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MODEL
Journal of Pediatric Urology (2014) xx, 1e7
Surgical complications and graft function following live-donor extraperitoneal renal transplantation in children 20 kg or less Mohammed S. ElSheemy a,*, Ahmed M. Shouman a, Ahmed I. Shoukry a, Sherif Soaida b, Doaa M. Salah c, Ali M. Yousef a, Hany A. Morsi a, Fatina I. Fadel c, Sameh Z. Sadek d a
Division of Pediatric Urology, Aboul-Riche Children’s Hospital, Cairo University, Cairo, Egypt Division of Pediatric Anesthesia, Aboul-Riche Children’s Hospital, Cairo University, Cairo, Egypt c Division of Pediatric Nephrology, Aboul-Riche Children’s Hospital, Cairo University, Cairo, Egypt d Urology Department, Kasr Al-Ainy Hospital, Cairo University, Cairo, Egypt b
Received 27 October 2013; accepted 13 December 2013
KEYWORDS Renal transplantation; Extraperitoneal approach; Live donor; Low body weight children; Pediatric
Abstract Objectives: To evaluate the effect of patient, surgical, and medical factors on surgical complications and graft function following renal transplantation (Tx) in children weighing 20 kg, because the number of this challenging group of children is increasing. Patients and methods: Between June 2009 and October 2013, 26 patients received living donor renal allotransplant using the extraperitoneal approach (EPA). The immunosuppression regimen was composed of prednisolone, mycophenolate mofetil, and ciclosporin or tacrolimus. Results: The m ean w e i gh t w a s 1 6. 46 2. 61 kg . Me an c o ld i sc he mia t ime w a s 53.85 12.35 min. The graft survival rate (GSR) and patient survival rate (PSR) were 96% at 3 years. Acute rejection episodes (AREs) occurred in eight patients (30%). Postoperative surgical complications were ureteral leakage (3), vesicoureteric reflux (2), and renal vein thrombosis (2) (with one graft nephrectomy). Mean follow-up was 37.5 7.4 months. Conclusion: Excellent PSR and GSR can be achieved in low weight ( 0.7). The final diagnosis was found to be acute vascular rejection which was complicated by partial RV thrombosis. Anticoagulants, ATG, and plasma exchange saved the graft. Urine leakage occurred in three patients, who were treated by ureterovesical reanastomosis (1 patient) or ureteroureteral anastomosis with the native ureter (2 patients) depending on suspicion of ischemia in the distal ureteric
segment. Surgical intervention was decided at D2 or D3 when the drain output exceeded the urinary catheter output. Vesicoureteric reflux was suspected in two patients due to graft dilatation detected by US in the follow-up visits. Obstruction was excluded by radioactive isotope renal scanning. Reflux was confirmed and graded by VCUG. They were subjected to the routine antimicrobial prophylaxis protocol that was followed in all patients (as there was no scars in the renogram). Ureteric complications increased in patients with pre-Tx lower urinary tract surgical interventions, but this was statistically insignificant. Comparison of perioperative parameters between patients with and without vascular and ureteric complications is presented in Table 3.
Discussion Despite the advances in immunosuppression, anesthetics, surgical techniques, and post-Tx management, low BW children remain a challenging subgroup. They have been reported to have a higher mortality and graft loss [5]. Our aim was to evaluate the effect of the patient, surgical, and medical factors on the surgical complications and graft function following Tx in children weighing 20 kg. Pre-emptive Tx is the aim in our center. Parents are encouraged to identify potential living-related donors when diagnosis is made. Unfortunately, most relative donors were motivated for Tx only once the child was on regular dialysis. Moreover, Tx was postponed in many children till the minimally accepted weight for Tx (MAW) in our center (10 kg) was attained by providing growth hormone and maximal nutritional support. This explains the relatively few cases transplanted pre-emptively. We consider a weight of 10 kg as the MAW to avoid marked size discrepancy between donor kidney and the child recipient with associated possible complications (acute tubular necrosis, graft thrombosis, and primary graft non-function) [5]. Conversely, most of our recipients were smaller in weight than matched healthy children even after maximal nutritional support. This may be explained by the urgent need for Tx due to problems with dialysis access in some patients or to avoid or shorten the pre-Tx dialysis period to improve the outcome. Even in very small patients (11 kg), it was not necessary to use an intraperitoneal approach (IPA). Grafts were well placed retroperitoneally. This has the advantages of rapid tolerance to oral feeding and absence of postoperative intestinal adhesions [4,6]. Furness et al. [6] used EPA in 29 children < 15 kg. One child required re-exploration secondary to fascial dehiscence. They reported that EPA enables concurrent safe retroperitoneal surgery, such as nephrectomy [6]. In another study, EPA was used in 62 children weighing
