Transplantation In Small Children Research Articles

Good outcomes after pediatric intraperitoneal kidney transplant.

Kidney transplantation in small children is technically challenging. Consideration of whether to use intraperitoneal versus extraperitoneal placement of the graft depends on patient size, clinical history, anatomy, and surgical preference. We report a large single-center experience of intraperitoneal kidney transplantation and their outcomes. We conducted a retrospective review of pediatric patients who underwent kidney transplantation from April 2011 to March 2018 at a single large volume center. We identified those with intraperitoneal placement and assessed their outcomes, including graft and patient survival, rejection episodes, and surgical or non-surgical complications. Forty-six of 168 pediatric kidney transplants (27%) were placed intraperitoneally in children mean age 5.5±2.3years (range 1.6-10years) with median body weight 18.2±5kg (range 11.4-28.6kg) during the study period. Two patients (4%) had vascular complications; 10 (22%) had urologic complications requiring intervention; all retained graft function. Thirteen patients (28%) had prolonged post-operative ileus. Eight (17%) patients had rejection episodes ≤6months post-transplant. Only one case resulted in graft loss and was associated with recurrent focal segmental glomerular sclerosis (FSGS). Two patients (4%) had chronic rejection and subsequent graft loss by 5-year follow-up. At 7-year follow-up, graft survival was 93% and patient survival was 98%. The intraperitoneal approach offers access to the great vessels, which allows greater inflow and outflow and more abdominal capacity for an adult donor kidney, which is beneficial in very small patients. Risk of graft failure and surgical complications were not increased when compared to other published data on pediatric kidney transplants.

Kidney Transplantation in Small Children: Association Between Body Weight and Outcome-A Report From the ESPN/ERA-EDTA Registry.

Many centers accept a minimum body weight of 10 kg as threshold for kidney transplantation (Tx) in children. As solid evidence for clinical outcomes in multinational studies is lacking, we evaluated practices and outcomes in European children weighing below 10 kg at Tx. Data were obtained from the European Society of Paediatric Nephrology/European Renal Association and European Dialysis and Transplant Association Registry on all children who started kidney replacement therapy at <2.5 y of age and received a Tx between 2000 and 2016. Weight at Tx was categorized (<10 versus ≥10 kg) and Cox regression analysis was used to evaluate its association with graft survival. One hundred of the 601 children received a Tx below a weight of 10 kg during the study period. Primary renal disease groups were equal, but Tx <10 kg patients had lower pre-Tx weight gain per year (0.2 versus 2.1 kg; P < 0.001) and had a higher preemptive Tx rate (23% versus 7%; P < 0.001). No differences were found for posttransplant estimated glomerular filtration rates trajectories (P = 0.23). The graft failure risk was higher in Tx <10 kg patients at 1 y (graft survival: 90% versus 95%; hazard ratio, 3.84; 95% confidence interval, 1.24-11.84), but not at 5 y (hazard ratio, 1.71; 95% confidence interval, 0.68-4.30). Despite a lower 1-y graft survival rate, graft function, and survival at 5 y were identical in Tx <10 kg patients when compared with Tx ≥10 kg patients. Our results suggest that early transplantation should be offered to a carefully selected group of patients weighing <10 kg.

Perioperative renal transplantation management in small children using adult-sized living or deceased donor kidneys: A single-center experience.

Kidney transplantation remains the treatment of choice for children with ESRD. Optimal perioperative management is critical in small recipients of ASK to assure adequate graft perfusion. We present a single-center experience outlining management for patients weighing <20kg who underwent primary renal transplantation with ASKs between 2007 and 2016. Sixty-three patients met study criteria and underwent 34 living-related, six living-unrelated, and 23 deceased donor kidney transplants. Median age and weight at transplant were 25months (IQR 18-37months; range 11months-6years) and 11.0kg (IQR 9.2-14.5kg; range 7.1-19.5kg). Eighty-nine percent of patients required vasoactive agents intra-operatively, with twenty patients requiring prolonged vasoactive agents post-operatively. Intra-operatively, patients received 51.9mL/kg of crystalloid, 27.3mL/kg of 5% albumin, and 13.6mL/kg of packed red blood cells. Most (93.7%) patients were extubated on POD#0. Weights peaked on post-operative days three through five. Over a median follow-up of 49months (IQR 31-86months; range 0-130months), four grafts were lost,two due to thrombosis and two secondary to chronic rejection. There was one patient death six months post-transplant due to causes unrelated to transplantation. Graft survival at 1, 5, and 10years was 98.4%, 96.6%, and 84.2%, respectively. Of surviving allografts, the median 1, 5, and 10years post-transplant eGFR was 122.9, 90.0, and 59.2mL/min/1.73m2 as determined by the 2009 Schwartz formula. Renal transplantation in small children using ASKs requires meticulous perioperative management including adequate fluid resuscitation and judicious use of pressors to assure adequate graft perfusion. The use of ASKs from living or deceased donors results in satisfactory short and long-term outcomes.

