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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE Table of Contents   
Year : 1997  |  Volume : 8  |  Issue : 3  |  Page : 302-309
Pediatric Renal Transplantation in Saudi Arabia


1 Saudi Center for Organ Transplantation, Riyadh, Saudi Arabia
2 Riyadh Armed Forces Hospital, Riyadh, Saudi Arabia
3 King Fahad National Guard Hospital, Riyadh, Saudi Arabia
4 Riyadh Medical Complex, Riyadh, Saudi Arabia

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   Abstract 

This study was performed to evaluate the short and long-term outcome of pediatric renal transplantation in Saudi Arabia. Four large centers participated in this study and there were 124 patients with evaluable data. They included 79 males and 45 females with ages ranging from 2­18 years with a mean of 12.2 years. There were 69 transplants from living donors and 55 from cadaveric donors. The cause of the original renal disease was unknown in 61.4% of the cases. Re-transplantation rate was 8% and the cause of failure of the first graft was venous thrombosis in 60% of the cases most of whom were transplanted before 1990. Acute rejection occurred in 31% of the patients and did not correlate with age at time of transplantation, sex, nationality, source of donor, place of transplantation or follow-up, year of transplant, or delayed graft function; however, those who eventually lost their grafts had significantly more number of acute rejection episodes. There were 24 cases (19%) of infection related to graft and 43 cases (34%) of extra-renal infection. Medical complications other than rejection and infection occurred in 37% of the study group. The 15 year survival rates of patients and grafts from living donors were 96.7% and 92.2% respectively, while the 11 year survival rates of patients and grafts from cadaver donors were 93% and 58.4% respectively. We conclude that pediatric renal transplantation in Saudi Arabia has been performing well in terms of the quantity and quality and the results are comparable to the reputed programs in other countries.

Keywords: Renal transplantation, Children, Infection, Rejection, Saudi Arabia.

How to cite this article:
Souqiyyeh MZ, Al-Khader AA, Shaheen FA, Huraib SO, Al-Harbi M. Pediatric Renal Transplantation in Saudi Arabia. Saudi J Kidney Dis Transpl 1997;8:302-9

How to cite this URL:
Souqiyyeh MZ, Al-Khader AA, Shaheen FA, Huraib SO, Al-Harbi M. Pediatric Renal Transplantation in Saudi Arabia. Saudi J Kidney Dis Transpl [serial online] 1997 [cited 2020 Nov 29];8:302-9. Available from: https://www.sjkdt.org/text.asp?1997/8/3/302/39360

   Introduction Top


Renal transplantation has been performed in patients of very young age to the elderly.

There have been many reports evaluating the outcome of transplantation in different age­ groups published from single transplant centers [1],[2],[3],[4],[5],[6],[7],[8] , as well as national and international registries [9],[10],[11],[12],[13],[14] . These reports suggest that the outcomes may vary depending on the transplant center or geographical area [15],[16] .

There is only one report, from a single center in Saudi Arabia, about the short-term outcome of renal transplantation in children [17] . We performed this study, which is the first multi­center report on pediatric renal transplantation from Saudi Arabia, to evaluate the short and long-term morbidity and mortality of renal transplantation in the pediatric age-group patients.


   Patients and Methods Top


Two hundred and ten post-transplant patients below 18 years of age were registered in the data-base at the Saudi Center for Organ Transplantation, Riyadh as of December 1996. They were reported from six transplant and follow-up centers in Saudi Arabia. A case­study based questionnaire was mailed to these six centers. Four of them answered the questionnaire and data were available on 130 patients (62%). Of these, 124 had adequate data which were analyzed. The questionnaire included the following:

a) date of birth, sex and nationality of the patients

b) cause of the original renal disease

c) details of type and duration of dialysis therapy before transplantation

d) details of previous renal transplant, if any, including donor source,

e) date and place of transplant and cause of graft failure details of current transplant including donor source, date and place of transplant, duration of hospitalization after transplantation, drugs used in induction and maintenance of immunosuppression and need for dialysis, if any, post-transplant

f) details of acute rejection episodes including the number of episodes, date of each episode, treatment of rejection, duration of hospitalization, if any, and whether the diagnosis was biopsy proven or not

g) surgical complications related to renal transplant and their nature, time of occurrence in relation to transplant and duration of hospitalization, if any

h) details of infections related to the renal graft, organism responsible, duration of hospitalization if any

i) details of infection outside the allograft, its location, organism responsible, duration of hospitalization, if any

j) details of other post-transplant medical and surgical complications, time of occurrence in relation to the transplant, mode of treatment (whether medical or surgical) and duration of hospitalization, if any.

