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Renal transplantation in infants
J S Najarian1, D J Frey, A J Matas
1Department of Surgery, University of Minnesota Medical School, Minneapolis.
Insights
Renal transplantation in infants shows excellent survival rates comparable to older children. Successful kidney transplants improve infant growth and development, highlighting the importance of living donors.
Area of Science:
- Pediatric Nephrology
- Transplant Surgery
- Immunology
Background:
- Infant renal transplantation timing remains a debated topic.
- Early kidney failure in infants necessitates timely intervention.
- Congenital anomalies like hypoplasia and obstructive uropathy are leading causes of renal failure in this age group.
Purpose of the Study:
- To evaluate the outcomes of renal transplantation in infants under two years of age.
- To compare graft and patient survival rates in different infant age groups and with older children.
- To identify factors influencing graft survival and patient outcomes in pediatric kidney transplantation.
Main Methods:
- Retrospective analysis of 79 renal transplants performed between 1965 and 1989 in 75 infants.
- Categorization of infants by age (≤12 months vs. 12-24 months), donor type (living related, living unrelated, cadaver), and transplant type (primary, retransplant).
- Intra-abdominal transplant technique with distal aortic anastomosis was employed.
Main Results:
- Overall patient survival is 91% at 5 years, and graft survival is 73% at 5 years.
- Cyclosporine immunosuppression achieved 100% patient survival and 82% graft survival at 5 years.
- No significant difference in outcomes was observed between infants ≤12 months and those 12-24 months, or compared to older children.
Conclusions:
- Infant renal transplantation yields excellent short- and long-term survival rates comparable to older children.
- Successful transplantation leads to improved growth, head circumference, and development in infants.
- Living donor kidney transplantation is recommended whenever feasible for optimal outcomes in pediatric patients.
Abstract:
The timing of renal transplantation in infants is controversial. Between 1965 and 1989, 79 transplants in 75 infants less than 2 years old were performed: 23 who were 12 months or younger, 52 who were older than 12 months; 63 donors were living related, 1 was living unrelated, and 15 were cadaver donors; 75 were primary transplants and 4 were retransplants. Infants were considered for transplantation when they were on, or about to begin, dialysis. All had intra-abdominal transplants with arterial anastomosis to the distal aorta. Sixty-four per cent are alive with functioning grafts. The most frequent etiologies of renal failure were hypoplasia (32%) and obstructive uropathy (20%); oxalosis was the etiology in 11%. Since 1983 patient survival has been 95% and 91% at 1 and 5 years; graft survival has been 86% and 73% at 1 and 5 years. For cyclosporine immunosuppressed patients, patient survival is 100% at 1 and 5 years; graft survival is 96% and 82% at 1 and 5 years. There was no difference in outcome between infants who were 12 months or younger versus those who were aged 12 to 24 months; similarly there was no difference between infants and older children. Sixteen (21%) patients died: 5 after operation from coagulopathy (1) and infection (4); and 11 late from postsplenectomy sepsis (4), recurrent oxalosis (3), infection (2), and other causes (2). Routine splenectomy is no longer done. There has not been a death from infection in patients transplanted since 1983. Rejection was the most common cause of graft loss (in 15 patients); other causes included death (with function) (7), recurrent oxalosis (3), and technical complications (3). Overall 52% of patients have not had a rejection episode; mean creatinine level in patients with functioning grafts is 0.8 +/- 0.2 mg/dL. Common postoperative problems include fever, atelectasis, and ileus. At the time of their transplants, the infants were small for age; but with a successful transplant, their growth, head circumference, and development have improved. Transplantation in infants requires an intensive multidisciplinary approach but yields excellent short- and long-term survival rates that are no different from those seen in older children or adults. Living donors should be used whenever possible. Patients with a successful transplantation experience improved growth and development, with excellent rehabilitation.