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Saudi Journal of Kidney Diseases and Transplantation
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RENAL DATA FROM THE ARAB WORLD  
Year : 2014  |  Volume : 25  |  Issue : 4  |  Page : 895-899
Recipient characteristics and outcome of pediatric kidney transplantation at the king fahad specialist hospital-dammam


1 Multi Organ Transplant Center, King Fahad Specialist Hospital, Dammam, Saudi Arabia
2 Multi Organ Transplant Center, King Fahad Specialist Hospital, Dammam; College of Medicine, King Saud University, Riyadh, Saudi Arabia

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Date of Web Publication24-Jun-2014
 

   Abstract 

The success of a pediatric kidney transplantation program can only be judged by reviewing its results. We aim to audit our short-term outcome of pediatric kidney transplantation at the King Fahad Specialist Hospital-Dammam. A retrospective chart review was performed to collect data about recipient demographics, etiology of end-stage kidney disease, type of dialysis, type of donor and outcome. Between September 2008 and April 2012, 35 pediatric kidney trans­plantations (<16 year) were performed of a total of 246 kidney transplants (14.2%). The mean age was 8.1 years, with a mean weight of 23.3 kg, and there were 21 (60%) boys in the study. Kidney dysplasia/hypoplasia was the most common etiology (51.4%). Pre-emptive kidney transplantation was performed in six (17%) patients. Peritoneal dialysis was the most common mode of dialysis [24 (69%) children]. Living donation was the source of kidney allografts in 13 (37%) cases. During a mean follow-up of 1.5 years, one patient died and one graft was lost due to kidney vein thrombosis. The one year patient and graft survival rates were 97% and 94%, respectively. Efforts should now be focused on achieving optimal long-term results. There is also a need to encourage pre-emptive transplantation and living donation in this population.

How to cite this article:
Khan IA, Al-Maghrabi M, Kassim MS, Tawfeeq M, Al-Saif F, Al-Oraifi I, Al-Qahtani M, Alsaghier M. Recipient characteristics and outcome of pediatric kidney transplantation at the king fahad specialist hospital-dammam. Saudi J Kidney Dis Transpl 2014;25:895-9

How to cite this URL:
Khan IA, Al-Maghrabi M, Kassim MS, Tawfeeq M, Al-Saif F, Al-Oraifi I, Al-Qahtani M, Alsaghier M. Recipient characteristics and outcome of pediatric kidney transplantation at the king fahad specialist hospital-dammam. Saudi J Kidney Dis Transpl [serial online] 2014 [cited 2019 Dec 7];25:895-9. Available from: http://www.sjkdt.org/text.asp?2014/25/4/895/135209

   Introduction Top


Successful kidney transplantation has been established as the most optimal and cost-effec­tive kidney replacement therapy for all age groups. [1],[2],[3],[4] For children, it prevents the pro­blems associated with dialysis and improves their survival, growth and quality of life. [2],[5] Advances in surgical techniques, anesthesia, intensive care and immunosuppressive proto­cols contributed to significant improvement in the outcome of pediatric kidney transplan-tation. [5],[6] Despite all these advancements, kid­ney transplantation in children remains a challenge because of their small size and the scarcity of appropriate allografts. [7] The number of kidney transplantation candidates is expec­ted to increase because of better health care and ease of access to dialysis, [8] although the percentage of the pediatric patients on waiting lists may remain stable or decrease because of ageing of children on the waiting list, growth of the overall list and the preferential kidney allocation to children. [7]

The Eastern province is the third most popu­lous province in Saudi Arabia. [9] The King Fahad Specialist Hospital-Dammam (KFSHD) is the major transplant center in the region and it serves as a referral center. In this center, adult and pediatric kidney transplantation started in 2008.

In this study, we aim to review the recipient characteristics and outcome of pediatric kidney transplantation at the KFSHD.


   Materials and Methods Top


After local institutional review board appro­val, data were collected by a retrospective chart review for all pediatric kidney trans­plantation patients (up to 16 years) who were transplanted at the KFSHD from September 2008 to April 2012. Children transplanted else­where, but followed at the KFSHD, were ex­cluded. Data were collected about demogra­phics, etiology of kidney failure, dialysis type, donor type and outcome.


