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Partial splenic ablation in preparation for renal transplantation in children
Insights
Partial splenectomy effectively prevents azathioprine-induced neutropenia in pediatric renal transplant candidates at risk. This spleen-preserving approach allows for standard azathioprine dosing, avoiding allograft rejection and infection risks.
Area of Science:
- Pediatric Nephrology
- Transplant Surgery
- Immunosuppression Management
Background:
- Patients with end-stage renal disease and certain conditions (hypersplenism, mild neutropenia) risk severe neutropenia with standard azathioprine doses post-transplant.
- Azathioprine intolerance necessitates dose reduction, increasing the risk of allograft rejection.
- While splenectomy prevents neutropenia, its risks in immunosuppressed patients are significant, prompting interest in spleen-preserving techniques.
Purpose of the Study:
- To evaluate the efficacy and safety of partial splenectomy in pediatric renal transplant candidates at risk of azathioprine-induced neutropenia.
- To determine if partial splenectomy allows for standard azathioprine dosing without neutropenia or sepsis.
Main Methods:
- Eight pediatric renal transplant candidates requiring splenic function reduction were identified.
- Partial splenic embolization was attempted in four children, with two initially successful but later requiring partial splenectomy.
- The remaining six children underwent partial splenectomy (approximately 75-80% resection).
Main Results:
- Partial splenectomy was successful in preventing azathioprine-induced neutropenia and sepsis in pediatric renal transplant recipients.
- Children undergoing partial splenectomy could be managed with routine azathioprine doses post-transplantation.
- No episodes of neutropenia or sepsis were observed in the children who underwent partial splenectomy.
Conclusions:
- Partial splenectomy is a recommended procedure for pediatric renal transplant candidates at risk of azathioprine-induced neutropenia.
- This spleen-preserving intervention facilitates safe and effective immunosuppression with azathioprine.
- Partial splenectomy balances the need to prevent neutropenia with preserving splenic immune functions.
Abstract:
Patients with end-stage renal disease who develop hypersplenism, patients with mild neutropenia, and those patients whose WBC fails to increase in response to cortisol administration will develop significant neutropenia following transplantation with routine doses of azathioprine. This "intolerance" of azathioprine mandates a reduction in the dose of azathioprine often resulting in allograft rejection. Splenectomy will prevent azathioprine-induced neutropenia, but the hazards of splenectomy in these immunosuppressed patients have led to attempts to salvage at least part of the spleen. Partial splenic ablation by embolization has been utilized in adults prior to transplantation to prevent azathioprine-induced neutropenia while preserving the spleen's protective mechanisms against infection. Eight children in our series of transplant candidates required a reduction of splenic function to prevent azathioprine induced neutropenia. One child had a functioning renal allograft but had recurrent neutropenia limiting the azathioprine dose. Partial splenic embolization was attempted in four children and was initially successful in two. Both patients later developed recurrent neutropenia and needed partial splenectomy. The two patients in whom partial splenic embolization was unsuccessful and five further patients in whom embolization was not attempted also underwent partial splenectomy. Approximately 75% to 80% of the spleen was resected. Six children have since undergone renal transplantation and one child had a transplant with chronic rejection at the time of partial splenectomy. Routine doses of azathioprine have been used in these children with no episodes of neutropenia or sepsis observed. We recommend partial splenectomy in those children requiring renal transplantation who are at risk for development of azathioprine induced neutropenia.