|Year : 2018 | Volume
| Issue : 6 | Page : 1303-1310
|A single-center 4-year experience with 47 pediatric renal transplants: Evolving trends
Hany M El Hennawy1, Ahmed Al Hashemy2, Nafaa Al Harbi3, Wael T Habhab4, Ahmed E Fahmy2
1 Department of Surgery, Section of Transplantation, Renal Transplant Unit, King Faisal Specialist Hospital and Research Center, Jeddah; Transplant Surgery Section, Surgery Department, Armed Forces Hospital-Southern Regions, Khamis Mushayt, Saudi Arabia
2 Department of Surgery, Section of Transplantation, Renal Transplant Unit, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
3 Department of Pediatric Nephrology, Renal Transplant Unit, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
4 Department of Nephrology, Renal Transplant Unit, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
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|Date of Submission||22-Oct-2017|
|Date of Acceptance||09-Jan-2018|
|Date of Web Publication||27-Dec-2018|
| Abstract|| |
Outcome of pediatric kidney transplantation (KT) has improved over the last several decades. We retrospectively reviewed the outcomes pediatric KT in King Faisal Specialist Hospital and Research Center-Jeddah, Saudi Arabia. Between May 2013 and November 2016, we performed renal transplantation in 47 children, 30 (64%) males, and 17 (36%) females. All patients received antibody induction with basiliximab or antithymocyte globulin along with triple immunosuppressive therapy with tacrolimus, mycophenolate mofetil and steroids. Twenty-four (51%) and 14 (30%) patients were on hemodialysis and peritoneal dialysis, respectively. Average duration on dialysis was 18.3 months. Nine patients (19%) had preemptive transplant. Forty-five patients (95.7%) received kidneys from living donors, 38 (83%) males and nine (17%) females, mean age (years), and body mass index were 30.8 ± 8.82 and 23.8 ± 4.54, respectively. Forty-one donors had left nephrectomy. Four right nephrectomies were reported, all of them were through open nephrectomy. Open nephrectomy was reported in 21 (46%) patients. Several laparoscopic nephrectomy techniques were performed; conventional laparoscopic donor nephrectomy, laparo-endoscopic single-site donor nephrectomy, and hand-assisted laparoscopic surgery in 10, 11, and three patients, respectively. The most common etiologies of end-stage renal disease were focal segmental glomerulosclerosis 19%, posterior urethral valve 8.5%, and congenital abnormalities 8.5% respectively. With a mean follow-up of 54 months, one and 4-year graft survival rates were 95.7% and 91.5%, respectively. One-and four-year patient survival rates were 100%. Outcomes were similar in patients < or ≥10 years. The graft survival was comparable in laparoscopic versus open donor nephrectomy (P = 0.72). Average serum creatinine was 0.85, 0.79, 0.79, and 0.84 at 7, 30, 90, 365 days, respectively. Four patients lost their graft due to renal vein thrombosis, chronic allograft nephropathy (cadaveric donor), Antibody-mediated rejection, and hemolytic-uremic syndrome at 0.75, 9, 19, and 24 months, respectively. The incidences of acute rejection and major infection were 2% and 4%, respectively. One patient developed posttransplant lympho-proliferative disease that was treated and is still with excellent graft function. Our pediatric KT experience is encouraging. Acute rejection, patient, and graft survival rates are similar and even better than many of western reports.
|How to cite this article:|
El Hennawy HM, Al Hashemy A, Al Harbi N, Habhab WT, Fahmy AE. A single-center 4-year experience with 47 pediatric renal transplants: Evolving trends. Saudi J Kidney Dis Transpl 2018;29:1303-10
|How to cite this URL:|
El Hennawy HM, Al Hashemy A, Al Harbi N, Habhab WT, Fahmy AE. A single-center 4-year experience with 47 pediatric renal transplants: Evolving trends. Saudi J Kidney Dis Transpl [serial online] 2018 [cited 2019 Jan 23];29:1303-10. Available from: http://www.sjkdt.org/text.asp?2018/29/6/1303/248297
| Introduction|| |
The annual incidence of end-stage renal disease (ESRD) is reported to be 7.8 children/ million children below the age of 20. Kidney transplantation (KT) is the treatment of choice of pediatric ESRD., Seventeen thousand and four hundred forty-six pediatric kidney-only transplants performed in the United States between 1987 and 2012. The prevalence of pediatric transplantation is low in developing countries; <1–5 per million child population.