The questionnaire also sought information about the outcome of the current transplant including graft nephrectomy and its date, return to dialysis and its date and death and its causes.

Codes of the type of surgical complications, location of infection related to the transplanted graft, location of extra-renal infection, types of extra-renal medical and surgical complications, and the cause of death were provided in the questionnaire.

The data were entered in a personal computer for the purpose of analysis and their correlations.

Statistical Analysis

The values in this study are expressed as mean ± standard deviation (SD). The Student's "t" test of the paired and unpaired data comparing mean + SD was used where appropriate. The chi-square and Fisher's exact tests were used to compare the statistical difference of the values in the study. The survival curves used the actuarial method.


   Results Top


The data of 124 post-renal transplant children and adolescents below the age of 18 years were studied. Of them, 10 had undergone second renal transplant while the remaining 114 were recipients of first allograft. Since the details of the first graft of the 10 re-transplanted patients were not available, the analysis of various parameters was made on the 124 current transplants. However, the 10 grafts that were lost resulting in re-transplantation were included for calculation of survival rates.

There were 79 males and 45 females in this study. The ages ranged from 2-18 years with a median of 13 years and a mean + SD of 12.2 + 4.6 years. [Figure - 1] shows the age-distribution of the patients at the time of transplantation. There were 83 patients (66.9%) aged 11 years and above, 33 patients (26.6%) between five and 10 years, and eight patients (6.5%) below the age of five years. [Figure - 2] shows the distribution of patients according to the year of undergoing renal transplantation. The peak transplant activity was between the years 1993-1995. Of the 124 study patients, renal transplantation was performed inside'Saudi Arabia in 84 (37 living donor. 47 cadaveric donor) while in 40 cases it was performed outside Saudi Arabia (32 living donor, 8 cadaveric donor). There were 92 Saudis and 32 non-Saudis in the study group. The patients were followed-up for a mean of 4.76 ± 3.4 years.

[Table - 1] shows the etiology of renal failure in these patients. The etiology was unknown in 61.4% of the cases and Alport's syndrome was seen in 10.5% of the cases. Prior to renal transplantation, 110 patients (88.7%) received hemodialysis (age 12.1 ± 4.1 years), and 14 patients (11.3%) were on peritoneal dialysis (age 9.1 ± 5.1 years). The mean duration on dialysis was 70 ± 40 weeks. The average period of stay in the hospital after transplantation was 5 ± 2 weeks. Nineteen patients (15.3%) required dialysis in the post-transplant period for a mean duration of two weeks due to delayed graft function.

The immunosuppression protocols for the patients were as follows:

prednisolone + azathioprine in 3 cases (living-related donors)
cyclosporine + prednisolone in 78 cases
cyclosporine + azathioprine in 38 cases
cyclosporine + prednisolone + ATG in 5 cases (4 cadaver and 1 living related donor including 3 re-transplants).

Ten patients had previous transplantation; nine from cadaver donors and one from a living donor. The failure of the first transplant was due to venous thrombosis in six cases (60%); four of these transplants were performed before 1990. Chronic rejection caused graft loss in three (30%) cases. The waiting period for re-transplant was less than one year in all cases. The follow-up period following re-transplantation was 5.8 + 1.8 years. Seven of these patients (70%) had functioning grafts when last seen, two patients lost their grafts and one died during the follow­up period.

A total of 38 patients (30.6%) experienced at least one episode of acute rejection. Among them, eight patients had two episodes while five others had three episodes of acute rejection. There was no significant correlation between age at time of transplantation, sex. nationality, source of donor, follow-up center or year of transplant and occurrence of acute rejection. Renal allograft biopsy was performed in 19/38 patients (50%) which confirmed rejection in all of them. All the rejection episodes were treated with pulse methylprednisolone therapy. ATG or 0KT3 was not used in any of the cases. The duration from the day of transplant to the first rejection was less than six months in 39% of the cases and between 2-5 years in 39% of the cases. The duration from the first to the second rejection was less than six months in 75% of the cases. The time from the second to the third rejection was more than six months in 80% of the cases. Seven grafts were lost due to irreversible acute rejection episodes.

There were six cases (4.8%) with surgical complications and all were related to ureteric or vascular anastomoses. Five of the six cases had their transplants performed before 1990. Four of these six cases had graft failure.

