[Renal transplantation in the pediatric age]

Renal transplantation is the optimal and preferred treatment for children with end-stage renal disease. Pediatric kidney transplantation results have improved significantly over the years and the actuarial survival of the children with renal transplantation has become excellent. These improvements are due to many factors, including better immunosuppressive regimens and therefore a decrease in acute rejection episodes and possible improvement of graft survival. The concentration of care in specialized pediatric transplantation centers allowed the improvement of kidney transplants also in children less than 6 years old. The same success is not always achieved in infants. The selection of the donor is another important factor. The survival rate of renal transplantation is better in case of living-related donors. Renal transplants performed from cadaveric donors <6 years of age have an actuarial survival lower than renal transplants from cadaver donors >6 years of age. Owing to the limited members of cadaveric kidneys available for transplants, also the donors <6 years old are sometimes a valuable resource. As far as HLA-matching and its relationship with renal transplant outcome is concerned, there are conflicting data, but important registers on adults and children show the positive relationship between histocompatibility matching and graft outcome. A major distinguishing feature of pediatric from adult renal recipients is the need for children to grow. It is well known that chronic renal insufficiency involves a growth failure. A functioning transplant may improve the growth, but a catch-up growth is rarely achieved. To overcome this problem many techniques, such as alternate-day steroid therapy, discontinuation of prednisone, the use of recombinant growth hormone, have been adopted. As to social rehabilitation, transplanted children attend the school and work more than dialyzed ones.