Several difficulties are seen in pediatric patients with renal failure which include hospita-lizations, psychosocial effects of dialysis, immature immune system, technical problems, and donor matching according to body size. Moreover, the potential for post renal transplant complications is greater in children than in adults.,,,
Outcomes after pediatric KT have improved significantly over time for all recipient subgroups, especially for highly sensitized recipients. Most improvement in graft and patient survival has come in the first year after transplantation. One-and five-year graft survival of 96% and 81%, respectively. The aim of this study to review the outcomes of pediatric KT in our center.
| Methods|| |
This is a retrospective chart review study of 47 pediatric KT performed at King Faisal Specialist Hospital and Research Center-Jeddah, Saudi Arabia during the period between May 2013 and November 2016. Standardized recipient selection and management protocols were followed with no exclusion criteria used. Donor and recipient medical records were reviewed, after approval from the Institutional Review Board. The variables analyzed were etiology of ESRD in these patients, relationship to donors, kidney retrieval procedure, donor renal vascular anomalies, surgical complications, rejection episodes, immunosup-pression regimens, compliance to immuno-suppression, graft survival, and overall survival (at 1,4 years).
Delayed graft function (DGF) was defined as the need for dialysis for any reason in the first week following transplantation. Renal allo-graft loss was defined as death with a functioning graft (DWFG), allograft nephrectomy, resumption of dialysis, re-transplantation, or return to the pre-transplant serum creatinine (SCr) level. Chronic graft dysfunction was defined as a persistently raised SCr of 2 mg/dL or more for more than three months.
Recipients evaluation and management
All recipients underwent a comprehensive pre-transplant medical, psychosocial, and financial evaluation, with emphasis placed on the cardiovascular system to determine operative risk.
Kidney transplant patients received depleting antibody induction with either Basiliximab 20 mg infused over 20–30 min intravenous as a single intra-operative dose or rabbit anti-thymocyte globulin (for immunologically high risk) at a dose of 1.5 mg/kg (maximum dose, 150 mg based on actual body weight) for 3–7 doses depending on initial graft function. Maintenance immunosuppression consisted of tacrolimus, mycophenolate mofetil, and steroids.
We used a standard open retroperitoneal surgical technique for all patients. Only in one patient with occluded both iliac and femoral vessels bilaterally, we had to do intraperitoneal implantation.
All patients received surgical site prophylaxis with a first-generation cephalosporin for 24 h, antifungal prophylaxis with nystatin or fluco-nazole for one month, and anti-pneumocystis prophylaxis with sulfamethoxazole-trimetho-prim (dapsone if allergic to sulfa) for at least 12 months. Antiviral prophylaxis consisted of oral valganciclovir for three to six months, depending on donor and recipient cytomegalo-virus serologic status. Posttransplant renal allograft function was evaluated by measuring SCr levels as well as estimating glomerular filtration rate using the abbreviated Modification of Diet in Renal Disease formula.
| Statistical Analysis|| |
Endpoints included patient survival as well as uncensored and death-censored graft survival. Other study endpoints included DGF and renal allograft function. Data were analyzed with Statistical Package for the Social Science software version 13.0 (SPSS Inc., Chicago, IL, USA). Actuarial patient and graft survival curves were also computed using the Kaplan–Meier method. Categorical data were summarized as proportions and percentages and continuous data were summarized as means and standard deviations.
| Results|| |
Between May 2013 and November 2016, we performed KT in 47 children, four through 17 years of age (mean 10.9 ± 3.79) including 29 patients (62%) who were aged 14 and younger with average body mass index (BMI) and weight (kg) were 16.4 ± 3.29 and 24.9 ± 3.85, respectively. The study group included 30 (64%) males/17 (36%) females. Forty-five patients (95.7%) received kidneys from living donors. Twenty-four (51%) and 14 (30%) patients were on hemodialysis (HD) and peritoneal dialysis, respectively. Nine patients (19%) had preemptive transplant. Average duration on dialysis was 18.3 months [Table 1].