Results of Kidney Transplantation in Small Children

Results of Kidney Transplantation in Small Children

Re: Successful Renal Transplantation in Small Children with a Completely Thrombosed Inferior Vena Cava.

Re: Successful Renal Transplantation in Small Children with a Completely Thrombosed Inferior Vena Cava.

Anesthetic management for liver transplantation in small children

Anesthetic and surgical management of small children is challenging because of technical difficulties and repeated re-explorations for vascular or biliary complications. Preoperative optimization and meticulous intraoperative and postoperative management can achieve the survival rates comparable to older children. In our institution, we have successfully managed living donor liver transplant in four small children ≤8 kg, and with these case reports, we have tried to present anesthetic concerns and management of these cases along with surgical and postoperative details.

Wow, that portal vein is small: Preventing portal vein thrombosis in liver transplantation for small children

Portal vein thrombosis after pediatric liver transplantation is a common and devastating complication. Occurring in up to 8% of pediatric liver transplant recipients who are less than 15 kg, it frequently leads to graft loss and the need for emergent retransplantation.1, 2 Children with biliary atresia are at particularly high risk and often develop an atretic portal vein; this makes the portal vein anastomosis particularly difficult. Adding further complexity is the frequent use of left lateral segment allografts, which frequently introduce portal vein size mismatching and orientation issues. Several options exist for managing the technical challenges related to portal vein anastomoses. Although the traditional approach has been end-to-end portal vein anastomoses, size differences often make this approach impossible. When this is the case, a proximal mesenteric vein anastomosis, branch vein patch, or donor venoplasty may be necessary to complete the anastomosis.3 When angulation issues result in low portal flow after transplantation, augmentation can be achieved through the ligation of the left renal vein or other mesocentral venous collaterals. Portocaval and porto-arterial anastomoses have also been proposed to increase flow. Although these approaches may effectively lower the risk of portal vein thrombosis after liver transplantation, they are less than optimal solutions for pediatric recipients with diminutive portal veins or preoperative portal vein thrombosis. A potential answer to this issue may be the use of a renoportal anastomosis. This approach has been described in adult liver transplantation with promising results.4 In pediatric patients, we believe that this technique provides a unique solution to issues relating to flow, size, and orientation mismatch. In general, there are no specific criteria for using a renoportal anastomosis; however, we find that size mismatch and portal flow issues are the most frequent indications. If the recipient portal vein measures 2 to 3 mm in size or is less than half the diameter of the donor portal vein, we often consider this technique. Additionally, if the portal vein flow is inadequate despite clamping of the left renal vein, we will also consider this approach. An appropriately sized venous conduit is prepared; this depends on the size relationship between the donor and recipient vessels. Suitable conduits include the external iliac vein, femoral vein, superior mesenteric vein, splenic vein, and saphenous vein (for living donors). The procurement of all these potential conduits is appropriate to facilitate as many technical options as possible during the transplant operation. The transplant hepatectomy proceeds as usual. As much length as possible of the recipient portal vein should be maintained. Before the completion of the hepatectomy and the clamping of the portal vein and inferior vena cava, the left renal vein of the recipient is exposed. On the back table, an end-to-end anastomosis is fashioned between the left portal vein of the donor and the vein conduit. The liver is brought to the field, and the hepatic vein anastomosis is completed. A clamp is placed on the recipient left renal vein toward the kidney, and the vein is ligated at the level of the inferior vena cava. The renoportal anastomosis is created between the conduit and the left renal vein. The clamps are removed, and the liver is reperfused. Once the bleeding is under control, a partial clamp is placed on the side of the vein conduit. An anastomosis is created between the end of the recipient portal vein and the side of the donor conduit (Fig. 1). The portal vein clamp is removed, and the arterial anastomosis is completed. In conclusion, using a renoportal anastomosis for hepatic portal inflow overcomes 2 issues that commonly challenge pediatric liver transplantation in small children. First, the renal vein, the donor left portal vein, and the conduit are well matched in size. Second, there frequently is little flow through the mesenteric venous system of these small children. Using the left renal vein as inflow provides a reliable amount of flow to the allograft. Although the sewing of the donor portal vein to the iliac vein conduit may not be necessary, it dilates with time and frequently becomes the dominant inflow to the liver. Even in the setting of pretransplant portal vein thrombosis, the left renal vein provides adequate inflow and likely also adequate mesenteric venous drainage. Michael J. Englesbe, M.D. Amit K. Mathur, M.D. Seth A. Waits, M.D. John C. Magee, M.D. Section of Transplant Surgery Department of Surgery University of Michigan Ann Arbor, MI