A total of 24 episodes of infection (19.3%) related to the graft were encountered.

Urinary tract infection by E. colt was the most frequent, seen in 13 cases. Two patients in this group needed graft nephrectomy for intractable infection while the others responded to appropriate antibiotic therapy. Infection of the surgical wound and perinephric infection occurred in three and one patient respectively and responded to appropriate treatment. Infection not directly related to the transplanted graft included respiratory infection, viral or bacterial, seen in. 17 patients (13.7%), followed by skin and soft tissue infection, seen in 10 patients (8.1%). All patients with infection required hospitalization of a mean of 2 + 1 weeks. Generalized infection was seen in nine patients (7.3%) and recurrent infection, in two cases (1.6%). All patients survived except one with gluteal abscess and septicemia. There was no significant correlation between the occurrence of infection and rejection episodes.

[Table - 2] shows the various medical and surgical complications, not related to the renal allograft, encountered in the study group. A total of 42 patients (33.9%) had medical complications; diabetes and hypertension constituted one third of them. There were four cases with surgical complications which were related to dental or soft tissues. These complications required hospitalization for a mean of 4 ± 3 weeks, and were successfully managed.

The total number of grafts lost was 17 of the 124 current transplants. Graft loss was due to irreversible acute rejection in seven, surgical causes in four, infection in two and death with functioning graft in four.

A total of seven patients died. Cardiovascular causes constituted the commonest cause of death seen in six (85.7%) patients. Four of the deaths occurred before 1990; five were transplanted from cadaver donors .

The cumulative actuarial patient and graft survival in living related donor transplants is shown in [Figure - 3]. The cumulative actuarial patient and graft survival in cadaver donor transplants is shown in [Figure - 4].

The cumulative period of follow-up was longer for living donor transplant recipients (15 years) as against 11 years for the cadaver donor transplant recipients. There was no significant difference in the overall patient survival between the living and cadaver donor recipients up till 11 years of follow-up. However the five year graft survival was significantly better in the living donor group (living 92.2%; cadaver 82.7%) (p<0.02).

When graft and patient survival was analyzed according to the age and sex of the recipients, no significant differences were found in the living donor group. However significant differences were found in the cadaver donor group. Patient-survival was better among male recipients at two years of follow-up (96.5% in males vs 85% in females p <0.03) as well as at 10 years of follow-up (96.5% in males vs 68.0% in females p < 0.01). Graft survival also was better in males at two years of follow-up (92% in males vs 85% in females p<0.02). However, there was no significant difference at 10 years of follow-up (77% in males vs 68% in females). There was no correlation between patient survival and different age-groups. However, recipients below the age of five years had better graft survival when compared to those above 5 years of age. The survival rates at six year follow-up in the age-groups < 5 years, 5-10 year and > 11 year were respectively 100%, 76% and 62% (p <0.05) and at 11 year follow-up were respectively 100%, 76%, 23.5% (p <0.02).


   Discussion Top


Pediatric renal transplantation constitute 4% of all renal transplants performed in Saudi Arabia till the end of 1996. This figure is comparable with what has been reported from other countries [10] . Also, there was a peak in the number of operations performed inside Saudi Arabia during the years 1990-1994, which coincided with the increase noted in the cadaveric donor pool as well as activity of the transplant centers. About 33% of the transplanted patients were aged 10 years or below; no patient, however, was under the age of two years as per a policy that exists in most transplant centers in Saudi Arabia. This is most likely due to the reported poor outcome of young recipients under two years of age [11] .

The etiology of end-stage renal disease in the pediatric population differs from that in the adults; e.g., diabetes accounts for 30% of renal failure in the adult population and none in the pediatric group [10] . Also, obstructive and dysplastic causes account for 3% of renal failure in the adults, while they account for 37­-40% in children [14],[18] . Five main causes of renal failure have been reported in children including renal hypoplasia, obstruction, focal and segmental glomerulosclerosis, reflux nephropathy and systemic immunological diseases [11] . In our study, these causes accounted for 35% of the cases while 61.4% were labeled as being of "unknown" or "undefined" etiology. A recent study shows that registries underestimate the diagnosis of hereditary disease in the transplant population [19] . Better diagnosis of the original disease should be practiced in order to define its impact on the outcome of transplantation.

