2. Kidney transplantation in children
challenges and hopes
Fahimeh Asgarian; MD
Children’s Medical Center
TUMS

3. ✦In children and adolescents affected by chronic renal failure the
treatment of choice is kidney transplant.
✦Globally, all-cause mortality rates for children on dialysis are
significantly higher than what is experienced by the transplant
population

4. ✦Dialysis is more disruptive to family lifestyle, schooling, and social
interactions.
✦Avoidance of dialysis preserves vascular and peritoneal access sites for
future use if the transplant should fail.
✦Dietary and fluid restrictions are necessary on dialysis.
✦Dialysis is associated with an increased risk of cardiovascular disease
and vascular calcification, which occur at a proportionately earlier age.

5. Kidney transplant differs between pediatric patients and adults in
several aspects.
✦Causes of ESRD
✦Types of complications
✦Optimal donor selection
✦Problems associated with growth
✦Comorbidities associated with the lower
urinary tract
✦Nonadherence to medication regimens
✦Child’s transition to adulthood

6. Causes of ESRD

7. Donor-recipient size mismatch
✦The following factors must be considered in pediatric KT recipients:
✦Renal function of the donor kidney
✦Age of the donor
✦Donor criteria
✦Matching degree of human leukocyte antigen (HLA)

8. ✦Donor-recipient size mismatch commonly results in graft hypoperfusion
and delayed graft function (DGF)
✦Kidneys obtained from very young donors can be associated with graft
thrombosis owing to small-sized anastomotic vessels

9. HLA mismatch
✦Most pediatric recipients require retransplantation.
✦Therefore, kidneys from HLA-mismatched donors are not preferred
✦Studies reinforce the fact that higher HLA mismatches limit long-term
graft survival.

10. The majority of pediatric recipients of a deceased donor kidney, 84%,
had four or more HLA mismatches compared with only 27% of living
donor recipients

11. UROLOGIC ISSUES
✦Urological disorders related to anomalies of the lower urinary tract
are a significant difficulty encountered in pediatric KT
✦Treatment of urological disorders may necessitate additional
procedures such as open vesicostomy and bladder augmentation

12. Surgical Issues
✦Small children (<20 kg)
✦Intraperitoneal/intra abdominal placement of graft
✦Anastomosis of the renal vein and artery to the recipient’s inferior
vena cava and aorta

13. Immunosuppression
✦Steroid therapy side effects:
✦Growth retardation
✦Glucocorticoids interfere with the width of the growth plate, increase
the apoptosis of chondrocytes, and reduce VEGF expression.

14. ✦Several different strategies to minimize steroid doses have been
attempted in pediatric KT
✦Early steroid withdrawal
✦Late steroid withdrawal
✦Complete steroid avoidance

16. PTLD and malignancy
✦PTLD is an abnormal proliferation of lymphocytes observed in
immunocompromised patients receiving transplantation.
✦Histopathological findings range from an infectious mononucleosis-
like presentation to that of non-Hodgkin lymphoma.

17. PTLD and malignancy
✦PTLD risk factors:
✦Epstein-barr virus (ebv)-seronegative status of recipients
✦Use of calcineurin inhibitors and antilymphocyte antibodies
✦The number of methylprednisolone pulses administered
✦Cytomegalovirus infection
✦ Younger age
✦Acute graft rejection episodes
✦Renal cell carcinoma was the most common type of non-PTLD
malignancy observed

18. Nonadherence & transition into adulthood
✦Nonadherence to medical recommendations is widespread
✦It rates as high as 75% in adolescents.

19. ✦Primary risk factors of nonadherence include:
✦Poor family functioning
✦Poor psychological functioning of the child
✦Poor family functioning includes poor family cohesion and
dysfunctional family dynamics

20. ✦Nonadherence should be monitored using objective methods:
✦Pill counts
✦Medication refill rates
✦Blood levels of medications
✦Thorough use of electronic devices
✦Effective health education that includes imparting behavioral skills
and using motivational strategies is warranted to assist such
adolescents.

21. ✦In general, a child’s transition into adulthood is a critically vulnerable
period
✦Successful transition of care requires that age-appropriate practices
be adopted by patients, their parents, and the staff involved with
performing pediatric and adult transplantations.

22. ✦Pediatric transplant patients should be instructed as to their medical
condition, its treatments, the need for treatment during childhood
and adolescence, and optimal self- care practices
✦They should understand and accept the eventual need for transfer of
care