   Statistical Analysis Top


The data were analyzed using descriptive sta­tistical methods. The data are presented as number, percentage, range, mean and median.


   Results Top


A total of 246 patients underwent kidney transplantation at the KFSHD, of whom 35 (14.2%) were children (<16 years). The age of the patients ranged between 2 years 8 months and 15 years 9 months (median: 8 years 8 months, mean: 8.1 years). There were 21 (60%) boys in the study. The most common etiology of kidney failure in the study patients was kidney dysplasia/hypoplasia. Body weight at transplantation ranged between 11.3 and 72 kg (median: 17 kg, mean: 23.3 kg). Pre-emptive transplantation was performed in six (17%) patients. Each of these six patients underwent kidney transplantation from a living donor.

Peritoneal dialysis was the mode of therapy for 24 (69%) study children before transplan­tation, while hemodialysis was the mode for five (14%) children; three children from the peritoneal dialysis group were later shifted to hemodialysis. Thirteen (37%) kidney allografts were from living donors. All the allografts were transplanted in the retroperitoneum. The aorta, inferior vena cava or iliac vessels of the recipients were used for vascular implantation. Extra-vesical anastomosis between spatulated donor ureter and recipient bladder (neouretero-cystostomy) with ureteral stent was performed in all cases. The stent was removed in four to six weeks. Immunosuppression included in­duction with basiliximab or anti-thymocyte globulin, followed by tacrolimus, mycophe-nolate mofetil and rapidly tapered cortico-steroids. The duration of follow-up ranged between three days and four years (median: 1 year 6 months, mean: 1.57 years).

One patient died at home, but the cause of death was unknown and it did not seem to be related to graft dysfunction as he was seen in the clinic one month prior to death with satis­factory kidney function. One graft was lost due to kidney vein thrombosis and the graft was re­moved on the third post-operative day. The overall patient and graft survival rates were 97% and 94%, respectively. The results are summarized in [Table 1].
Table 1: Recipient characteristics and outcome of pediatric kidney transplantation.

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   Discussion Top


This is, to the best of our knowledge, the first report of pediatric kidney transplantation from the Eastern Province, since the inception of kidney transplantation in Saudi Arabia in 1979. [10],[11] Although the duration of follow-up of our patients was short, the patient and graft survival rates of 97% and 94% were encou­raging and comparable to those reported from Saudi Arabia and other parts of the world. [12],[13],[14],[15]

Establishment of pediatric kidney transplan­tation is a challenging task. Pre-requisites for the successful development of such a program include, but are not limited to, manpower, skills and expertise, infrastructure, administrative support and societal approval. A program may decide not to transplant children below a cer­tain age because of the lack of one or more of these items. [16],[17] Because of an appropriate set­up and the presence of a dedicated pediatric nephrology service, children of all ages and those above 10 kg were transplanted from the beginning at the KFSHD.

The prevalence and incidence of end-stage kidney disease (ESRD) in the pediatric popu­lation (up to 15 years) in Saudi Arabia have been estimated at 16.4 and 4.76 per million population, respectively. [18] This is comparable to the prevalence of ESRD in children in the United States. [19]

The percentage of children (14%) contri­buting to the total number of kidney trans­plants performed in our center was conside­rably higher than that from other centers (4- 7%). [16],[20],[21] This reflects a larger referral base and a wider range of acceptance criteria for kidney transplantation in the pediatric popu­lation at our center. There are more boys than girls in our cohort. Similar gender proportions have been reported from other centers and data bases. [12],[13],[16],[17],[20] This is related to the fact that males suffer more from congenital anatomical urogenital malformations than females in the pediatric age group. [13],[22]

The most common etiology of ESRD in our study was kidney dysplasia/hypopasia. Similar results have been reported from the United States [13] and previous reports from Saudi Ara-bia. [22] Almost 70% of the children were started on peritoneal dialysis, which is the preferred mode of dialysis in the pediatric age group. [13] This is technically easy and has a lesser risk of infection. Hemodialysis was reserved for older children, failure of peritoneal dialysis or contra­indication to peritoneal dialysis.