Single Kidney Transplantation in Small Children from Small Paediatric Donors

Background: Paediatric single kidney transplantation (sKT) from small pediatric donors (i.e. ≤ 5yrs and/or ≤10Kg) has been seeing with reluctance because of multiple factors (i.e. insufficient nephron mass, high rates of ACR and high rates of vascular and urological complications) which may negatively influence both early and late post-transplant outcome. Therefore small kidneys from paediatric donors have been usually transplanting en-bloc in adults and in children too. Up to date only one series on this topic (sKT from donor ≤ 6 yrs.) has been reported in the Literature. Aim: To analyze our single centre experience with children receiving sKT from paediatric donors < 4 years. Patients and methods: Single centre retrospective analysis of results of sKT in children < 4 years old at UKT between 2004 and 2011. Univariate analysis was performed according to t-Student test and graft/patient survival was estimated by the Kaplan-Mayer method Results: Between 2004-2011, 20 paediatric sKT have been performed at UKT: – 7 from donors ≤4 yrs (Study Group): 6 in small recipients ≤5yrs and 1 in a 16 years old recipient – 13 from donors > 5 yrs Post-operative course in Study Group: – CIT: 16,5±6,4 hours – WIT: 32±7,2 minutes – PGF in 5 – DGF (defined as Creatinine>3 for more than 5POD) in 2 – No patient received post-operative dialysis or vasopressor support – average ICU stay: 5±1,2 days – average hospital stay: 19±4,5 days – postoperative complications according to Dindo-Clavien classification o 5 Grade I-II o 1 Grade III – BPAR was observed in 1 case, successfully treated. – 1 out of the 6 small recipients developed graft loss due to chronic rejection after 6 months. He died one month later due to massive bleeding during implantation of Hickmann-Catheter. -Surival rates (mean follow-up 34 months) -Overall graft and patients survival: 95% -Overall graft and patients survival in group 1: 85,7% Conclusions: Paediatric sKT from small paediatric donors in small recipient is feasible, sure and associated with good outcome. In times of organ paucity, in order to avoid further organ wastage, renal grafts from small paediatric donors should be allocated singularly to different paediatric recipient instead en-bloc for one adult or adolescent.

Renal transplantation in infants and small children

There are still concerns about renal transplantation in small children. The aim of this study was to identify prenatal data, underlying diseases, patient and graft survival, graft function and growth in young renal transplant recipients at our center. A retrospective analysis was performed on 50 kidney transplants performed during the period 1981-2008 in children weighing <13 kg. Their median age at transplantation was 1.4 (range 0.4-3.7) years and the median weight was 9.5 (3.4-12.1) kg. The underlying diseases were congenital in 88% of the patients and acquired in 12%. Ten-year patient survival was 88% (82% before 1998 and 95% since 1998). Ten-year graft survival was 82% (75 and 95%, respectively). Graft function (glomerular filtration rate) deteriorated from a mean of 75-48 ml/min/1.73 m(2) within 10 years. There was rapid catch-up growth within the first years post-transplant, from a median height of -2.44 standard deviation score (SDS) at transplantation to -0.74 SDS after 3 years. In small children, patient and graft survival were as good as those in older children. Renal function deteriorated during the first years post-transplant but stabilized within a few years. In most children, there was a substantial improvement in growth within the first years after transplantation.