It is reported that peritoneal dialysis is used in the majority of the pediatric population before they undergo transplantation [9] . In our study patients, hemodialysis was used in the majority and only 10% were on peritoneal dialysis; this is due to the better availability of hemodialysis in Saudi Arabia. Even among adults, peritoneal dialysis is being used in only 2.5% of the population in Saudi Arabia [20] . The patients treated with peritoneal dialysis were relatively younger than those on hemodialysis but there was no significant difference between these groups in the outcome of transplantation. We had only one pre-emptive renal transplant in our study (0.8%), while it usually forms around 26% of the pediatric transplantations elsewhere [21] . Nevertheless, prior dialysis does not affect the outcome of transplantation [18] .

Re-transplantation is reported to account for 23% of all transplantations in children [2] . In our study, it was performed in only 8% of the cases. The reported survival rates in these patients are acceptable even after long-term follow-up [10] .

In the cyclosporine era, most transplant centers use double or triple immunosuppressive regimen [3],[8],[11],[12] . The survival of patients and grafts are better [11] and there is a lesser incidence of infection, rejection and other medical problems [12] . Some studies have reported an increased immunological activity in young children with a propensity to reject their transplanted grafts [22] . A marginal improvement in survival by sequential induction immunosuppressive therapy using OKT3 has been reported. However, this was at the expense of a higher incidence of infection and malignancy [23] . Only few patients in our study were on azathioprine (living related donor transplants) or sequential induction immunosuppressive therapy. The majority of children were on double or triple, cyclosporine based, regimens. Interestingly, the younger age-group patients in our study, did better in terms of rejection and graft survival.

Acute rejection episodes are reported to occur in 24-38% of the pediatric renal transplant recipients [22] . In our series, the frequency was 31%. Late initial acute rejection, greater than two episodes of rejection, cadaver donor transplants, African­American race, and cyclosporine dose < 5 mg/kg/day at end of 30 days post-transplant are all considered major factors leading to chronic rejection and graft failure [4],[10],[11],[24] . Delayed graft function was seen in 13% of our study group. However, this sub-group did not have any increased incidence of acute rejection or decreased graft survival rates when compared with the others.

We found a high incidence of previous acute rejection episodes in the patients who lost their grafts. However, cadaver donor source or delayed graft function did not have any correlation with the outcome in our study group. High daily doses of cyclosporine are usually used in children followed-up after transplantation in Saudi Arabia; however, dosing was not analyzed separately in our study.

The reported prevalence of surgical complications related to the graft is about 7.5% and are due to technical reasons in more than half the cases [25] . The experience m Saudi Arabia was similar, particularly in the early years of pediatric renal transplantation. However, there has been a decline in the incidence of surgical complications since 1990.

Hypertension can complicate the course of pediatric renal transplantation in 70% of the cases needing multiple drugs for control [26] . In our study, hypertension was seen in about 6% of the patients. Diabetes mellitus also occurred in about 6% of the cases. Urinary tract and respiratory infections were the most frequent in our study group which is similar to other reports [2],[11] .

The reported range of patient-survival in the recipients of grafts from living donors at one and five years of follow-up is 96-100% and 92.3-97% respectively; the range of the patient-survival in the recipients of grafts from the cadaver donors at one and five years of follow-up is 93.2-100% and 92.0-­96% [2],[8],[9] . In our study, the one and five year patient-survival for transplantation from living donors were 98.4% and 96.7% respectively; the corresponding figures for cadaver donor transplants were 96.2% and 93.0% respectively. These results are comparable with results mentioned above.

The reported graft survival rates from living donor transplants at one and five years of follow-up are 90-100% and 75-95% respectively, while that for cadaver donor transplants for the same periods of follow-up are 74-96% and 46-69% respectively [2],[3],[8],[9],[11] . In our study, the graft survival of living donor transplants at one and five years were 96.9% and 92.2% respectively; graft survival for cadaver donor transplants at one and five years were 96.2% and 82.7% respectively. These results are comparable to the figures alluded to above, while the survival of grafts from the cadaver donors in our study was even better.

After 15 years of follow-up, we found a graft survival, for the living donor transplant group of 92%, and for the cadaver donor group, the graft survival after 11 years follow-up was 58.4%. The overall graft­survival reported in literature for pediatric renal transplant recipients is about 81% at 15 years of follow-up [7],[27],[28] .

The recipient's age, particularly those who are very young, is considered by some as a risk factor for graft-survival [23] . On the other hand, there are also reports suggesting that there is no effect of patient's age, donor source and number of previous transplants, on patient survival; some claim even better survival in children than in adults, especially in those who have less systemic complications [24],[29] . We found in our study that the recipients below five years of age had better graft survival than the age-group of 5-10 years followed by the age-group of 11-15 years both in the living and cadaver donor groups.

