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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2005  |  Volume : 16  |  Issue : 3  |  Page : 342-347
Pediatric Renal Transplantation in Syria: A Single Center Experience

Pediatric Nephrology Department, Surgical Kidney Hospital, Ibn Alnafis Medical Complex, Damascus, Syria

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Renal transplantation (RTx) is widely accepted as the preferred method of treatment for children with end-stage renal disease (ESRD). This is a retrospective analysis of the results of RTx in children performed at the Surgical Kidney Hospital, Damascus, Syria. Between November 2002 and November 2004, a total of 176 RTx procedures have been performed in our center. Of them, 11 recipients (6%) were younger than 14 years of age. The mean age was 11 years with range of 5 to 14 years. There were six males (55%) and five females (45%). All patients received kidneys from living donors. Seven donors were related (64 %) while four (36%) were unrelated .The cause of ESRD in these patients were reflux nephropathy in three, nephronophthisis and hypoplastic kidneys in two cases each and polycystic kidney disease, rapidly progressive crescentic glomerulonephritis, Alport's syndrome and chronic pyelonephritis in one patient each. All grafts were placed extra-peritoneally. Immunosuppression was based on triple therapy with cyclosporine (CsA) mycophenolate mofetil (MMF), and prednisolone. Tacrolimus (TAC), MMF, and prednisolone, and sirolimus (SRL), MMF, and prednisolone were used in one patient each. Induction immunosuppression in immunologically high-risk patients was, with anti-thymocyte globulin (ATG) in one patient and basiliximab in two patients. The mean duration of follow-up was 12 months {3 to 24 months}. All 11 (100 %) patients were alive at last follow-up with functioning graft. Ten patients (88%) had normal graft function and one (12%) had mild graft dysfunction. Complications encountered were infections in four patients, early steroid-responsive acute rejection in one patient, and mild biopsy-proven chronic rejection in another patient; the latter probably due to poor compliance. No urological complications were encountered. Our study, despite involving a small number of patients with a relatively short duration of follow-up, suggests that the results of pediatric renal transplant at our center are encouraging.

Keywords: Kidney transplantation, Children, Living donors, Syria.

How to cite this article:
Saeed MA, Sherif S. Pediatric Renal Transplantation in Syria: A Single Center Experience. Saudi J Kidney Dis Transpl 2005;16:342-7

How to cite this URL:
Saeed MA, Sherif S. Pediatric Renal Transplantation in Syria: A Single Center Experience. Saudi J Kidney Dis Transpl [serial online] 2005 [cited 2021 May 5];16:342-7. Available from: https://www.sjkdt.org/text.asp?2005/16/3/342/32866

   Introduction Top

In contrast to developed countries, children form a much larger proportion of the popu­lation in developing countries. [1] The reported incidence of end-stage renal disease (ESRD) of seven cases per million child population in the developing countries is similar to, or slightly higher than, that reported from deve­loped countries. [1],[2],[3],[4],[5] The causes of ESRD in children are most commonly congenital ab­normalities of the urinary tract (40%) and chronic glomerulonephritis (33%). [1],[3],[4],[6] Con­sanguineous marriages contribute to the high incidence of hereditary diseases in children in some developing countries. [1] Prevention of renal disease, particularly vesicoureteric reflux and urological abnormalities, which are common causes of chronic renal failure in children, [7] must be a priority.

A well-functioning renal allograft is the best treatment for a child with ESRD, perhaps even more so than in an adult. It offers the recipient the opportunity of a better quality of life as well as improved growth and psycho­motor development. With the low incidence of cadaver donor transplantation in developing countries, living related donor transplantation is the main option for these children. Pediatric nephrologists in developing countries make a strong plea for the elimination of dis­criminatory practices against children [6] and claim "the same rights for subjects who were living in the same country but with the unique difference of age and size". [5]

We herewith report the experience of our center in Syria with renal transplantation in children.

