Original Paper
Urologia Internationalis
Received: March 22, 2013 Accepted after revision: July 4, 2013 Published online: November 22, 2013
Urol Int 2014;92:323–327 DOI: 10.1159/000354277
Outcome of Single Pediatric Deceased Donor Renal Transplantation to Adult Kidney Transplant Recipients Frank Friedersdorff Tom Florian Fuller Peter Werthemann Hannes Cash Department of Urology, Charité – Universitätsmedizin Berlin, Campus Mitte, Berlin, Germany
Key Words Kidney transplantation · Pediatric donors · Adult recipients · Complications · Risks
number of recipients over an ‘en-bloc’ transplantation. The price for a single pediatric kidney transplant may be a higher vascular complication rate and a higher rejection risk. Despite the higher risks, transplantation of a single pediatric donor kidney should be performed when accomplishable.
Abstract Introduction: In times of organ shortage more kidneys were transplanted in ‘expanded criteria kidney’ programs. This study examines the outcome of adult kidney recipients from pediatric donors. Materials and Methods: This single-center retrospective analysis evaluated eight adult patients who received a kidney from a deceased pediatric donor (age 5–17) between 06/2000 and 09/2011. Results: The median donor age was 14 years (range 5–17). The median recipient age was 49 years (range 25–57). The median cold ischemia time was 13.3 h (range 4.3–20.1), while the median warm ischemia time was 53 min (range 42–60). The median follow-up was 35.8 months (range 7–142). Acute rejection was observed in 50.0% of cases. The median HLA mismatch was 2.0. The median 1-year creatinine level was 0.95 mg/dl, the uncensored 1-year graft survival was 75.0% and the 3-year graft survival 62.5%, respectively. No recipient died within the follow-up period. As severe surgical complications, one stenosis of the renal artery and one lymphocele needing surgical revision were observed. Conclusions: Renal transplantation of a deceased single pediatric donor to an adult recipient can be performed safely and shows a good outcome. Wherever feasible, single pediatric kidney transplantation can double the
© 2013 S. Karger AG, Basel
E-Mail [email protected] www.karger.com/uin
There is still disparity between the demand for and the supply of organs for renal transplantation. For a patient on the waiting list for deceased donor renal transplantation (DDRT), prolonged renal dialysis in associated with a higher mortality and reduced quality of life [1, 2]. Constant efforts have been made in recent years in order to increase the donor pool. Especially the transplantation of kidneys with ‘expanded criteria’ and the Eurotransplant Senior Program have increased the number of older organs for DDRT [3]. Programs for AB0-incompatible living donor renal transplantation (LDRT) and cross-over LDRT have widened the possibility for LDRT [4–6]. Due to the shortage of organs, kidneys of deceased pediatric donors have been transplanted to adult recipients, although this remains a rare option. The organs are either transplanted as ‘en-bloc’ kidneys or as solitary organs [7– 9]. Published studies on deceased pediatric donor renal transplantation (DPDRT) showed a higher vascular and Dr. Frank Friedersdorff Charité – Universitätsmedizin Berlin, Campus Mitte Charitéplatz 1 DE–10117 Berlin (Germany) E-Mail frank.friedersdorff @ charite.de
Downloaded by: NYU Medical Center Library 128.122.253.228 - 5/29/2015 5:22:38 PM
© 2013 S. Karger AG, Basel 0042–1138/13/0923–0323$38.00/0
Introduction
Materials and Methods In our retrospective study we analyzed the cases of adult recipients of DPDRT who were transplanted between June 2000 and September 2011 at Charité, Campus Mitte. Overall eight cases were transplanted in this constellation. During the same time period more than 1,000 DDRTs were performed at our center. With regard to the acceptance of pediatric kidneys for adult recipients our center does not follow a strict profile and decisions are made on an individual basis. In all cases single kidneys were transplanted; no ‘en-bloc’ transplantation was performed. Data were acquired using an electronic database (TBase) [13]. We analyzed demographic data as well as complications, rejection rates, graft and patient outcome. DPDRT was performed in a standard extraperitoneal fashion using a Gibson incision without further adjustments. The vascular anastomosis was performed by the urologist as an end-to-side anastomosis between the renal vessels and the external iliac vessels. For the vascular anastomosis we used Polydioxanon sutures. Ureteroneocystostomy was accomplished using the extravesical Lich-Gregoir technique or the Politano technique. A ureteral double-J stent was routinely used. The stent was typically removed 6 weeks post transplantation. Graft function was monitored by Doppler ultrasound, serum creatinine and urine output measurements. Delayed graft function was defined as the need for at least 1 hemodialysis session during the first 7 days after transplantation. Delayed graft function and elevated (>0.8) resistance indices upon repeat measurements as well as a 20% rise in serum creatinine were indications for renal biopsy around postoperative day 7 to rule out rejection. Immunosuppression consisted of prednisone, mycophenolate mofetil and a calcineurin inhibitor. Oral prednisone was tapered to a dose of 10 mg during the first 6 months. Cyclosporine and tacrolimus target serum levels were between 150 and 250 ng/ml and between 10 and 12 ng/ml, respectively. Induction therapy with antilymphocyte agents or CD25 antibodies was applied in patients with a high immunologic risk. Rejection episodes were treated with high-dose steroids.