The reported causes of death include infection, cardiovascular causes, hemorrhage and malignancy [29] . Transplantation from cadaver donors, age below one year at transplantation, deterioration of graft function due to rejections or thrombosis have been considered as risk factors for death [29],[30],[31],[32] . In our study, the commonest cause of death was cardiovascular, followed by infection; no association with previous transplantation, rejection or age was found.

We conclude from this study that pediatric renal transplantation in Saudi Arabia has been performing well, and the results are comparable to the programs in other countries. Also, the performance has been improving over the years both quantitatively and qualitatively with regard to the operative procedure as well as follow-up. However, our study involved about 60% of the total pediatric renal transplant recipients registered at the central data base. In order to have an accurate picture, the remaining 40% also should be studied and their data analyzed.


   Acknowledgment Top


Thanks to Mr. M.A. Taher and Mr. Pedly F. Atienza of SCOT for their excellent secretarial assistance in preparing the manuscript.

 
   References Top

1.Chavers BM, Matas AJ, Giliingham KJ, Schmidt WJ, Najarian JS. Pediatric renal transplantation at the University of Minnesota: the cyclosporine years. CHn Transplant 1994:203-12.  Back to cited text no. 1    
2.Shapiro R, Tzakis A, Scantlebury V, et al. 18. Improving results of pediatric renal transplantation. J Am Coll Surg 1994;179(4):424-32.  Back to cited text no. 2    
3.Helling TS, Nelson PW, Reed L, Alon U, Hellerstein S, Warady BA. A seven year experience with kidney transplantation for pediatric end stage renal disease. Mo Med 1994;91(l):33-7.  Back to cited text no. 3    
4.Bynon JS Jr, Hudson SL, Kohaut EC, Benefield MR, Waldo FB, Diethelm AG. Pediatric renal transplantation at the University of Alabama at Birmingham, 1968 to 1993. Clin Transpl. 1993;259-65.  Back to cited text no. 4    
5.Bartosh SM, Aronson AJ, Swanson Pewitt EE , Thistlethwaite JR Jr. OKT3 induction in pediatric renal transplantation. Pediatr Nephrol 1993;7(l):45-9.  Back to cited text no. 5    
6.Schneck FX, Jordan ML, Jensen CW, et al. Pediatric renal transplantation under FK-506 immunosuppression. J Urol 1992;147(6):1585-7.  Back to cited text no. 6    
7.Kim MS, Jabs K, Harmon WE. Long­term patient survival in pediatric renal transplantation program. Transplantation 1991 ;51 (2):413-6.  Back to cited text no. 7    
8.Johnson RW, Webb NJ, Lewis MA, Postlethwaite RJ, Dyer PA, Connolly JK. Outcome of pediatric cadaveric renal transplantation: a 10 year study. Kidney Int SuppI 1996;53:S72-6.  Back to cited text no. 8    
9.Avner ED, Chavers B, Sullivan EK, Tejani A. Renal transplantation and chronic dialysis in children and adolescents: the 1993 annual report of the North American Pediatric Renal Transplant Cooperative Study. Pediatr Nephrol 1995;9(1):61-73.  Back to cited text no. 9    
10.Hirata M, Terasaki PI. Pediatric renal transplantation. Clin Transpl 1994:395­-402.  Back to cited text no. 10  [PUBMED]  
11.McEnery PT, Alexander SR, Sullivan K, Tejani A. Renal transplantation in children and adolescents: the 1992 annual report of the North American Pediatric Renal Transplant Cooperative Study. Pediatr Nephrol 1993;7(6):711-20.  Back to cited text no. 11    
12.Tejani A, Stablein D, Fine R, Alexander S. Maintenance immunosuppression therapy and outcome of renal transplantation in North American children - a report of the North American Pediatric Renal Transplant Cooperative Study. Pediatr Nephrol 1993;7(2):132-7.  Back to cited text no. 12    
13.Tejani A, Fine R, Alexander S, Harmon W, Stablein D. Factors predictive of sustained growth in children after renal transplantation. The North American Pediatric Renal Transplant Cooperative Study. J Pediatr 1993;122(3):397-402.  Back to cited text no. 13    
