Unique surgical and immunologic features of renal transplantation in children

Abstract

We have performed 93 renal allografts in recipients having a mean age of 12.6 yr. Sixty percent of the kidneys were from parental donors, 10 from siblings, and 30 from cadavers. Young children present unique surgical, hemodynamic, and immunologic management problems. Modifications of standard transplantation surgical techniques have been developed that allow for routine retroperitoneal placement of adult kidneys in patients as young as 2.4 yr. These modifications include the surgical incision itself, the vascular anastomosis, and the operation's urologic components. Fluid management must allow maximum perfusion of the adult organ without compromise of the child's cardiovascular system. The most critical aspects of the undertaking reside in immunologic matching of the donor-recipient pair and in postoperative immunosuppression. Parent-to-child combinations usually share one HLA haplotype, are stimulatory in mixed lymphocyte cultures, and produce killing in cell-mediated lympholysis assays. Traditional wisdom predicts an unfavorable outcome with such allografts. Immunosuppression has been predicated on the outcome of these tests. In unfavorable parent-to-child pairs, and when poorly matched cadaveric kidneys are used, we have routinely employed a prolonged postoperative intravenous course of whole rabbit antihuman thymocyte sera prepared in our institution. The results show that in both situations the 1-yr kidney survival is 92%. Early rejection episodes have essentially been eliminated, and with them the need for large increments in steroid dosage. The children have eventually been placed on alternate-day steroid therapy, thus allowing for as near normal growth and development as possible. The data indicate not only that the very young child with endstage renal disease is an appropriate recipient for a renal allograft but also that growth failure itself may be an indication for early transplantation. We have performed 93 renal allografts in recipients having a mean age of 12.6 yr. Sixty percent of the kidneys were from parental donors, 10 from siblings, and 30 from cadavers. Young children present unique surgical, hemodynamic, and immunologic management problems. Modifications of standard transplantation surgical techniques have been developed that allow for routine retroperitoneal placement of adult kidneys in patients as young as 2.4 yr. These modifications include the surgical incision itself, the vascular anastomosis, and the operation's urologic components. Fluid management must allow maximum perfusion of the adult organ without compromise of the child's cardiovascular system. The most critical aspects of the undertaking reside in immunologic matching of the donor-recipient pair and in postoperative immunosuppression. Parent-to-child combinations usually share one HLA haplotype, are stimulatory in mixed lymphocyte cultures, and produce killing in cell-mediated lympholysis assays. Traditional wisdom predicts an unfavorable outcome with such allografts. Immunosuppression has been predicated on the outcome of these tests. In unfavorable parent-to-child pairs, and when poorly matched cadaveric kidneys are used, we have routinely employed a prolonged postoperative intravenous course of whole rabbit antihuman thymocyte sera prepared in our institution. The results show that in both situations the 1-yr kidney survival is 92%. Early rejection episodes have essentially been eliminated, and with them the need for large increments in steroid dosage. The children have eventually been placed on alternate-day steroid therapy, thus allowing for as near normal growth and development as possible. The data indicate not only that the very young child with endstage renal disease is an appropriate recipient for a renal allograft but also that growth failure itself may be an indication for early transplantation.