Extraperitoneal renal transplantation in small children results in a transient improvement in early graft function

Renal transplantation is considered more technically challenging in small children compared to adults, especially when live donor adult kidneys are used. Transplanted kidneys have traditionally been placed intraperitoneally, although over the last decade extraperitoneal positioning has been attempted. The aim of this study was to establish whether there is a difference in kidney function and outcome dependent on the surgical approach to transplantation. The medical notes of all children under the age of six who received a renal transplant at our unit between January 1998 and October 2009 were reviewed. Demographic data, operation details, HLA mismatch, immunosuppression regime, complications, and function of the graft were analyzed. A total of 30 transplants were performed in children under six yr of age. The one-yr patient and graft survival were 97% and 93%, respectively. Eighteen were undertaken via an intraperitoneal approach, with the remaining being placed extraperitoneally. There were no significant differences in the number of complications observed between the two groups, and median length of stay was comparable (extraperitoneal 19.5 days vs. intraperitoneal 20.5 days). The plasma creatinine values for the two groups were compared using multivariate linear regression analysis and adjusted for age, weight, gender and baseline plasma creatinine. Between days 2 and 14 post-operatively, there was a significant difference in absolute plasma creatinine between the two surgical approaches. However, the trend of change in mean plasma creatinine values over time did not differ significantly between the two groups. Extraperitoneal kidney transplantation in small children is safe and technically feasible. From our series, there appears to be early improved function, although there is no long-term difference in function between approaches.

Implantation of a Berlin Heart Ventricular Assist Device

Until recently the only mode of mechanical circulatory support available in North America for use as bridge to cardiac transplantation in small children was extra-corporeal membrane oxygenation. However, since 2005 the Berlin Heart pediatric ventricular assist device has been increasingly widely used for both biventricular and left ventricular support. The device is available in a wide range of sizes, allowing its use in children as small as 5 kg and as large as 60 kg. It has been applied in end-stage heart failure of both structural/congenital and myopathic etiology (including myocarditis). In the article the technique for implantation of the device will be described, with focus on certain details that facilitate safe implantation and subsequent explantation, whether in the setting of a heart transplant operation or in the setting of recovery of native heart function.

Successful living donor liver transplant in a very small child.

Liver transplantation in small children poses perioperative challenges that are different from those seen in adults. We present our successful anaesthetic experience in a 7-month-old infant who has been the youngest case of successful living donor liver transplant performed in our institution till the day this article was being prepared.

Biventricular Assist Devices as a Bridge to Heart Transplantation in Small Children

Experience with the use of biventricular assist device (BiVAD) support to bridge small children to heart transplantation is limited. We used BIVAD support (Berlin EXCOR) in 9 pediatric heart transplant candidates from 4/05 to 7/07. The median patient age was 1.7 years (12 days to 17 years). The median patient weight was 9.4 kg (3 to 38 kg). All children were supported with multiple intravenous inotropes+/-mechanical ventilation (6) or ECMO (3) before BiVAD implantation. All had significant right ventricular dysfunction. The median pulmonary vascular resistance index (Rpi) was 6.0 WU/m(2). Eight patients were successfully bridged to heart transplantation after a median duration of BiVAD support of 35 days (1 to 77 days). One death occurred after 10 days of support from perioperative renal failure in a 3 kg infant. Five patients required at least 1 blood pump change. One patient had a driveline infection requiring treatment. There were no acute neurological complications, no thromboembolic events, and no bleeding complications. In 2 patients with Rpi >10 WU/m(2) unresponsive to pulmonary vasodilator therapy, Rpi dropped to 1.4 and 4.6 WU/m(2), after 33 and 41 days of support, respectively. All 8 survivors underwent successful heart transplantation. Of 5 patients supported >30 days, 3 developed an extremely elevated (>90%) panel reactive antibody by ELISA that was not confirmed by other methods; none had a positive donor-specific retrospective crossmatch. There was 1 episode of rejection (with hemodynamic compromise) in the 8 transplanted patients. Rpi was normal (<3 WU/m(2)) without pulmonary vasodilators in all patients within 3 months after transplant. There have been no deaths after transplant with a median follow-up of 19 months. BiVAD support can effectively be used in small children as a bridge to heart transplantation and can be accomplished with low mortality and morbidity. BiVAD support may offer an additional means to reverse extremely elevated pulmonary vascular resistance. Surveillance for HLA antibody sensitization during BiVAD support may be complicated by the development of non-HLA antibodies which may not reflect true HLA presensitization.

