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Pediatric renal transplantation
Insights
Pediatric renal transplantation survival rates have improved, but acute rejection remains a challenge in young children. Further research is needed to understand and mitigate rejection, and to optimize growth post-transplant.
Area of Science:
- Pediatric Nephrology
- Transplant Immunology
- Growth Hormone Therapy
Background:
- Renal transplantation is a primary treatment for pediatric end-stage renal disease.
- Survival rates for pediatric kidney transplants have significantly improved.
- Acute rejection remains a critical issue, particularly in younger children.
Purpose of the Study:
- To analyze trends and outcomes in pediatric renal transplantation.
- To investigate mechanisms of heightened immune response and acute rejection in young children.
- To evaluate the necessity and safety of growth hormone therapy post-transplant.
Main Methods:
- Analysis of a large dataset from North American Pediatric Renal Transplant Cooperative Study.
- Utilizing surveillance biopsies to identify molecular mediators of acute rejection.
- Longitudinal studies on growth patterns after transplantation.
Main Results:
- 1- and 2-year graft survival rates for cadaveric donor pediatric renal transplants increased from 72% and 65% (1987) to 83% and 78% (1991).
- Graft failure due to acute irreversible rejection disproportionately affects children under 6 years old.
- Catch-up growth post-transplant is inconsistent, often necessitating recombinant growth hormone intervention.
Conclusions:
- While graft survival has improved, acute rejection in young children requires further investigation.
- Recombinant growth hormone may be necessary for optimal growth but requires controlled trials due to potential chronic rejection concerns.
Abstract:
Renal transplantation in children is now a well established mode of optimal therapy for children with end-stage renal disease. The cooperative endeavors of the pediatric renal transplant physicians in the USA and Canada have generated a large volume of data that lends itself to rigorous scientific analysis. With changing practice patterns, the percentage 1- and 2-year graft survivals for cadaveric donor pediatric renal transplants have increased to 83 and 78%, respectively, in 1991 compared with 72 and 65% in 1987. Graft failure from acute irreversible rejection continues to take its toll in children under the age of 6 years. With funding from the National Institutes of Health a major cooperative effort has been organized by the North American Pediatric Renal Transplant Cooperative Study to determine the mechanisms that lead to heightened immune response in young children. Surveillance biopsies done in the early post-transplant days will attempt to identify the molecular mediators of acute rejection. Rehabilitation of children will not be satisfactory without accelerated growth after transplantation. Unfortunately, the longitudinal studies of the natural histories of growth after transplantation demonstrates that catch up growth occurs only in a subset of young children and that for the majority of older children, intervention with recombinant growth hormone is necessary. However, concern regarding the potential of recombinant growth hormone to induce chronic rejection necessitates a controlled trial.