14.McEnery PT, Stablein DM, Arbus G, Tejani A. Renal transplantation in children. A report of the North American Pediatric Renal Transplant Co- operative Study. N Engl J Med 1992;326(26):1727-32.  Back to cited text no. 14    
15.Guyot C. Renal transplantation in children: a report of the French Society of Pedatric Nephrology. Transplant Proc 1994;26(1):22.  Back to cited text no. 15    
16.Tyden G, Berg U, Tibell A, Bohlin AB, Englund M. The Stockholm experience with pediatric renal transplantation. Transplant Proc 1993;25(4):2569- 70.  Back to cited text no. 16    
17.Shehab AB, Fallatah A, Sheikh A, et al. Impact of donor source on short-term outcome of renal transplantation in children. Saudi J Kidney Dis Transplant 1994;5{3):347-353.  Back to cited text no. 17    
18.Nevins TE, Danielson G. Prior dialysis does not affect the outcome of pediatric renal transplantation. Pediatr Nephrol 1991;5(2):211-4.  Back to cited text no. 18    
19.Nyberg G, Friman S, Svalander C, Norden G. Spectrum of hereditary renal disease in a kidney transplant population. Nephrol Dial Transplant 1995;10:859-65.  Back to cited text no. 19    
20.The Saudi Center for Organ Transplantation Data. 1997;8(l):45-50.  Back to cited text no. 20    
21.Fine RN, Tejani A, Sullivan EK. Pre­emptive renal transplantation in children: report of the North American Pediatric Renal Transplant Cooperative Study (NAPRTCS). Clin Transplant 1994;8(5):474-8.  Back to cited text no. 21    
22.Ettenger RB. Age and the immune response in pediatric renal transplantation. Eur J Pediatr 1992;151SuppI l:S7-8.  Back to cited text no. 22    
23.Ettenger R, Marik J, Rosenthal JT. Sequential therapy in pediatric cadaveric renal transplantation: a critical analysis. J Am Soc Nephrol 1992;2(12 Suppl):S304-11.  Back to cited text no. 23    
24.Tejani A, Cortes L, Stablein D. Clinical correlates of chronic rejection in pediatric renal transplantation. A report of the North American Pediatric Renal Transplant Cooperative Study. Transplantation 1996;61(7):1054-8.  Back to cited text no. 24    
25.Sheldon CA, Churchill BM, Khoury AE, McLorie GA. Complications of surgical significance in pediatric renal transplantation. J Pediatr Surg 1992;27(4):485-90.  Back to cited text no. 25    
26.Baluarte HJ, Gruskin AB, Ingelfinger JR, Stablein D, Tejani A. Analysis of hypertension in children post renal transplantation-a report of the North American Pediatric Renal Transplant Cooperative Study. Pediatr Nephrol 1994;8(5):570-3.  Back to cited text no. 26    
27.Ettenger RB, Rosenthal JT, Marik J, et al. Long term results with cyclosporine immune suppression in pediatric cadaver renal transplantation. Transplant Proc 1991;23:1011-2.  Back to cited text no. 27  [PUBMED]  
28.Optimizing renal transplantation in children. Proceedings of the 1st North American Pediatric Renal Transplant Cooperative Study Workshop. September 27-28, 1989, Washington D.C. Pediatr Nephrol 1991;5(l):103-72.  Back to cited text no. 28    
29.Leichter HE, Sheth KJ, Gerlach MJ, Franklin S, Stevens L, Casale AT. Outcome of renal transplantation in children aged 1-5 and 6-18 years. Child Nephrol Urol 1992;12(l):l-5.  Back to cited text no. 29    
30.Tejani A, Sullivan EK, Alexander S, Fine R, Harmon W, LHienfeld D. Post­transplant deaths and factors that influence the mortality rate in North American Children. Transplantation 1994;57(4):547-53.  Back to cited text no. 30    
31.Sheldon CA, Churchill BM, McLorie GA, Arbus GS. Evaluation of factors contributing to mortality in pediatric renal transplant recipients. J Pediatr Surg 1992;27(5):629-33.  Back to cited text no. 31    
32.Gagnadoux MF, Charbit M, Guest G, Arsan A, Broyer M. Clinical evaluation of 70 pediatric renal transplants after 10 to 17 years. Ann Pediatr Paris 1991;38(6):413-7.  Back to cited text no. 32    

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Correspondence Address:
Muhammad Ziad Souqiyyeh
Consultant Nephrologist, Saudi Center for Organ Transplantation, P.O. Box 27049, Riyadh 11417
Saudi Arabia
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