Early treatment of acute rejections gives favorable long‐term function after renal transplantation in small children

AR is considered as a risk factor for CAN after kidney TX. We combined data on AR with long-term graft function and histopathology to assess whether early treatment of AR is beneficial for long-term graft outcome in small children. Seventy-seven children with a mean age of 4.7 yr were studied. Early AR were diagnosed with FNAB and treated with methylprednisolone already before clinical signs occurred. The children were grouped into three groups (clinical, subclinical, and no AR) and then followed prospectively up to seven yr after TX with measured GFR and core needle biopsies to assess histopathological findings with the CADI score. Early AR, whether clinical or subclinical, did not affect long-term graft survival (80% with AR vs. 83% without AR, at 10 yr). Late AR, more than one yr after TX, had an inferior graft survival 50% vs. 84% (p = 0.02). GFR declined and the CADI scores increased with time, but there were no significant differences between the three groups. Prompt and early treatment of post-operative AR gives favorable long-term graft function compared with children without AR. Late AR is a risk factor for inferior long-term graft function.

Successful Renal Transplantation in High-Risk Small Children with a Completely Thrombosed Inferior Vena Cava

Inferior vena cava (IVC) thrombosis is generally a contraindication to renal transplantation in small children because of the technical difficulty and limitations in allograft venous outflow drainage that risk graft thrombosis. The records of six consecutive children (9.9-27.4 kg) with end-stage renal disease and thrombosed IVCs were reviewed. Small deceased donor renal allografts were utilized in all cases where immediate posttransplant venous renal outflow would theoretically not exceed the drainage capacity of the iliac or adjacent pelvic collateral veins. There is 100% patient survival with two patients returning to dialysis at seven and three years posttransplantation. There were no surgical complications or delayed graft function. Postoperatively, progressive renal vein and simultaneous iliac venous enlargement was observed in five of six recipients concomitant with renal allograft enlargement. In these patients, maximum renal volume achieved was between 152 and 275 ml and last recorded Schwartz glomerular filtration rates ranged from 67 to 118 ml/min. The sixth allograft had an early, severe rejection episode that limited renal growth and attainment of good renal function. All patients demonstrated resumption of growth rates commensurate with age but without significant catch-up growth. A small deceased donor kidney can provide freedom from dialysis and better quality of life for small children with IVC thrombosis during an age when dialysis treatment is difficult and the complications of the thrombosed IVC may compromise life. Good renal function was attained in patients without rejection episodes. In those with rejection, our approach allowed for patient growth during allograft function, providing a bridge for a repeat transplant.

Kidney transplantation in small children with live related donors: 20 years of experience

Objectives Kidney transplantation (Tx) with a live related donor is the best option available for the treatment of end-stage renal disease at any age. Modern dialysis has allowed many very young and small children to receive a renal transplant with good results in spite of the limitations of space and the size of the adult kidney. Here, we report our experience with renal Tx with live related donors in this complex group of pediatric patients. Material and methods From 1978 to 2004 a kidney transplantation was performed in 211 pediatric patients. Of this group, 23 patients between 1 and 10 years of age (16 males and seven females) of less than 17 kg (8.9–16.9 kg) received their first live related donor transplantation between 1985 and 2004. Renal insufficiency was secondary to nephropathy in 11 patients, infravesical obstruction in six and renal dysplasia or renal infarcts in six. Results Patient and graft survival was 100% and 95.6% with an average follow up of 89.6 months (6–231). There were no vascular or urological complications. Urinary infection in five (21.7%) and acute rejection in three (13%) were the most common complications. One patient has returned to dialysis 11 years after Tx. Conclusions Young pediatric patients with a low body weight did not suffer a higher percentage of postoperative surgical complications, and the follow-up results are similar to those in older patients. A complex urological malformation has not prevented a living related Tx. These results encourage us to perform this procedure more frequently in younger patients when a live donor is available.

Paediatric kidney transplantation in small children - a single centre experience

Kidney transplantation (KTx) remains a challenging procedure in small children. This study presents our centre results. From 1983 to 2004, 40 of 442 paediatric KTx were performed in children with a body weight <11 kg. Median body weight was 9.2 kg (range: 7.2-10.9), median age was 2.7 years (range: 0.9-5.9). Preoperative dialysis was performed in 87.5%. In 24 cases (60%) grafts came from cadaveric (CAD) and in 16 cases (40%) from living related donors (LRD). Median donor age of CAD was 8 years (range: 1-40). The overall 1-, 5-, 10-, 15-year patient survival was 93%, 90%, 90% and 87% respectively. The overall 1-, 5-, 10-, 15-year graft survival was 90%, 80%, 66% and 56% respectively. There was no significant difference in survival of CAD or LRD grafts. Median follow-up was 13.7 years. Initial graft function rate was 100% for LRD and 79% for CAD. The relative glomerular filtration rate (GFR) showed no statistical difference between CAD and LRD. Main reasons for graft loss were chronic transplant nephropathy. Paediatric KTx is the treatment of choice even in very small children. Living donor KTx is the preferable donor source in terms of primary graft function and timing to transplantation.