Etiologies of ESRD [Table 2] were focal segmental glomerulosclerosis (FSGS) (n = 9), post-urethral valve (n = 4), congenital (n = 4), Alport syndrome (n = 2), autosomal recessive polycystic kidney disease (n = 2), chloride losing diarrhea (n = 2), hereditary nephritis (n = 2), neurogenic bladder (n = 2), Ig A nephro-pathy (n = 1), and others/unknown (n = 19).
Postsurgical complications included four patients lost their graft due to renal vein thrombosis, chronic allograft nephropathy (cadaveric donor), antibody-mediated rejection (ABMR), and hemolytic-uremic syndrome at 0.75, 9, 19, and 24 months, respectively. One patient developed (posttransplant lymphopro-liferative disease that was treated and still with excellent graft function [Table 3]. No major infections were reported.
One case of primary nonfunction; the smallest recipient (11 kg), postoperative allograft ultrasound revealed poor perfusion with suspicion of venous thrombosis, immediate exploration on the first postoperative day (POD) was done and anastomosis was redone. Unfortunately, the renal function did not improve and graft nephrectomy was done after three weeks. The second exploration was for adhesiolysis of bowel obstruction on POD14.
Retroperitoneal implantation was done in all cases except one that was done intraperitoneal as his iliac and femoral vessels were occluded bilaterally. Anastomosis was done to the aorta and small unnamed venous collateral. Postope-ratively, this patient had ureteral stricture requiring re-stenting. There were no problems in closure of wound in any patient. We used the external iliac artery for anastomosis in 32 patients (68%) and the common iliac artery in 15 patients (32%).
With a mean follow-up of 54 months, one-and four-year graft survival rates were 95.7% and 91.5%, respectively. One-and four-year patient survival rates were 100% [Figure 1]. There were no re-transplants. The graft survival was comparable in laparoscopic versus open donor nephrectomy (P = 0.72) and in single versus multiple renal arteries in the donor kidney (P = 0.63). Outcomes were similar in patients < or ≥10 years. Average serum creatinine was 0.85, 0.79, 0.79, and 0.84 mg/dL at 7, 30, 90, and 365 days respectively.
Living donors [Table 4] were 38 males (83%) and nine females (17%), mean age 30.78 ± 8.82 years and BMI were 30.8 ± 8.82 and 23.8 ± 4.54, respectively. Forty-three donors (91.5%) had left nephrectomy. Four right nephrec-tomies (8.5%) were reported, all of them were through open nephrectomy. Open nephrectomy was reported in 21 (44.7%) patients. Several laparoscopic nephrectomy techniques were performed; conventional laparoscopic donor nephrectomy, laparoendoscopic single site donor nephrectomy and hand-assisted laparos-copic donor nephrectomy in 10, 11, and three patients, respectively.
| Discussion|| |
In our study, the most common age group was six to 12 year (53%) and our mean age was 10.9 ± 3.79 years, while according to the North American Pediatric Renal Transplant Cooperative Study (NAPRTCS) 2014 annual report, the most common age group was 13–17 year (39.2%) and 52.7% of patients were at or below 12 years of age. It is thus clear that transplantation is performed in comparatively younger children (range 6–12 years) in our set up. This difference may be attributed predominantly to the lack of a cadaveric donor program. In addition, the annual report of the NAPRTCS in 2014 also states that 40.9% of pediatric transplant recipients were female vs. only 36% in our series. Nineteen percent of the transplants were pre-emptive in our series as compared with 25% in the NAPRTCS registry. It is also worth mentioning here that 96% of patients in this series received living donor renal transplantation compared with the NAPRTCS registry data, which showed 50% cadaveric renal transplantations. The mean age of the donors in our study was 30.78 ± 8.82 years, comparable to 37.6 ± 7.5 years as mentioned by Mehrabi et al.