The trend for pre-emptive kidney transplan­tation is increasing with up to a quarter of patients transplanted in this manner. [13] We per­formed only six (17%) pre-emptive transplants. However, pre-emptive transplantation may not always be an option, especially in patients with Wilm's tumor or unavailability of a living donor. Both pre-emptive transplantation and living donation are potential areas for improve­ment in our program. [12],[23]

There are different surgical techniques des­cribed for graft implantation in pediatric reci­pients. Depending on the child's weight, the kidney may be implanted in the peritoneal cavity or in the retroperitoneum. [23] We, how­ever, always implanted the graft in the retro-peritoneum regardless of the weight of the child. This technique has the added advantage of not violating the peritoneal cavity, which can be used for dialysis post-transplant, in case it was needed.

During the follow-up period, we lost one graft and one patient died. The graft was lost in a 15-year-old boy who had ESRD due to fami­lial focal segmental glomerulosclerosis (FSGS) and received a kidney from a deceased donor. He developed graft kidney vein thrombosis on the third post-operative day, which could not be salvaged. He was later found to have hyper-coaguable state. The most common cause of death in pediatric kidney transplant recipients is infection, [13] and this could have contributed to the death of the second child.

Despite the limitation of retrospective review, this study shows that during the short term, our program of pediatric kidney transplantation has achieved optimal patient (97%) and graft (94%) survival rates. The focus should now be on achieving good long-term results. The transplanted children should be monitored closely and patients and their families should be educated to improve compliance, especially when they approach adolescence. Infection, cardiovascular morbidity and malignancy are other factors leading to failure in pediatric kidney transplantation besides non-compliance to immunosuppressive therapy. [5],[24],[25] Close sur­veillance and judicious use of immunosup-pression may reduce graft and patient loss from these factors. Equally important is not to overlook their mental and physical growth and social adjustment. [5],[26] The ultimate goal of kid­ney transplantation in these children with ESRD is to see them grow into successful adults who contribute positively to the wellness and deve­lopment of the family, society and country.

 
   References Top

1.Tonelli M, Wiebe N, Knoll G, et al. Systematic Review: Kidney transplantation compared with dialysis in clinically relevant outcome. Am J Transplant 2011;11:2093-109.  Back to cited text no. 1
    
2.Humar A, Nevins TE, Remucal M, Cook ME, Matas AJ, Najarian JS. Kidney transplantation in children younger than 1 year using cyclos-porine immunosuppression. Ann Surg 1998; 228:421-8.  Back to cited text no. 2
    
3.Knoll GA. Is kidney transplantation for every-one? The example of the older dialysis patient. Clin J Am Soc Nephrol 2009;4:2040-4.  Back to cited text no. 3
[PUBMED]    
4.Howard K, Salkeld G, White S, et al. The cost-effectiveness of increasing kidney transplan-tation and home-based dialysis. Nephrology 2009;14:123-32.  Back to cited text no. 4
    
5.Abe T, Ichimaru N, Kakuta Y, et al. Long-term outcome of pediatric kidney transplantation: A single center experience. Clin Transplant 2011; 25:388-94.  Back to cited text no. 5
    
6.Shapiro R, Sarwal MM. Pediatric kidney trans-plantation. Pediatr Clin North Am 2010;57: 393-400.  Back to cited text no. 6
    
7.Magee JC, Bucuvalas JC, Farmer DG, Harmon WE, Hulbert-Searon TE, Mendeloff EN. Pediatric transplantation. Am J Transplant 2004;4(Suppl 9):54-71.  Back to cited text no. 7
    
8.Moeller S, Gioberge S, Brown G. ESRD patients in 2001: Global overview of patients, treatment modalities and development trends. Nephrol Dial Transplant 2002;17:2071-6.  Back to cited text no. 8
    
9.Statistical year book 2009, Central Department of Statistics and Information, Kingdom of Saudi Arabia. Available from: http://www.cdsi.gov.sa [Last accessed on 15 January 2003].  Back to cited text no. 9
    
10.Al-Khader AA, Al-Sulaiman MH, Mousa DH, Hawas F. Some of the lessons learnt from kidney transplant recipients cared for at the Riyadh Armed Forces Hospital. Saudi J Kidney Dis Transplant 1996;7:139-44.  Back to cited text no. 10
    
