Dacco V, Testa S, et al. Epidemiology ofchronic renal failure in children: Data from the Ital Kid project. Pediatrics 2003;111:382-7. |
|10.||Esbjorner E, Berg U, Hansson S. Epidemiology of chronic renal failure in children: A report from Sweden 1986-1994. Pediatr Nephrol 1997;11:438-42. |
|11.||Deleau J, Andre JL, Briancon S, Musse JP. Chronic renal failure in children: An epidemiological survey in Lorraine (France). Pediatr Nephrol 1994;8:472-6. |
|12.||Webb NJ, Johnson R, Postlethwait RJ. Renal transplantation. Arch Dis Child 2003;88:844-7. |
|13.||El-Mekresh M, Osman Y, Ali-El-Dein B, El-Diasty T, Ghonein MA. Urological complication after living- on or renal transplant. BJU Int 2001;87:295-306. |
|14.||Warady BA, Hebert D, Sullivan EK, Alexander SR, Tejani A. Renal transplantation, chronic dialysis and chronic renal insufficiency in children and adolescents. The 1995 Annual Report of the North American Paediatric Renal Transplant Cooperative Study. Pediatr Nephrol 1997;11:49-64. |
|15.||Mehrabi A, Kashji A, Önshoff BT, et al. Long-term result of paediatric kidney transplantation at the University of Heidelberg: A 35 year single-centre experience. Nephrol Dial Transplant 2004;19 (Suppl 4):iv69-74. |
|16.||Uddin GM, Hodson EM. Renal Transplantation: Experience in Australia. Indian J Pediatr 2004;71: 137-40. |
|17.||Moudgil A. Renal Transplantation. Indian J Pediatr 2003;70:257-64. |
|18.||Souqiyyeh MZ, Al-Khader AA, Shaheen FA, Huraib SO, Al-Harbi M. Pediatric Renal Transplantation in Saudia Arabia. Saudi J Kidney Dis Transpl 1997;8:302-9. |
|19.||Gheith O, Sabry A, El-Baset SA, et al. Study of the effect of donor source on graft and patient survival in pediatric renal transplant recipients. Pediatr Nephrol 2008;23:2075-9. |
Pediatric Nephrologist, King Hussein Medical Center, Amman
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]