Challenges in Chronic Kidney Disease Management and Kidney Transplantation in a Toddler With Autism Spectrum Disorder

Transplantation in a young child comes with multiple difficulties and the challenge increases in children with intellectual disability disorder such as autism spectrum disorder (ASD). Apart from the usual requirements, these children require detailed planning including ethical considerations as well as strategies for anesthesia and sedation.

A male child with bilateral polycystic kidneys secondary to an HNF1B mutation had gastrostomy tube insertion at six months to overcome the challenges of polyuria and failure to thrive. Later, he was diagnosed with ASD and started on cognitive behavioral therapy. Pre-emptive kidney transplant was planned at three years, with the mother as the donor. On completing the pre-transplant workup, an anesthetic team and a child psychologist were consulted to discuss the sedation and anesthesia plan.

The transplant procedure was uneventful, and the child was shifted to our transplant intensive care unit for planned extubation in the presence of family members. During the perioperative period, initial pain management involved administering a slow infusion of low-dose morphine with fentanyl. However, he failed initial extubation trials because of agitation, and subsequently, risperidone as well as dexmedetomidine were also introduced. Gradual tapering of medications was performed based on the pain scores. Following the pain management protocol and gradual tapering of medications, he was successfully extubated on day 5 in the presence of his parents and discharged on day 10.

The case highlights the challenges associated with transplantation in a young child compounded with additional risks posed by ASD.