11.Al-Dayel A, Ezzibdeh M, Daoud M, et al. Experience with kidney transplantation in the Eastern Province of Saudi Arabia. Saudi J Kidney Dis Transplant 1996;7:149-52.  Back to cited text no. 11
    
12.Souqiyyeh MZ, Al-Khader AA, Shaheen FA, Huraib SO, Al-Harbi M. Pediatric kidney transplantation in Saudi Arabia. Saudi J Kidney Dis Transplant 1997;8:302-9.  Back to cited text no. 12
    
13.NAPRTCS 2010 Annual Transplant Report. Available from: https://web.emmes.com/study/ped/annlrept/annlrept.html [Last accessed on 15 January 2003].  Back to cited text no. 13
    
14.El-Husseini AA, Foda MA, Bakr MA, Shokeir AA, Sobh MA, Ghoneim MA. Pediatric live-donor kidney transplantation in Mansoura Urology & Nephrology Center: A 28-year perspective. Pediatr Nephrol 2006;21:1464-70.  Back to cited text no. 14
    
15.Pitcher GJ, Beale PG, Bowley DM, Hahn D, Thomson PD. Pediatric kidney transplantation in a South African teaching hospital: A 20-year perspective. Pediatr Transplant 2006;0:441-8.  Back to cited text no. 15
    
16.Saeed MB, Sherif S. Pediatric kidney trans-plantation in Syria: A single center experience. Saudi J Kidney Dis Transplant 2005;16:342-7.  Back to cited text no. 16
    
17.Rizvi SA, Naqvi SA, Hussain Z, et al. Living-related pediatric kidney transplants: A single center experience from a developing country. Pediatr Transplant 2002;6:101-10.  Back to cited text no. 17
    
18.Al-Sayyari AA, Shaheen FA. End stage chro-nic kidney disease in Saudi Arabia. Saudi Med J 2011;32:339-46.  Back to cited text no. 18
    
19.U S Kidney Data System, USRDS 2012 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Kidney Disease in the United States, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2012. Available from: http://www.usrds.org [Last accessed on 15 January 2003].  Back to cited text no. 19
    
20.Heberal M, Bereket G, Karakayali H, Arslan G, Moray G, Bilgin N. Pediatric kidney trans-plantation in Turkey: A review of 56 cases from a single center. Peditr Transplantation 2000;4:293-9.  Back to cited text no. 20
    
21.2009 Annual Report of the U.S. Organ Pro-curement and Transplantation Network and the Scientific Registry of Transplant Recipients: Transplant Data 1999-2008. U.S. Department of Health and Human Services, Health Resources and Services Administration, Healthcare Systems Bureau, Division of Transplantation, Rockville, MD. Available from: http://www.ustransplant.org [Last accessed on 15 January 2003].  Back to cited text no. 21
    
22.Kari JA. Chronic kidney failure in children in the Western area of Saudi Arabia. Saudi J Kidney Dis Transplant 2006;17:19-24.  Back to cited text no. 22
    
23.Ruiz E, Ferraris J. 25 years of live related kidney transplantation in children: The Buenos Aires experience. Indian J Urol 2007;23:443-51.  Back to cited text no. 23
[PUBMED]  Medknow Journal  
24.Filler G, Huang SH. Progress in pediatric kid-ney transplantation. Ther Drug Monit 2010;32: 250-2.  Back to cited text no. 24
    
25.Gulati A, Sarwal MM. Pediatric kidney trans-plantation: An overview and update. Curr Opin Pediatr 2010;22:189-96.  Back to cited text no. 25
    
26.Bartosh SM, Leverson G, Robillard D, Sollinger HW. Long-term outcome in pediatric kidney transplant recipients who survive into adulthood. Transplantation 2003;76:1195-200.  Back to cited text no. 26
    

Top
Correspondence Address:
Iftikhar A. R. Khan
Multi Organ Transplant Center, King Fahad Specialist Hospital, P. O. Box 15215, MBC 067, Dammam - 31444
Saudi Arabia
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DOI: 10.4103/1319-2442.135209

PMID: 24969213

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