| Abstract|| |
Renal transplantation is the ideal renal replacement therapy for children with endstage renal disease (ESRD). Follow-up of pediatric transplant recipients is tedious because of special problems like non-compliance to treatment and a very active immunological status. Twenty-five pediatric patients with ESRD who received kidney transplants in four different centers were followed up at the Jeddah Kidney Center, Saudi Arabia for a mean period of 22 months. The donor source for transplantation was as follows: living related (LR) in seven, cadaveric (CAD) and living unrelated (LUR) in nine patients each. The overall graft survival was 88% and patient survival 100% at the end of the follow-up period. Living related kidney recipients exhibited 100% graft survival at 22 months and also had the best kidney function. All the graft losses were due to irreversible rejection episodes. Medical complications were common and comprised of hypertension (82%), infection (52%) and rejection (44%). Recipients of LR donor kidneys had the lowest incidence of these complications. Surgical problems encountered were few and minor and needed only conservative management. In our experience, children having renal transplantation have an excellent outcome at short-term particularly with LR donors.
Keywords: ESRD, Children, Renal transplantation, Donor source.
|How to cite this article:|
Shehab AB, Fallatah A, Sheikh IA, Al-Koussi MM, Gabal MS, Shaheen FA. Impact of donor source on short-term outcome of renal transplantation in children. Saudi J Kidney Dis Transpl 1994;5:347-53
|How to cite this URL:|
Shehab AB, Fallatah A, Sheikh IA, Al-Koussi MM, Gabal MS, Shaheen FA. Impact of donor source on short-term outcome of renal transplantation in children. Saudi J Kidney Dis Transpl [serial online] 1994 [cited 2020 Dec 5];5:347-53. Available from: https://www.sjkdt.org/text.asp?1994/5/3/347/41167
| Introduction|| |
The reported annual incidence of end-stage renal disease (ESRD) in children is 1 to 5 per million population  . Immunologic causes are still on top of the etiologic list of ESRD in children in the western hemisphere , . However, reports from this region are controversial with some reporting similar findings and others mentioning that hereditary and congenital malformations of the urinary tract head the list ,,, . This latter finding must be critically considered in donor selection particularly for living related kidney transplantation.
Renal transplantation is the ideal renal replacement therapy in children and should be performed early, preferably on a preemptive basis  . Also, the outcome of pediatric renal transplantation has been reported to be greatly dependent upon donor source particularly in young children. There is a striking difference in graft survival in favor of living related over cadaveric kidney donor transplants , . However, the results of cadaveric donor transplantation in children is showing steady improvement in graft outcome with the advent of cyclosporine , . We studied the impact of the donor source, on pediatric renal transplantation in 25 children who were transplanted and/or followed up at the Jeddah Kidney Center (JKC), Jeddah, Saudi Arabia.
| Materials and Methods|| |
Twenty-five children who received 25 renal allografts for ESRD constituted the subjects of this study. Ten children had their transplants performed at Jeddah Kidney Center (JKC), five were performed at other centers in Jeddah city, two in Western Countries and eight in Indian centers. All were followed up at JKC. The demographic data of these children are shown in [Table 1]. Seven children received their grafts from living related donors (LR) and cadaveric (CAD) kidneys were used in nine patients. Living unrelated donors (LUR) constituted the donor source in nine other cases.
All the children received triple immunosuppressive therapy with prednisolone (Pred), azathioprine (Aza) and cyclosporin A (CyA). For the transplants performed at the JKC, Pred was administered intra-operative in a dose of 250 mg given by the intravenous (i.v.) route which was subsequently tapered to 20 mg/day by the tenth post-transplant day. This dosage was maintained for the next three months after which it was gradually reduced to 10 mg daily. Azathioprine was given in a dose of 2 mg/kg/day guided by the blood leukocyte count. Cyclosporin A was initially given in a dose of 8 mg/kg/day in 3 equal doses and the maintenance dose was according to CyA whole blood level. These children were followed-up on out-patient basis for variable periods (4 to 60 months) with a mean of 22 months, on out-patient basis. During their visits, careful history taking and thorough clinical examinations were carried out. Urine analysis, complete blood count, biochemical profile for renal and liver functions, blood sugar and lipid profile were obtained. Chest X-ray and graft ultrasound were performed every 3 months and whenever indicated. Growth rate was observed and recorded.
Rejection episodes were treated with 125 mg methylprednisolone infusion for 3 to 5 consecutive days. In steroid resistant cases and those with repeat rejections, anti-T lymphocyte globulin was used in a dose of 1 mg/kg/day, administered i.v. for 10 consecutive days. All children were kept on prophylactic cotrimoxazole, daily for the first 3 months aftertransplantation.
| Results|| |
Follow-up data of these 25 children were analyzed in terms of patient survival, graft outcome and function. In addition, the development of hypertension, rejection and infection as well as any surgical complications were studied in relation to the three groups of donors namely, LR, CAD and LUR. The overall patient survival during the study period was 100%. All the LR grafts were functioning normally at the time of reporting. Two grafts (1 LUR and 1 CAD) were lost due to irreversible acute rejection, one and four months after transplantation respectively. A third graft (LUR) was lost after 36 months secondary to chronic rejection. Thus, the overall graft survival is 88%. Living related kidney recipients had significantly better renal function expressed by serum creatinine level in comparison with the recipients of either CAD or LUR kidneys (P < 0.05). No significant difference was found between the last two groups. There was no graft loss due to any surgical complications. [Table 2] shows graft survival and mean serum creatinine in these groups of patients. A good correlation was found between serum creatinine (Se Cr) and duration of follow-up [Figure 1].