First Living Related Kidney Transplantation Results in Excellent Outcomes for Small Children

Objective The aim of this study was to evaluated the outcomes of living related kidney transplantation in small children. Materials and methods Ten pediatric patients with body weights less than 10 kg received parental kidney transplants (five mothers and five fathers). An intra-abdominal approach was used in nine children and a retroperitoneal approach in one child. Bilateral, left, or right nephrectomy was performed in seven, two, and one child, respectively. Immunosuppression consisted of either cyclosporine ( n = 7) or tacrolimus ( n = 3) with either mizoribine ( n = 4) or mycophenolate mofetil (MMF) ( n = 5) or azathioprine ( n = 1), and methylprednisolone ( n = 10). Antilymphocyte globulin was used in the first series of four children; basiliximab in the most recent five children. Results All renal allografts functioned immediately after transplantation despite the mismatched size of the large renal allografts. Nine of 10 children were alive with a functional allograft at 6 to 196 months posttransplantation. One child died of intra-abdominal bleeding 5 days posttransplantation. One child has suffered chronic allograft nephropathy 11 years posttransplantation (serum creatinine 3.3 mg/dL). The remaining eight children display good renal function (serum creatinine = 0.2 to 1.43 mg/dL). Steroids were withdrawn in eight of nine children; one child continues on alternative-day therapy. One child (LD55) exceeded the mean standard height. The most recent height standard deviation (SD) scores were superior (−1.75 ± 1.39 [−3.83 to 0.54]; P < .0082) to those at transplantation (−2.91 ± 0.79 [−2.00 to −4.14]). Conclusions The outcomes of living related kidney transplantation in small children were excellent despite the operative risks and the difficulty of cardiovascular and fluid management. Transplantation for small children appears to result in much better quality of life and growth than dialysis.

Non-transplant cardiac surgery for end-stage dilated cardiomyopathy in small children

Between October 1997 and December 2000, a total of 7 pediatric patients with end-stage dilated cardiomyopathy (DCM) were referred to our service for heart transplantation; non-transplant cardiac surgery was offered as a biologic bridge. Two patients died before surgery and the in-hospital surgical mortality rate was 50%: 75% in 4 patients who received emergency surgery and 0% in 2 patients who received urgent surgery. Non-transplant cardiac surgery improved clinical outcome and acted as a biologic bridge, instead of a mechanical bridge, to heart transplantation in small children with DCM and severe heart failure.

Renal Transplantation in Small Children – A Comparison between Surgical Procedures

Objectives: Renal transplantation is the therapy of choice for patients with end–stage renal failure. From the surgical point of view, small children remain a challenging patient group. Methods: We report our experience with 61 consecutive kidney transplantations in small children aged ≤6 years. Outcome and graft survival rates were presented with special reference to the surgical procedure used to perform the renal transplantation. Results: Of the 31 renal grafts, placed into the fossa iliaca (group 1), 8 grafts were lost shortly after transplantation due to a vascular complication (5 venous thromboses and 3 arterial thromboses). Six allografts were lost because of acute rejection. All in all, the 1– and 5–year graft survival rate in this group was 55.8% (p = 0.0106)/51.6% (p = 0.0134), respectively. Thirty grafts were placed retroperitoneally, using the aorta and the distal caval vein to perform end–to–side anastomoses (group 2). One graft was lost because of a venous thrombosis 6 weeks following transplantation, 3 further grafts were lost during the 1st year after transplantation due to acute rejection. The 1– and 5–year graft survival rate in that group was 86.6% (p = 0.0106)/83.3% (p = 0.0134), respectively. Comparing the 1–year graft survival rates of the two patient groups with special reference to vascular complications, we observed a 1–year graft survival rate of 74.2% (group 1) versus 96.6% (group 2; p = 0.026). Conclusions: Our results on kidney transplantation in small children have considerably improved with the consistent use of the aorta and the distal caval vein to perform vascular anastomoses. The number of vascular complications following renal transplantation decreased, and especially for very small children the retroperitoneal placement of the graft is a safe, feasible surgical procedure that should be performed whenever possible.