MODEL
Journal of Pediatric Urology (2014) xx, 1e7
Surgical complications and graft function following live-donor extraperitoneal renal transplantation in children 20 kg or less Mohammed S. ElSheemy a,*, Ahmed M. Shouman a, Ahmed I. Shoukry a, Sherif Soaida b, Doaa M. Salah c, Ali M. Yousef a, Hany A. Morsi a, Fatina I. Fadel c, Sameh Z. Sadek d a
Division of Pediatric Urology, Aboul-Riche Children’s Hospital, Cairo University, Cairo, Egypt Division of Pediatric Anesthesia, Aboul-Riche Children’s Hospital, Cairo University, Cairo, Egypt c Division of Pediatric Nephrology, Aboul-Riche Children’s Hospital, Cairo University, Cairo, Egypt d Urology Department, Kasr Al-Ainy Hospital, Cairo University, Cairo, Egypt b
Received 27 October 2013; accepted 13 December 2013
KEYWORDS Renal transplantation; Extraperitoneal approach; Live donor; Low body weight children; Pediatric
Abstract Objectives: To evaluate the effect of patient, surgical, and medical factors on surgical complications and graft function following renal transplantation (Tx) in children weighing 20 kg, because the number of this challenging group of children is increasing. Patients and methods: Between June 2009 and October 2013, 26 patients received living donor renal allotransplant using the extraperitoneal approach (EPA). The immunosuppression regimen was composed of prednisolone, mycophenolate mofetil, and ciclosporin or tacrolimus. Results: The m ean w e i gh t w a s 1 6. 46 2. 61 kg . Me an c o ld i sc he mia t ime w a s 53.85 12.35 min. The graft survival rate (GSR) and patient survival rate (PSR) were 96% at 3 years. Acute rejection episodes (AREs) occurred in eight patients (30%). Postoperative surgical complications were ureteral leakage (3), vesicoureteric reflux (2), and renal vein thrombosis (2) (with one graft nephrectomy). Mean follow-up was 37.5 7.4 months. Conclusion: Excellent PSR and GSR can be achieved in low weight ( 0.7). The final diagnosis was found to be acute vascular rejection which was complicated by partial RV thrombosis. Anticoagulants, ATG, and plasma exchange saved the graft. Urine leakage occurred in three patients, who were treated by ureterovesical reanastomosis (1 patient) or ureteroureteral anastomosis with the native ureter (2 patients) depending on suspicion of ischemia in the distal ureteric
segment. Surgical intervention was decided at D2 or D3 when the drain output exceeded the urinary catheter output. Vesicoureteric reflux was suspected in two patients due to graft dilatation detected by US in the follow-up visits. Obstruction was excluded by radioactive isotope renal scanning. Reflux was confirmed and graded by VCUG. They were subjected to the routine antimicrobial prophylaxis protocol that was followed in all patients (as there was no scars in the renogram). Ureteric complications increased in patients with pre-Tx lower urinary tract surgical interventions, but this was statistically insignificant. Comparison of perioperative parameters between patients with and without vascular and ureteric complications is presented in Table 3.
Discussion Despite the advances in immunosuppression, anesthetics, surgical techniques, and post-Tx management, low BW children remain a challenging subgroup. They have been reported to have a higher mortality and graft loss [5]. Our aim was to evaluate the effect of the patient, surgical, and medical factors on the surgical complications and graft function following Tx in children weighing 20 kg. Pre-emptive Tx is the aim in our center. Parents are encouraged to identify potential living-related donors when diagnosis is made. Unfortunately, most relative donors were motivated for Tx only once the child was on regular dialysis. Moreover, Tx was postponed in many children till the minimally accepted weight for Tx (MAW) in our center (10 kg) was attained by providing growth hormone and maximal nutritional support. This explains the relatively few cases transplanted pre-emptively. We consider a weight of 10 kg as the MAW to avoid marked size discrepancy between donor kidney and the child recipient with associated possible complications (acute tubular necrosis, graft thrombosis, and primary graft non-function) [5]. Conversely, most of our recipients were smaller in weight than matched healthy children even after maximal nutritional support. This may be explained by the urgent need for Tx due to problems with dialysis access in some patients or to avoid or shorten the pre-Tx dialysis period to improve the outcome. Even in very small patients (11 kg), it was not necessary to use an intraperitoneal approach (IPA). Grafts were well placed retroperitoneally. This has the advantages of rapid tolerance to oral feeding and absence of postoperative intestinal adhesions [4,6]. Furness et al. [6] used EPA in 29 children < 15 kg. One child required re-exploration secondary to fascial dehiscence. They reported that EPA enables concurrent safe retroperitoneal surgery, such as nephrectomy [6]. In another study, EPA was used in 62 children weighing
