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Clinical management of the pediatric renal-allograft recipient
C L Abitbol1, G W Burke, G Zilleruelo
1Department of Pediatrics, University of Miami/Jackson Memorial Medical Center, Fla.
Insights
Pediatric kidney transplant success hinges on careful donor selection and timing, with early transplantation favored for infants and specific criteria for cadaveric transplants. Post-transplant care involves meticulous monitoring and immunosuppression to manage complications like rejection and cytomegalovirus infection.
Area of Science:
- Pediatric Nephrology
- Transplantation Medicine
- Immunology
Background:
- Pediatric renal transplantation is complex, requiring thorough pre-transplant evaluation.
- Optimal timing and donor selection are critical for successful outcomes in pediatric kidney recipients.
Purpose of the Study:
- To outline the comprehensive management strategies for pediatric renal transplant recipients.
- To detail pre-transplant, peri-operative, and long-term post-transplant care protocols.
Main Methods:
- Pre-transplant assessment including psychosocial evaluation and donor/recipient matching (HLA-A, -B, -DR).
- Medical preparation involving interferon and acyclovir prophylaxis for specific viral risks.
- Postoperative management focusing on fluid balance and multi-drug immunosuppression (corticosteroids, ciclosporin, azathioprine, ALG/ATG, OKT3, FK-506).
Main Results:
- Early transplantation is recommended for infants (<1 year) with live-related donors.
- Cadaveric transplants are best for older children (>3 years) with older donors (>5 years).
- Pre-emptive transplantation is feasible for a subset of patients.
Conclusions:
- Long-term management addresses medical, surgical, immune, and infectious complications.
- Key challenges include managing acute/chronic rejection, hypertension, and cytomegalovirus (CMV) infection.
- A multidisciplinary approach is essential for optimizing pediatric renal transplant outcomes.
Abstract:
Management of the pediatric renal-transplant recipient requires careful pretransplant evaluation including psychosocial assessment and cautious donor/recipient selection. Early transplantation is preferable in infants less than 1 year of age if a suitable live-related donor is available. However, cadaveric-allograft transplantation is best reserved for patients older than 3 years with donors older than 5 years. Pre-emptive transplantation is suitable for approximately one fifth of the population. Medical preparation includes careful HLA-A, -B, and -DR loci matching, interferon treatment for positive hepatitis antigenemia, and acyclovir prophylaxis for a cytomegalovirus (CMV) antibody-negative patient to a seropositive donor. Postoperative management requires close monitoring of the patient's volume status with careful fluid replacement in the form of colloid and crystalloid. Immunosuppression involves multiple drug regimens that include corticosteroids, ciclosporin, azathioprine, antilymphocyte (or -thymocyte) globulin (ALG/ATG), monoclonal antibodies (OKT3), and a ciclosporin alternative: FK-506. Long-term complications dictate management and are divided into medical, surgical, immune, and infectious categories. These are predominated by treatment of acute and chronic rejection, hypertension, and CMV infection.