   Patients and Methods Top

This is a retrospective analysis of the results of 11 pediatric renal transplantations undertaken at our center since the inception of a pediatric transplant program in November 2002. The analysis was made till November 2004. The upper age cut off of pediatric patients at our center is 14 years while this ranges from 12 to 19 years worldwide. [8]

We reviewed the recipient characteristics which included age, gender, etiology of ESRD, prior method of dialysis, anti-cytomegalovirus (CMV) IgG and IgM antibodies, human immuno­deficiency virus (HIV), hepatitis B surface antigen (HBsAg), Anti hepatitis C virus (HCV) antibodies, pre-RTx hemoglobin level, daily urine volume, micturating cystourethrogram (MCUG), the number of, if any, pre-RTx blood transfusions and growth parameters before RTx by using French growth charts (Dr. M. Sempe) where weight is expressed in percentile scoring system (from 3 to 97%); the height is expressed in standard deviation scoring (from - 4 SD to + 3 SD) . Panel reactive antibodies (PRA), HLA {class I (A and B foci) and class II (DR foci)} matching and mismatching between the recipient and the donor, and cross matching test (cytotoxic method) were routinely done for all patients.

Our present policy is to perform RTx only for those with compatible ABO blood group, negative cross-match test, having at least one HLA match (A, B, or DR), and absence of a history or ongoing viral hepatitis C or B; however, the issue on hepatitis is going to be changed, and we are planning to accept inter­feron-responding patients with a negative HCV-PCR test.

All donors in this study were living, either related or unrelated, because still we do not yet have a cadaveric organ donation program in Syria. The donor characteristics were also reviewed and included age, difference in age between the recipient and the donor, gender and pre-donation viral status (same as for the recipients).

The therapeutic regimens were reviewed. We administered induction therapy for high-risk patients only (previous blood transfusion, positive PRA, poor HLA matching, and re­transplant). De novo and conversion protocols for each patient, urological and medical com­plications as well as patient and graft survival were also reviewed. Graft dysfunction was defined as serum creatinine above 1.5 mg/dl; graft loss was considered if serum creatinine exceeded 3 mg/dl.

   Results Top

Recipient Characteristics

A total of 176 RTx procedures, for both adults and children, have been performed in our center during the study period (from November 2002 till November 2004); 11 recipients (6%) were younger than 14 years of age. The mean age was 11 years (range 5 to 14 years) and there were six males and five females. All children were on hemodialysis (HD) before being trans­planted with a mean duration on HD of 5.7 months (range 2 weeks to 17 months). There were no pre-emptive RTx. The etiology of ESRD in these children is shown in [Table - 1]. The mean number of pre-RTx blood trans­fusions (BT) was 2.4 per patient (range 0-6 times); two patients had no history of previous BT while three patients had a history of a single BT. The mean duration from the last BT to the RTx was four months, the shortest duration was one month. The mean hemoglobin level just before RTx was 7.5 g/dl (range 5.3 to 12).

Pre-RTx HBsAg., HCV Ab, and HIV serology were negative in all recipients and donors. All the recipients and donors had IgG antibodies against CMV while none had IgM antibodies.

Of the study patients, three were anuric, five had oliguria, and three others were non-oliguric. The MCUG was routinely done for all recipients; it was normal in seven patients and the remain­ing four showed varying degrees of vesico­ureteric reflux (VUR); one had bilateral VUR, and two had significant post-micturation urine residue. Growth evaluation prior to RTx showed that seven patients (63%) were below the 3rd percentile for weight, two (18%) were between 3 to 25 th percentile, and 2 others (18%) were at or above the 25 th percentile. The mean height deficit was - 2.3 Standard Deviations (SD) (range - 0.7 to - 5 SD).

Donors Characteristics

The mean age of the donors was 35 years (range 23 to 45 years) and the mean difference in age between donors and recipients was 24 years (range 12 to 35 years). There are seven males (64%) and four females (34%). There were seven related donors (64%); they were mostly parents (4 mothers, 2 fathers, and one uncle); there were four unrelated donors (34%), all of whom were young men. The mean HLA mismatch number was 2.9 (range 2-4 mis­matches); while the mean match number was 2.4 (range 1 - 3 matches) [Table - 2].

Three patients (27%) received induction therapy; the first was a 5-year-old boy, transfused once, organ donor being living unrelated with poorly matched HLA (one match on A). Basiliximab was given to him. The second was an 11-year-old girl, poly­transfused (5 BT), poorly matched HLA (one match on A), with an unrelated living donor; she was also given Basiliximab. The third one was a 14-year-old girl with a history of RPGN, poly-transfused (6 BT), highly sensitized (PRA 40%); she was given anti-thymocyte globulin (ATG). Maintenance immunosuppression given is shown in [Table - 3].

