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The 1989 report of the North American Pediatric Renal Transplant Cooperative Study
S R Alexander1, G S Arbus, K M Butt
1Clinical Coordinating Center, Brooklyn, NY 11203.
Insights
Pediatric kidney transplant outcomes show live donors yield better graft survival than cadaver donors. Early rejection is more common with cadaver transplants, impacting long-term success.
Area of Science:
- Nephrology
- Pediatric Surgery
- Immunology
Background:
- Pediatric kidney transplantation is a critical treatment for end-stage renal disease.
- Understanding factors influencing graft survival and rejection is essential for improving outcomes.
- The North American Pediatric Transplant Cooperative Study (NAPTC) collects vital data on pediatric transplants.
Purpose of the Study:
- To summarize and analyze data from a large cohort of pediatric kidney transplants.
- To identify key factors affecting graft survival, rejection rates, and patient mortality.
- To evaluate the impact of donor source (live vs. cadaver) and recipient age on transplant success.
Main Methods:
- Analysis of 761 pediatric kidney transplants performed between January 1, 1989, and February 16, 1989.
- Data collection from 57 participating centers with ongoing patient follow-up.
- Statistical evaluation of transplant frequency, diagnoses, pre-transplant dialysis, immunosuppression, rehospitalization, rejection episodes, graft survival, and mortality.
Main Results:
- Live-donor transplants had a 1-year graft survival of 0.88 compared to 0.71 for cadaver-donor transplants.
- Median time to first rejection was significantly shorter for cadaver (36 days) versus live-donor (156 days) transplants.
- Recipient age and donor age (for cadaver donors) were significant prognostic factors for graft survival.
Conclusions:
- Live donor kidney transplantation offers superior graft survival in children compared to cadaver donors.
- Early rejection is a significant challenge, particularly with cadaveric grafts, necessitating optimized immunosuppression strategies.
- Recipient and donor factors play crucial roles in pediatric kidney transplant success, guiding future therapeutic approaches.
Abstract:
This report of the North American Pediatric Transplant Cooperative Study summarizes data contributed by 57 participating centers on 754 children with 761 transplants from 1 January 1989 to 16 February 1989. Data collection was initiated in October 1987 and follow-up of all patients is ongoing. Transplant frequency increased with age; 24% of the patients were less than 5 years, with 7% being under 2 years. Common frequent diagnoses were: aplastic/dysplastic kidneys (18%), obstructive uropathy (16%), and focal segmental glomerulosclerosis (12%). Preemptive transplant, i.e., transplantation without prior maintenance dialysis, was performed in 21% of the patients. Dialytic modalities pretransplant were peritoneal dialysis in 42% and hemodialysis in 25%. Bilateral nephrectomy was reported in 29%. Live-donor sources accounted for 42% of the transplants. Among cadaveric donors, 41% of the donors were under 11 years old. During the first post-transplant month, maintenance therapy was used similarly for live-donor and cadaver source transplants, with prednisone, cyclosporine, and azathioprine used in 93%, 83%, and 81%, respectively. Triple therapy with prednisone, cyclosporine, and azathioprine was used in 78%, 75%, and 75% of functioning cadaver source transplants at 6 months, 12 months, and 18 months as opposed to 60%, 63%, and 54% for live-donor procedures, with single-drug therapy being uncommon. Rehospitalization during months 1-5 occurred in 62% of the patients, with treatment of rejection and infection being the main causes. Additionally, 9% were hospitalized for hypertension. During months 6-12 and 12-17, 30% and 28% of the patients with functioning grafts were rehospitalized. Times to first rejection differed significantly for cadaver and live-donor transplants. The median time to the first rejection was 36 days for cadaver transplants and 156 days for live-donor transplants. Overall, 57% of treated rejections were completely reversible although the complete reversal rate decreased to 37% for four or more rejections. One hundred and fifty-two graft failures had occurred at the time of writing, with a 1-year graft survival estimate of 0.88 for live-donor and 0.71 for cadaver source transplants. In addition to donor source, recipient age is a significant prognostic factor for graft survival. Among cadaver donors, decreasing donor age is associated with a decreasing probability of graft survival. Thirty-five deaths have occurred; 16 attributed to infection and 19 to other causes. The current 1-year survival estimate is 0.94. There have been 9 malignancies.