P4.28: Renal function outcomes in paediatric intestinal transplant recipients

Abstract

Background: Renal dysfunction after intestinal transplantation is a well recognised complication. Calcineurin inhibitors have a direct impact on the kidney with post-operative day 7 tacrolimus associated with kidney function at 1yr. Catheter related sepsis, prolonged usage of intravenous fluid, parental nutrition, diabetes and graft failure have all been associated with chronic kidney disease. Methods: Review of first-time paediatric intestinal graft recipients at a single centre between August’09-June’18. CKD was defined as Cystatin-C(CysC)>1mg/l measured at baseline, 6mths,1yr,2yr and 5yr post-transplant. Demographic and data associated with CKD post-transplantation were collected (Tac lvls at POD 7,3,6 and 12mths). Immunosuppression protocol consisted of Basiliximab induction then maintenance with tacrolimus and prednisolone +/- sirolimus. Target tacrolimus levels were between 12–15µ/L in the first 3wks, 8–12µ/L 3wks -3mths, 5–8µ/L out to1yr post transplantation. Statistical analysis was applied when appropriate, and analyses performed using SPSS. Results: 21 paediatric patients(53% male; 43%short gut syndrome, 38%paediatric intestinal pseudo-obstruction), median age of 5 yrs(4,7.8) underwent either isolated intestinal(43%), liver and intestinal(28%) or multivisceral transplantation(29%). 38% continued with tacrolimus and steroids alone, 57% sirolimus added. 4 patients required re-transplantation at a median time from first transplantation of 33.5mths (3.5,80). 4 patients died at a median time of 9.5mths(4.8,16). CysC level of all patients at baseline was 1.01(0.8,1.2), with 38% of children having evidence of pre-existing CKD (CysC lvl 1.16(1.1,1.5). There was significant association with CysC level at 6mth and Tacrolimus lvl at 3mths, r=-0.5 p=0.03. CysC lvl improved between 6mths and 1yr post transplant. No significant association was found between CKD at 6mths or 1yr and type of immunosuppression, prolonged use of intravenous fluids, parental nutrition, diabetes, graft failure, line sepsis or Tac lvl POD 7. Conclusion: Renal dysfunction is already prevalent at the time of intestinal transplantation therefore continuing close monitoring of renal function and tacrolimus levels is advisable. In our cohort renal dysfunction peaked at 6mths post transplant then improved following titration of tacrolimus level. A larger prospective study is required to identify paediatric variables that effect renal function following intestinal transplantation.