Pre-transplant bilateral native nephrectomy was performed in one patient who had poly­cystic kidney. Bilateral or unilateral perioperative ureteral ligature was performed in four patients with VUR.

The mean total ischemic time was 50 minutes (range 28-70 min.), the mean time of arterial anastomosis was 15 minutes (range 10-21 min.), and the mean time of venous anastomosis was 18 minutes (range 4-34 min.). No urologic complications were seen.

Medical Complications

We did not encounter any case of delayed graft function (DGF). There were four patients who developed one infectious episode each. One patient developed urinary tract infection (UTI) and the other developed hepatitis with elevated liver enzymes and positive HCV­PCR, both in the first month after RTx. Between one and six months post-RTx, two other patients developed viral infections, one with CMV and the other with varicella zoster virus (VZV). Both were successfully managed and made full recovery. Other medical complications encountered are shown in [Table - 4].

Patient and Graft Survival

One patient (poorly compliant) had a slow and progressive increase of his serum creatinine, which, six months post-RTx, had reached 2.9 mg/dl. Allograft biopsy revealed mild chronic rejection. He was converted from tacrolimus (TAC) to sirolimus (SRL); this was very success­ful and the patient showed an impressive improvement of his allograft renal function with a serum creatinine coming down to 0.6 mg/dl at last follow-up. The overall patient survival after a mean duration of follow-up of 12 months was 100% (11/11). Also the graft survival in this series was 100% (11/11).

   Discussion Top

Pediatric recipients accounted for 6% of all RTx recipients at our center, which is com­parable to that of the Scientific Registry of Transplant Recipients/University of Michigan, OPTN/SRTR database [9] where it accounted for 7%. The youngest child in our series was five years old. This is because we have preferred to start kidney transplantation with older children. However, there are many encouraging reports detailing the results of transplantation in very young children. [10] Hemodialysis was the method of dialysis for all patients in this study, the reason being that peritoneal dialysis program in our center and in many other centers in our country are still facing many difficulties. Particularly common are the infectious compli­cations, which are making this treatment modality far from safe and effective, especially for those who are being prepared for RTx. We believe that a mean duration of 5.7 months on HD before RTx is reasonably short; this is due to the fact that we transplant kidneys from living donors only since the cadaveric organ donation program in our country is yet to begin.

The majority of our patients, 82% (9/11) received blood transfusions before transplant­ation. The 1998 report of the North American Pediatric Renal Transplant Co-operative Study (NAPRTCS) indicated that 41% of living donor recipients had not received any transfusions before transplantation. Our own results were either related to difficulties in erythropoietin procurement, or to a non-adherence of some patients to their prescribed medications, or to their scheduled follow-up.

From the viral check-up, one can realize, despite the small number of patients, that the prevalence of CMV in our country is very high. At the time of transplantation, most of the children were growth retarded, with a mean standard deviation score (SDS) of - 2.3 (range - 0.7 to - 5 SD); however the mean height deficit in our study group was not much less than that of the 1998 report of the NAPRTCS which was - 2 SD. This was despite the fact that recombinant growth hormone could not be afforded for any of our patients before transplantation.

The majority of the donors were living related (64%); this may be because we try very hard to convince parents to donate. However, in some cases where related donors are not available, and because we still do not have a cadaveric program in our country, the last and the only solution is to accept unrelated donors, which is legally allowed in our country. Most of the donors were young. This is because we insisted, whenever possible, to choose the donors with least difference from the recipients. This is to improve their graft survival in the long-term.

All living related donors had at least one HLA haplotype matching with their recipients, while most of the unrelated donors had only one or two antigen match. There was only one patient who had zero mismatch on HLA foci-DR; this patient is doing very well despite discontinuing MMF due to hepatitis C and is currently on CsA with a small dose of steroids.

