Saudi Journal of Kidney Diseases and Transplantation

: 1994  |  Volume : 5  |  Issue : 3  |  Page : 333--335

Renal transplantation in children

MB Abdurrahman 
 579 Moonrock Avenue, Sudbury, Ontario, P3E 5Z5, Canada

Correspondence Address:
M B Abdurrahman
579 Moonrock Avenue, Sudbury, Ontario P3E 5Z5

How to cite this article:
Abdurrahman M B. Renal transplantation in children.Saudi J Kidney Dis Transpl 1994;5:333-335

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Abdurrahman M B. Renal transplantation in children. Saudi J Kidney Dis Transpl [serial online] 1994 [cited 2020 Dec 4 ];5:333-335
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Renal transplantation in children has come a long way in a short span of less than 40 years, from the initial period when the wisdom of the procedure was being questioned [1] to the present period of increasing tendency towards pre-emptive transplantation [2] . Pre-emptive transplantation is renal transplant without dialysis. Experience with renal transplantation as well as our understanding of transplant imrnunobiology has been improving each year. The net result is an improvement in the long-term survival of renal transplant patients.

With the proclamation of Saudi Senior Ulama Council Fatwa number 99 of 1982 transplantation has become increasingly available in the Kingdom of Saudi Arabia. As of 25 October, 1993 (10 Jumadi I, 1414 H) there were 95 haemodialysis and 11 transplant centers [3] . Currently, there are 13 renal transplant centers, and up till May 1993 a total of 1208 renal transplants have been performed in the Kingdom [4] . Most of the centers cater exclusively for adults.

Although renal dialysis has been available for some time, the world over, a successful renal transplantation has become the preferred form of treatment in children with end-stage renal disease (ESRD). Is there then, a need in Saudi Arabia, for renal transplant centers meant exclusively for children? To some extent the answer to this question depends on the incidence of ESRD in children, and whether there are peculiar problems associated with the disease and its management. Unfortunately there are no national data on the epidemiology of ESRD in the Kingdom. Reports from two institutions in Riyadh [5],[6] and a review of the experience in several hospitals [7] indicate that chronic renal failure and ESRD are recognized problems in children. Moreover, there are the occasional reports pertaining to renal transplant carried out in children [8],[9],[10] from which one can infer that in Saudi Arabia renal transplantation in children are carried out not infrequently. The recent data from the Saudi Center for Organ Transplantation (SCOT) on the age distribution of dialysis patients show that about 250 were less than 21 years of age [3] .

Although the number of children with ESRD and therefore in need of renal transplantation is small compared with adults, the problems associated with renal transplant in children are numerous, varied, and often peculiar. These problems have been highlighted very well in the elaborate review of the NAPRTCS data by McEnery [11] in this issue of The Journal. The report covers a large number of patients [3] and transplants [2],[8] from 82 centers across Canada and USA, over a period of six years. The three most frequent causes of ESRD were hypoplastic-dysplastic kidney, obstructive uropathy and focal segmental glomerulosclerosis. Among children up to five years of age, congenital lesions accounted for about 50% of the causes of ESRD. These findings are similar to those reported from Saudi Arabia [5],[6] .

Some of the highlights of this review by McEnery deserve mention. The factors associated with increased relative risk of graft failure included recipient age less than two years, cadaver donor age less than six years, and focal segmental glomerulosclersis as the etiology of ESRD. The main causes of the graft failure were rejection, vascular thrombosis, primary non-function and infection. On the whole there was no appreciable decrease in height deficit following renal transplantation. However, the younger the patient at the time of transplant, the better was the prognosis for catch-up growth. Also of concern was the development of malignancies after transplant: 27 in the first five years of study. It is encouraging to note the high graft survival figures at two years: 96% in recipients who received live donor kidneys and 94% in the recipients of cadaver kidneys.

This difference in the graft survival based on donor source has been further elaborated by Shehab et al [8] in this issue of the Journal. The authors report their findings on the follow up of 25 children who had renal transplantation from three categories of donors: live related, cadaveric and live unrelated. Hypertension, infection and rejection were comparatively more frequent among patients who received live unrelated donor kidneys. Analysis of the effect of kidney donor source on the outcome of the renal graft is made difficult by the small number of patients and by the differences in patients' demographic data.

An important problem that deserves prominent attention is the family stress and disruption which results from having a young child with ESRD. The whole family may have to commute between renal replacement therapy centers and their home, or the parents may be forced to leave the other children at home while they accompany the patient. The stress and disruption were particularly glaring when Saudi children were being sent abroad for renal transplantation. It was not unusual for parents to spend over a year in a strange country with alien culture.

The findings from the above mentioned and other similar studies have important implications for renal transplantation in children. Continuing growth is the singular factor that distinguishes a child from an adult. The period of most rapid growth is in the first two years of life. For several reasons children with ESRD have impaired growth. Whereas most of the biochemical abnormalities of ESRD are corrected by renal transplantation, growth often shows minimal or no improvement. Children who develop ESRD in infancy frequently develop concomitant neurologic abnormalities(progressive encephalopathy, microcephaly, convulsions and abnormalities in EEG and brain CT scan) and developmental delay [11],[12] . For these reasons, there is a strong argument for encouraging pre-emptive renal transplantation. However, the benefit of improved growth by pre-emptive transplant in the young patients must be weighed against the reality of the highest risk of graft failure in this age group. It would seem logical that a young patient receive a kidney from a young donor, for size convenience and anticipated long life span. Disappointingly, kidney from young cadaver donors less than 10 years of age are associated with increased incidence of graft failure and vascular thrombosis [9],[11],[13] .

There are still uneasy questions regarding renal transplantation in children. Probably the most controversial one is the question of patient selection. Should age, mental status, risk of recurrence of primary disease and psychosocial status be taken into consideration? There doesn't seem to be a "right" or "wrong" answer to this question that involves the philosophy, ethics and conscience of renal transplant. What is the life expectancy of kidney donated by a 40 year old person and transplanted into a 10 year old child? Will the child outlive his new kidney, and therefore be a candidate for a second transplant later? What are the risks of a transplanted child developing secondary malignancy? Are there possible psychosocial complications when the child grows up to know his donor? Lastly, can one speculate about the future direction of renal transplant in children in the Kingdom? There is a strong case for the development of a few pediatric renal transplant centers, with SCOT as the coordinating center. I hope it is no longer necessary to issue a reminder that children are not miniature adults, and therefore the experience in adults cannot be extrapolated to children. If each of the current 13 transplant centers were to cater for children the number is likely to be so small that no one center will be able to acquire and maintain the necessary expertise.

As progress continues to be made in medical care and bio-technology, there is bound to be an increasing number of children who will survive the many causes of ESRD. The management of such children calls for a multidisciplinary team of various healthcare and non-healthcare workers. It is equally important that due emphasis be placed on managing appropriately the preventable causes of ESRD so that children with such lesions should not have to deteriorate to ESRD. It is sad to admit that even in these days of highly advanced medical technology and expertise; some children still reach ESRD as a result of undiagnosed or mismanaged obstructive uropathy, reflux nephropathy and urinary tract infection.[14]


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