In a series by Rabih et al, the authors used the common iliac artery for anastomosis in 50 cases (96%) and the internal iliac artery in two cases (4%). In our series, majority of arterial anastomoses were to the external iliac arteries. The common iliac artery was used in 15 recipients (32%) (13 single vessel and 2 multiple vessel donors). These differences are probably due to the age differences in patient’s cohort as well as institutional experience and surgeon preferences.
Emiroğlu et al in their series of 73 patients had reported the incidence of perirenal hematoma that required early postoperative reexplo-ration in two patients (2.7%), lymphocele in four cases, (5.5%) and urinary leakage in one case (1.4%), which resolved spontaneously in all five cases. In other series, the incidence of lymphocele ranges from of 0% to 20%. The incidence of transplant renal artery stenosis ranges from 1%–23% in different series on pediatric renal transplantations.,, Decreased blood supply to the donor ureter and faulty surgical techniques are the main causes of urologic complications; however, other problems, such as immunosuppressive drugs and rejections, can cause late obstruction. Although low-dose steroid protocols and meticulous operative techniques tend to reduce the incidence or urologic complication.
In our cohort, 11 postsurgical complications were noted in six patients [Table 3]. We had one patient (2%) of ureteric stricture compared with the literature (2.5%–25%).,,, Furthermore, one patient (graft with three arteries) had delayed graft function. Fortunately, we had no RAS or lymphocele complications [Table 2].
ABMR in pediatric kidney transplant continues to be a frustrating condition to treat because there still remain many unidentified potential antigens leading to ABMR. Children and adults are at different stages of their immune system development, and, thus, the full pathophysiology of alloimmunity is still not completely understood, and the efficacy and safety of the treatment in adults may not be directly translated to children. In our cohort, we had one graft loss because of ABMR.
KT in pediatric patients has become a routinely successful procedure owing to precise surgical techniques, better immunosup-pressive management, and early diagnosis/ effective treatment of complications. One-and five-year patient survival rates of 98% and 94%, and one-and five-year graft survival rates of 93% to 95% and 77% to 85%.,,
The NAPRTCS registry data shows one-and three-year graft survival rates of 96.4% and 93.4% (2007–2013) in living donor renal transplantations. In developing country; the patients’ survival rate at one and three years posttransplant was nearly 100%. The corresponding graft survivals were 97.1%, 94.12% and 91.2% respectively. The one-and four-year graft survival rates noted in our cohort were 95.7% and 91.5%, respectively.
Greco et al have reviewed various methods of live donor nephrectomies by systematically analyzing 57 comparative studies available in the literature. There was no difference in functional graft outcome between open and laparoscopic donor nephrectomies. Likewise, we also found no functional difference in outcome between the two groups.
In our cohort, there was no difference in graft survival between donor kidneys with single or multiple arteries, which was similar as reported in the literature.,
Srivastava et al found that only 61% of the patients were strictly compliant to immuno-suppressants at five-year post-transplant. Shellmer et al concluded that noncompliance is more prevalent in adolescent transplant recipients than in younger children. Poor family and child functioning are risk factors of nonadherence. In our cohort, we faced no compliance problems.
| Conclusion|| |
Renal transplant in pediatric patients is a safe procedure in our department, based on patient and graft survivals, with a low rate of graft loss from surgical problems. As a result, our center is showing success with pediatric renal transplant procedures comparable with the developed centers in the world.
Conflict of interest: None declared.
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Dr. Hany M El Hennawy
Department of Surgery, Section of Transplantation, King Faisal Specialist Hospital and Research Center, Jeddah 21499
[Table 1], [Table 2], [Table 3], [Table 4]
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