The main immunosuppression protocol that we adopted was calcineurin-inhibitor (CNI) (CsA or TAC), MMF, and steroid; TAC was reserved for high-risk patients or teenaged girls as de novo protocol. We converted two patients from CsA to TAC due to a steroid-responsive acute rejection in one, and hirsutism in another. The only patient who did not receive this main protocol (CNI + MMF + Steroid) was a highly sensitized, poly-transfused girl, who received ATG as induction therapy and SRL, TAC, and steroids as maintenance immuno­suppression. One patient was converted from TAC to SRL as a result of graft dysfunction with a biopsy-proven mild chronic rejection.

The small number of patients might explain why we did not encounter any urological complications. We consider the occurrence of infectious complications as being low. The short duration between the transplant operation and the development of HCV infection in one patient could possibly indicate that this patient was in the incubation period when we screened him for HCV prior to the operation.

Biopsy-proven acute rejection was encountered in one patient only (9%), after a mean duration of follow-up of one year. This is a very low incidence, but larger number of cases and longer duration of follow-up are needed to determine the precise incidence of acute rejection. Post-transplant hypertension was found in five patients (45%) which is comparable to that of the 1996 report of NAPRTCS where hypertension was observed in about 55% of living related donor recipients. [11] Dyslipidemia was observed in two patients on CsA and one on SRL. Biopsy-proven mild CsA toxicity was noticed in one patient who was then changed over to TAC. No MMF-related gastro­intestinal adverse events were noted in this series. Similarly, no cases of post-transplant diabetes mellitus (PTDM) were encountered. The excel­lent one-year graft and patient survival in this study was encouraging. However, we admit that the patient number was too small and the follow-up duration was also not long enough.

In conclusion, despite the small number of patients and the short duration of follow-up, the results of pediatric renal transplantation in our center are not only encouraging but also far better than keeping these children attached two or three times a week to their hemodialysis machines.

   References Top

1.Al-Khader AA. Cadaveric renal transplant­ation in the Kingdom of Saudi Arabia. Nephrol Dial Transplant 1999;14: 846-50.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]
2.Eke FU, Eke NN. Renal disorders in children. Pediatr Nephrol 1994;8:383-6.  Back to cited text no. 2  [PUBMED]  
3.Garcia CD, Goldani JC, Garcia VD. Twenty years of pediatric renal replacement therapy in the state of Rio Grand do Sul, Brazil. Transplant Proc 1992;24:1804-5.  Back to cited text no. 3  [PUBMED]  
4.Garcia CD, Goldani JC, Garcia VD. Pediatric dialysis in the state of Rio Grand de Sul, Brazil. Pediatr Nephrol 1992;6:74-7.  Back to cited text no. 4    
5.Grunberg J. The challenge of care of children with renal disease in developing countries: a Latin American outlook. Indian Pediatr 1996;33:91-4.  Back to cited text no. 5  [PUBMED]  
6.Saieh AC. The management of end-stage renal disease in underdeveloped countries: a moral and an economic problem. Pediatr Nephrol 1990;4:199-202.  Back to cited text no. 6    
7.Henning P, Tomlinson L, Ridgen SP, Haycock GB, Chancer C. Long term outcome of treatment of end stage renal failure. Arch Dis Child 1988;63:35-40.  Back to cited text no. 7    
8.Morris PJ. Renal Transplantation in Children. Kidney Transplantation principles and practices, fifth edition. W. B. Saunders company, 2000;37:604.  Back to cited text no. 8    
9.Magee JC, Bucuvalas JC, Farmer DG, Harmon WE, Hulbert-Shearon TE, Mendeloff EN. Pediatric transplantation. Am J Transplant 2004;4 Suppl 9:54-71.  Back to cited text no. 9  [PUBMED]  
10.Trompeter RS, Bewick M, Haycock GB, Chantler C. Renal transplantation in very young children. Lancet 1983;1:373-5.  Back to cited text no. 10  [PUBMED]  
11.Stablein DM, Sullivan EK. Renal transplant­ation, dialysis, chronic renal insufficiency. The 1996 Annual Report of the North American Renal Transplant Cooperative Study.  Back to cited text no. 11    

Correspondence Address:
Mohamed Bassam A Saeed
Pediatric Nephrology Department, Surgical Kidney Hospital, Ibn Alnafis Medical Complex, PO Box 8292, Damascus
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PMID: 17642804

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