Eighty-two percent of the children proved to have hypertension at the time of reporting. [Table 3] shows the patients who had hypertension and the number of drugs needed to control it. All LUR recipients and seven of the eight cadaveric graft recipients had hypertension. On the other hand only four out of seven LR recipients were hypertensive. However, these patients represent the highest percentage among those needing more than one anti- hypertensive drug. In spite of these observations, no significant differences were found between these three groups in either the incidence of hypertension or the number of drugs given.
Forty-four percent of all children had at least one rejection episode. [Table 4] describes the incidence of rejection among the three study groups. Living related kidney recipients had the lowest incidence (2/7), while LUR had the highest (5/9); however such difference was statistically not significant. Also, LR recipients who had rejections had the lowest frequency in contrast to cadaveric and LUR recipients. Nevertheless, the difference was not statistically significant. A total of 21 rejection episodes were diagnosed in 11 patients. The rate of rejection/patient among the 3 groups is also shown in [Table 4]. A marked difference was found in favor of LR recipients.
Fifty-two percent of all recipients had infections. The incidence and type of infection is detailed in [Table 5]. Less than 30% of LR recipients in contrast to 78% of LUR recipients had at least one infection. Although such difference appears to be considerable, it was not statistically significant. Respiratory infections were the commonest followed by urinary tract infections. A significant correlation was observed between the occurrence of infection and rejection in 17 patients. Among those who had rejections, there was a history of infection in 73%. Moreover, no infection was reported in 64% of the recipients who never had any rejection episode.
In our series, few surgical complications were encountered. There was infected dialysis access site in one patient, ileus in another and prolonged serous fluid drainage in two cases. All patients responded well to conservative treatment alone.
Children's growth in terms of height increase was observed in the 10 pediatric patients who were transplanted at our center. [Figure 2] demonstrates the changes in height in relation to observation period post-transplant. All children have achieved reasonable height gain.
[Table 6] describes various rehabilitation aspects among these children. The most relevant one was the high incidence of resumption of going to school following successful renal transplant as was seen in seven out of 10 children.
| Discussion|| |
Twenty-five children who had their kidney transplants performed in four different centers were analyzed. It was evident that children who had their transplants performed outside Saudi Arabia had the longest period on dialysis. This was probably due to lack of suitable donors. Fifteen children (60%) had their transplants in Saudi centers of the Western Province over the last four years. Most of these children were transplanted within the last one and half years explaining their relatively short follow-up period. Since LUR kidney transplant is prohibited by law in Saudi Arabia, all children operated in this country received either LR or CAD grafts
The impact of donor source was evident from our results. Since we do not have the exact number of children who have been transplanted outside Saudi Arabia, it is really difficult to know the outcome of these patients. However, 10 such children came to our center for follow-up. The overall graft survival for all children transplanted in the four centers is 88% and the patient survival is 100%. All graft losses were secondary to rejection episodes (two acute, one chronic).
Recipients from LR donors had relatively shorter period of follow-up than recipients from CAD and LUR donors. This might partly explain the significantly better renal function of this first group as a direct correlation has been demonstrated between the duration of follow-up and Se Cr. On the other hand, the higher incidence of hypertension and rejection among CAD and LUR recipients might also be responsible for the higher Se Cr levels in these patients.
The overall prevalence of hypertension in our study patients was 82%, which is comparable to other reports , . The prevalence of hypertension among CAD and LUR recipients was 88% and 100% respectively, in comparison to 57% among recipients of LR donors. The longer followup period as noted among CAD and LUR recipients might play a role in the pathogenesis of hypertension particularly in recipients receiving CyA. The longer exposure to CyA might induce vascular changes responsible for the pathogenesis of hypertension. Also, the higher incidence and number of rejections among CAD and LUR recipients might explain this difference. We found that among the hypertensive patients, recipients of LR donor kidney received more than one drug to control their blood pressure. This could be due to the relatively high dose of steroids given to these patients during the first year after transplantation.
Forty-four percent of all children had at least one rejection episode. Recipients of LR kidneys had the lowest (28%) while those who received kidneys from LUR donors had the highest (55%). Moreover, the two LR recipients who had acute rejection episodes had maximum of two attacks. On the other hand, in the majority of LUR recipients, the children had more than two attacks, rendering their rejection rate/patient the highest; 1.33 in comparison to 0.44 among LR recipients. This marked difference in the incidence and frequency of rejection could be explained by higher chances of better tissue matching among intrafamilial transplantation.
