Kidney transplantation in children weighing less than 15 kg: extraperitoneal surgical access-experience with 62 cases.

Small children are a challenging group in whom to perform KT. This retrospective study analyzed the results of 62 KTs in children weighing <15 kg, performed between 1998 and 2010, using extraperitoneal access and anastomosis of the renal vessels of donors to the aorta and IVC or iliac vessels of the recipients. Thirty-two (51.6%) grafts were LRDTs and 30 (48.4%) were DDRTs-28 of them pediatric. The mean age at KT was 3.7 ± 2.2 yr (1-12), and the mean weight was 12.3 ± 2.1 kg (5.6-14.9). Ten children weighed <10 kg, and five (8.1%) children presented previous thrombosis of the venous system. At one and five yr, patient survival was 93.2% and 84.2%, and graft survival was 85.2% and 72.7%. There were no differences between the rates for LRDT and DDRT. There were six vascular complications (four vascular thromboses, one laceration, and one renal artery stenosis) and two perirenal collections. Extraperitoneal access is a valid KT technique in children weighing <15 kg.

Educational program of organ donation and transplantation at medical school.

A favorable attitude of health professionals to organ donation can positively influence the decision of families of potential donors. By increasing health professionals knowledge about donation and transplantation and qualifying them to disseminate information, education has produced a positive response to increase the insufficient number of donors. Educating students early in their careers may become crucial in this setting. In order to supply the necessary information about the process of donation and transplantation, a medical school in association with the Hospital Transplant Coordination Department created an educational program of organ donation and transplantation. This course is intended for medical, biomedical, and nutrition students. The objective of our program is to supply basic knowledge about organ donation and transplantation to students of medicine, nutrition, and biomedicine and to enhance their commitment to this process. Each semester, 50 to 90 students are enrolled in the course, which involves a total of 25 hours. Various aspects are approached such as brain death, donor management, political and legal aspects of donation, and skin, lung, bone marrow, heart, pancreas, liver, and kidney transplantation. Between March 2006 and June 2007, three courses were carried out and 200 students were trained. The students evaluated the course and rated it as excellent, concluding that it contributed to their education. Their attitude toward organ donation and transplantation was strongly positive at the end of the course. This project aims to educate and stimulate students in the process of organ donation and transplantation and should be implemented in other medical schools.

Renal transplantation in children younger than 6 years old.

Herein we report our experience in renal transplantation in 38 children (40 transplants), ages 1 to 5 years, between 1989 and 2005. Demographics as well as patient and graft survivals are reported. Mean age at transplantation was 3.3 +/- 1.3 years, and mean weight was 14 kg (range, 5.7-25 kg); 92.5% were Caucasian, 7.5% African-Brazilian. The main etiology for end-stage renal disease (ESRD) was uropathic/vesicoureteral reflux (45%) followed by glomerulopathy (25%), congenital/hereditary diseases (10%), and hemolytic uremic syndrome (12.5%). Prior to transplantation, 5% were on hemodialysis, 85% on peritoneal dialysis, and 10% preemptive. All children were followed for at least 6 months posttransplantation, except 2 who died in the first month. In 75% of cases, kidneys were obtained from living-related donors, and in 25% from deceased donors. Thirty-nine kidneys were extraperitoneally placed. Primary immunosuppressant therapy consisted of cyclosporine (61%), tacrolimus (39%), mycophenolate (49%), and azathioprine (51%). A steroid-free protocol was used in 17% of patients. In the last 21 cases, basiliximab or daclizumab was added. There were 13 (32.5%) graft losses (4 artery/vein thromboses, 3 chronic rejections, 3 deaths, 3 other causes). The 5-year patient and graft survival rates were 89.6% and 72.2%. We have concluded that renal transplantation can be performed with good long-term results in children younger than 6 years old.

Results of en bloc renal transplants of pediatric deceased donors into adult recipients.

UNLABELLED: Various strategies have evolved to expand the donor pool due to the extreme shortage of organs. Herein we reviewed our experience with en bloc pediatric kidney transplantation since 1998. METHODS: From January 1998 to December 2004, nine adult patients underwent kidney transplantation using en bloc kidneys from donors <5 years old (range, 1 to 4). The mean age of the recipients was 45.1 years (range, 34 to 57). RESULTS: In recipients of en bloc pediatric transplantation, cold ischemia time ranged from 14 to 26.2 hours (mean, 21.3 hours). Mean serum creatinine at 3, 6, and 12 months after transplantation was 1.53 +/- 0.57, 1.27 +/- 0.27, and 1.15 +/- 0.26 mg/dL compared with 1.93 +/- 1.35, 1.81 +/- 1.17, and 1.73 +/- 0.85 (P = .08) in recipients of single kidneys from ideal cadaveric donors (UNOS criteria, n = 368). Patient and graft survival at 1 year were 88.8% compared with 91.2% and 85% with ideal donors (P = NS), respectively. Three cases required additional surgery. There was one death due to a cerebral vascular accident. CONCLUSION: The present study confirmed the excellent results achieved with transplantation using en bloc kidneys from young donors.

