NEPHROLOGY

Renal Transplantation in Children and Adolescents

R. S. Fennell, III, M.D., E. H. Garin, M.D., W. Pfaff, M.D., B. Brient, M.D., A. lravani, M.D., R. D. Walker, M.D., G. A. Richard, M.D.

and Methods

an update for practitioners who may have to advise patients about renal transplantation. h presents data from a very large series with impressive survival statistics.

Editorial Comment: This is

Patient

Population

Fifty-one kidney transplants were performed in ~4~ children and adolescents. The patients ranged in from 4 to 21 years of age, with the ~e~i~n age 12 years. Thirty-eight of the 44 were 17 years or less at the time of transplantation. There were 20 boys and 24 girls, 17 of whom were black and 27 of whom were white. ~&dquo;~~~e I depicts the causes of renal

CHILDREN ~~~.~~~~ have undergone undergone past fifteen years.’-&dquo;’ Early

renal transrena! have the for plantation reports showed graft survival comparable to the adult population but with an increased . mortality rate in children, especially when kidneys were obtained from cadaveric sources. 1-3,- :. 4,6-9 Observed ~~.~~u~-~. ..... ~ growth was often suboptimal were. prepared for r€na!trans- . All for Factors patients responsible post-transplantation. plantation by hemodialysis and had functiongrowth appeared to be dependent on. bone the sex of at the time of ing Scribner shunts o,r.arteriovenous fistulas - . transplant, maturity ~.t the time of surgery. Dialysis was. performed the recipient and the powth suppressive efin a unit especially designed and staffed for ;’~..:.- ~: fects of corticosteroids.1-10-15 The following is .~ .~Mdrenandadole~ea~ conduits bad to :~ a report of kidney transplantation in children ;~&dquo; ~ and adolescents at the University of Florida ~/ be created for, two patients ’with’obs-tructive, ../ .B This B uropathy prior to transplantation*. Bilateral ,:. :’, :.. over the past 4 and one-half, years. ; B ex Ipenence d*emonstrates an improvement in nephrectomies were performed at least.four ~ .:~ ~ B. to six weeks prior to transpla~ntation in 18 pa- -.,’ ~’;: .’ and :~ patient survival with gqaft survival growth tients. ~T~’::MdicMmm~~~~a ’nephrectomy :~’~ ::’: patterns comparable to the previously cited ’’&dquo; series,. ~:~;:/::~.:::’&dquo; ’ ~./&dquo;’. ~::’ &dquo;’.-~.&dquo; were- recur,,ent un, nary tract, i,-iftctions (nine ;’..

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~~z~~~~r~~, ~~~~~ ~~~~~~n~~~an~~ ~ ~~n~~~n the Department of Pediatrics, University of Florida, Gainesville, Florida. From

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(six children) and massive proteinuria with persistently low serum protems (three children).

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Correspondence to: R. S. Fennell, III, M.D., Box J296, ~~~~~ ~~~e~~~t~ :’~~:~:&dquo;’ :~r, ~’ ’.~. ’.~ ~ ~ ~ j ,~~~h;: ;.~.’.~’ ~~: ~-.~ ’~.~~ JHMHC, Department of Pediatrics, University of Florida, Gainesville, FL 32610. ~. ~~~~y~ ~~~~ ~~~~~~~ l~~ rel atives in, i 36 in-, ~&dquo;.’ :.’’~~~ Received for publication September 20,1978; revised~ ~~n~~~ ~n~ ~n~~~~~~. ~~~.~.~~~i~ ~~~~~~~ in 15 ,/;j/~.:j~: March 2, 1979, and accepted May 12. 1979. ~

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518 Downloaded from cpj.sagepub.com at SETON HALL UNIV on April 5, 2015

T’wgL~ 1. Causes

of Renal Frzilure in Trarzs~la,nt Population

increased to 4,000 cells/>I or more. Some recipients could not tolerate as much as 2 mg/kg daily and were maintained on between I to 2 mg/kg daily. Prednisone was administered on the day of transplantation at 2 mg/kg daily in four divided doses and tapered to I mg/kg daily administered in a single dose by 4 to 6 weeks posttransplantation. No preoperative immunosuppressive regimen was used in our patient population. Depending on clinical status, prednisone administration was further tapered to 0.5 mg/kg daily usually by six months posttransplantation and to 0.2 to 0.3 mg/kg daily by one year after the transplantation. By 9 to 12 months post-transplantation, a modified alternate day schedule was attempted by gradually shifting the majority of the prednisone therapy to one day, finally leaving the patient on 1 to 2.5 mg of prednisone on the low dose alternate day. Rabbit antilymphocyte globulin was prepared in the laboratories of the Department of Pathology at the University of Florida and administered on days 0, 2,4, 6 and 8 to cadaveric and single hapiotype living related recipients in a 100 mg dosage. Prior to 1977, such patients were given the antilymphocyte globulin randomly as part of a controlled t~i~; after January 1977, all patients were given the count

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procedures. Standard tissue typing was performed, including blood group compatibility, screening for preformed antibodies, HLA typing and mixed lymphocyte cultures (in instances of living related donors), prior to surgery. If several family members were possible donors (given the equivalence of other medical factors), the best immunologic and, psychologically prepared individual was se-

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~~e~~c~* Nineteen fathers, lmothers and 6 siblings served as donors. There were 32 single hapiotype (2 out of 4 antigen) matches and 4 double haplotype donors (3 siblings and 1

parent)... Operative Approach

.

antiglobulin.

..

The retroperitoneal approach was used in all recipients with the kidney placed in the false pelvis and the donor artery anastomosed to the recipient’s hypogastric or common iliac

Acute

the common iliac vein

or

the inferior

rejection has been defined by multiple and’laboratory findings such as fever, hypertension, graft swelling and tenderness, oliguria, proteinuria, hyperchloreclinical

vena

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cava. The ureter was implanted into the blad- .~ der using

mic metaboiie.’ad:d’osis’~’nd~a&dquo;~r!S€ in serum ..:/er€atinine of:0.3;~m~dt~c’r~.more/ove.r ~r~viously stable level. Because these findings are not necessarily specific for acute rejection, the

~

extra vesical

an ureterone’ocystofdmy; :~Lich-Gregoirc)/procedure// . B ~..: ~~’~ BBB.

lmmunosuppressive, Regimens

:~;.~&dquo;.:,.’....

......

Acute

artery. Venous anastomosis was performed to ~.

Rejection

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response to increased corticosteroid therapy was, retrospettively confirmatoqy. In the ~~ &dquo;’~ sence of ciihical response= other causes iiere ~’’ excluded by renal .’ intrat€B:ous’~.pyei