Infection is a serious problem faced by transplant recipients. Immunosuppression results in better graft tolerance but reduces the general immunity resulting in increased susceptibility to repeated infections  . In this study, the overall prevalence of infection was 52%. The highest prevalence was among LUR recipients (78%). Bacterial infections of the respiratory and urinary tracts were the most frequent among our patients. A mutual relationship has been described between infection and rejection , . In this study also, similar association was found. In our study children, the use of prophylactic co-trimoxazole might have played an important role in reducing the incidence of infection, a finding that is also reported by Hughes  . All children showed reasonable growth rate in terms of height gain. The ideal way to asses this height change is to use the standard deviation score (SDS) which presents the child's height in terms of standard deviation above or below the median of normal controls of age and sex matched healthy children. However, these normal control measurements vary according to the nationality and race. Thus it was difficult for us to adopt SDS since the studied number of children was relatively small and they were distributed among four different nationalities.
Living related and CAD donors are the only accepted sources for transplantation in Saudi Arabia. They carry the highest chance of survival with the best possible renal function. In this series, surgical complications were few and did not warrant any aggressive treatment. Hypertension, infection and rejection were the commonest medical problems noted and all these complications occurred more frequently in recipients of LUR and CAD donor kidneys. Early diagnosis and prompt management of these post transplant complications resulted in 100% patient and 88% graft survival among these patients at 22 months of follow-up. However, the relatively small number of patients does not allow making any strong conclusions possible. Similar studies on a larger number of patients are strongly recommended.
| References|| |
|1.||Fine RN, Ettenger RB. Renal transplantation in children. In: Morris PJ (ed). Kidney transplantation, principles and practice. Philadelphia: W.B. Saunders, 1989:635-91. |
|2.||Potter DE, Holliday MA, Piel CF, Feduska NJ, Belzer FO, Salvatierra O Jr. Treatment of end-stage renal disease in children: a 15 year experience. Kidney Int 1980;18:103-9. [PUBMED] |
|3.||Rizzoni G, Broyer M, runner FP, et al.Combined report on regular dialysis and transplantation of children in Europe, XIII,1983. Proc Eur Dial Transplant Assoc Eur Ren Assoc 1985;21:66-95. [PUBMED] |
|4.||Sally S, Sobh MA, Shehab El-Din AB, Foda MA, Ghoneim M. Evaluation of outcome of pediatric kidney transplantation (abstract) IX Congress of the Egyptian Society of Nephrology. 1989:6. |
|5.||Shokier AA, Sobh MA, Gaber AO, Ghoneim MA. Radio isotopic evaluation of renal function in cyclosporine treated pediatric and adult renal transplant recipients and their living donor: a study of 152 Donor recipient pairs. Kidney Int 1993;In Press. |
|6.||Mattoo TK, Al-Mohalhal S, Al- Sowailem AM, Al-Harbi M, Mahmood MA. Chronic renal failure in children in Saudi Arabia. Ann Saudi Med 1990;10:496-9. |
|7.||Aldrees A, Kurpad R, Al-Sabban EA, Ikram M, Abu-Aisha H. Chronic renal failure in children in 36 Saudi Arabian hospitals. Saudi Kidney Dis Transplant Bull 1991;2:134-8. |
|8.||Offner G, Hoyer PF, Meyer B, PichlmayrR, Brodehl J. Pre-emptive renal transplantation in children and adolescents. Transpl Int 1993;6:125-8. |
|9.||Arbus GS, Hardy BE, Balfe JW, et al. Cadaveric renal transplants in children under 6 years of age. Kidney Int Sup. 1983; 15:S111-5. |
|10.||Conley SB, Flechner SM, Rose G, Van Buren CT, Brewer E, Kahan BD. Use of cyclosporine in pediatric renal transplant recipients. J Pediatr 1985;106:45-9. [PUBMED] |
|11.||Tejani A, Butt KM, Khawar MR, et al. cyclosporine experience in renal transplantation in children. Kidney Int Sup. 1986;19:S38-43. |
|12.||Tejani A. Post-Transplant hypertension and hypertensive encephalopathy in renal allograft recipients. Nephron 1983;34:73-8. [PUBMED] |
|13.||Ingelfinger JR. Hypertension in children with ESRD. In: Fine RN, Gruskin AB (eds). End stage renal disease in children. Philadelphia. WB Saunders, 1984:340-58. |
|14.||Byrd LH, Tapia L, Cheigh JS, Aronian J, Stenzel KH, Rubin AL. Association between Streptococcus faecalis urinary infections and graft rejection in kidney transplantation. Lancet 1978;2:1167- 9.Schooley RT, Hirsch MS, Colvin RB, et al. Association of herpes virus infections with T-lymphocyte-subset alteration, glomerulopathy, and opportunistic infections after renal transplantation. N Engl J Med 1983;308:307-13. [PUBMED] [FULLTEXT]|
|15.||Hughes WT. Pneumocystis carinii pneumonia. N Engl J Med 1977;297:1381-3. [PUBMED] |
|16.||Ettenger RB, Grimm P, Firzli ES. Kidney transplantation in children. In: Donovitch GM (ed). Hand Book of Kidney transplantation. Boston, Little Brown and Company; 1992:305-37. |
Faissal A.M Shaheen
King Fahad Hospital, Jeddah
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]