300 pediatric renal transplantations: A single-center experience.

UNLABELLED: Our objective was to relate the results of 300 consecutive kidney transplants performed in children at a single center. PATIENTS AND METHODS: An analysis of kidney transplants was performed on patients less than 18 years old engrafted from May 1977 to August 2005. RESULTS: Among 300 kidney transplants, 48% of the patients were female, 87% were Caucasian, and 13% were African-Brazilian. The mean age at transplant was 11.5 +/- 4.5 years with 39 (13%) less than 6 years of age. The most frequent etiology of renal failure was vesicoureteral reflux/obstructive uropathy (36%) followed by glomerulopathy (27%). The donor was deceased in 32.3% and living related in 77.7% (parents 82%). The mean posttransplant follow-up was 4.8 +/- 4.3 years. The initial immunosuppression was CyA + AZA + PRED in 45%; CyA + MMF + PRED in 9.6%; TAC + AZA + PRED in 7.3%; TAC + MF + PRED in 9.7%; or TAC + MF without PRED in 10%. Sirolimus was employed initially in three cases. Induction with OKT3/ATG occurred in three patients and 112 received an anti-IL2 receptor antibody. The 103 graft losses during 28 years of follow-up were secondary to chronic allograft nephropathy in 51 (49.5%), vascular thrombosis in 5 (4.8%), acute rejection in 12 (11.6%), and recurrence of original disease in 13 (12.6%). Sixteen (15.5%) died with functioning grafts. Graft survival in the first, fifth, and tenth year were 90%, 72%, and 59%, respectively. Patient survival in the first, fifth, and tenth years were 95%, 93%, and 85%, respectively, with infection as the main cause of death.

Pre-emptive pediatric kidney transplantation or not?

BACKGROUND: Kidney transplantation prior to dialysis (pre-emptive kidney transplantation, PKT) has been controversial because of the paucity of clinical evidence to clarify the risks and benefits of PKT. Several authors have confirmed a significant advantage of PKT in the treatment of patients with end-stage renal disease (ESRD). The aim of this study was to examine the characteristics of patients who received PKT or non-pre-emptive kidney transplant (NPKT). METHODS: We used a cohort of 323 consecutive kidney-transplanted children (53% boys) from Hospital da Criança Santo Antonio, Porto Alegre, Brazil, who underwent transplantation between January 2000 and December 2010. RESULTS: The main causes of ESRD were congenital anomalies of the kidney and urinary tract (CAKUT) (39%) and glomerulopathies (27.5%). The 12-, 36-, 60-, and 90-months death-censored graft survival rates were 97%, 92%, 86%, and 76%, respectively, in the PKT group, and 87%, 79%, 72%, and 65% in the NPKT group (P < .05). CONCLUSIONS: The results of this study suggest that pre-emptive transplantation is beneficial (hazard ratio = 0.37; 95% confidence interval: 0.18-0.82). The main causes of graft loss (n = 67) were recurrence of primary disease (21%), chronic allograft injury (17%), and death with a functioning graft (16%). We recommend PKT as a better choice for transplantation whenever possible to minimize ESRD morbidity and provide better long-term patient and graft survival.

Duct-enterostomy as a treatment of pancreatic fistula in a bladder-drained pancreas transplant.

A case of combined pancreaticoduodeno-renal transplant with good graft function was complicated by recurrent episodes of graft pancreatitis treated by vesical catheter drainage. Four months after transplantation, a fistula from the pancreatic body associated with ascitis was identified. Anastomosis between pancreatic fistula and an individualized jejunal loop was performed. The duodenocystostomy was not disconnected. A splint placed inside the wirsung was exteriorized percutaneously through the jejunal loop and removed 30 days after the operation. Both kidney and pancreas grafts are functioning normally 2 years after transplantation.

Immunosuppression in pancreas transplantation: mycophenolate mofetil versus sirolimus.

The use of mycophenolate mofetil (MMF) in pancreas transplantation has increased graft survival and decreased the incidence of acute rejections episodes (ARE), regardless of the choice of calcineurin inhibitor. The combination of MMF with tacrolimus (TAC) is the most common protocol, it is considered the gold standard for new protocols. In the last few years, there have been reports of a small number of patients treated with sirolimus (RAPA), usually combined with TAC. Patient and pancreas survival rates as well as the incidence of ARE were similar to protocols with TAC and MMF. Twenty simultaneous pancreas and kidney (SPK) transplantations were performed using an immunosuppressive protocol of TAC, RAPA, and steroids (STE) after 2000. The incidence of ARE was 25%; all episodes responded to STE. Only 2 patients (10%) displayed hypercholesterolemia requiring treatment with statins. The use of RAPA as an alternative to MMF is promising, although presently one with limited experience. The combination of MMF and RAPA with or without a calcineurin inhibitor is an option to be evaluated in the future.