Results
From June 2000 to September 2011 eight adult patients received single renal grafts from pediatric donors. The median donor age was 14 years (range 5–17). The 324
Urol Int 2014;92:323–327 DOI: 10.1159/000354277
Table 1. Demographic data
Median donor age, years (range) Median recipient age, years (range) Graft distribution, left/right Recipient gender, female/male Median HLA mismatch Underlying cause of ESRD Polycystic kidney disease FSGS Chronic glomerulonephritis Previous bilateral RCC Nephrolithiasis in single kidney Median follow-up, months (range)
14 (5–17) 49 (25–57) 5 (62.5%)/3 (37.5%) 5 (62.5%)/3 (37.5%) 2.0 3 2 1 1 1 35.8 (7–142)
ESRD = End-stage renal disease; RCC = renal cell carcinoma.
youngest donor was 5 years old, the oldest 17 years. The 17-year-old donor was included because of growth pattern in the lower percentiles of the Centers for Disease Control and Prevention growth chart and thus comparable to a 15–16-year-old donor (www.cdc.gov/ growthcharts). Four donors were female and four male. Overall five right kidneys and three left organs were donated. Seven recipients had had no previous renal transplantation, for one patient is was the second organ. One patient had previously been transplanted and had received a LDRT from her mother at the age of 6 years. The renal function was preserved for 18 years. The median recipient age was 49 years (range 25–57). Five recipients were male, three female. The underlying caused for end-stage renal disease were polycystic kidneys in three cases, bilateral renal cell carcinoma with bilateral nephrectomy in one case, one case of nephrolithiasis in a functional single kidney, two patients with focal segmental glomerulosclerosis (FSGS) and one patient with chronic glomerulonephritis. The demographic data are shown in table 1. The median cold ischemia time was 13.3 h (range 4.3– 20.1). While the median warm ischemia time was 53 min (range 42–60), the overall median operating time was 217.5 min (range 195–257). The median HLA mismatch was 2.0. The kidney was transplanted in the right iliac fossa in six cases and the right iliac fossa in two cases. The median follow-up was 35.8 months (range 7–142). Six out of eight patients (75.0%) experienced complications. A summary of complications is shown in table 2. One patient developed a graft failure due to recurrence of a focal sclerosing glomerulosclerosis 6 months postoperatively. Another patient (32 years of age) also developed graft failFriedersdorff/Fuller/Werthemann/Cash
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urinary complication rate [10, 11]. Also an increased risk for acute rejection and a higher rate of delayed graft function were noted [12]. An inferior outcome of DPDRT may be explained by the lesser nephron mass of the small kidneys, which would favor ‘en-bloc’ transplantation. For ‘en-bloc’ transplantation a higher vascular risk may have to be taken into account. The aim of our study was to evaluate the outcome of adult recipients of DPDRT (age ≤17 years) at our center.
2 Mean creatinine (mg/dl)
1.02
0.89 0.91
0.75
0.89
0.70
0.87 0.82
w ee k m on th 6 m on th 12 s m on th 24 s m on th 36 s m on th 48 s m on th 60 s m on th 72 s m on th s 1
Fig. 1. Creatinine follow-up.
100
80 Graft survival (%)
+
+ +
+ +
+
60
40
20
Survival function
+ Censored
0 0
20
40 60 Follow-up (months)
80
Fig. 2. Kaplan-Meier curve for graft survival.
Table 2. Postoperative complications
Lymphocele requiring surgical treatment Asymptomatic lymphocele Seroma Renal artery stenosis Graft lost due to acute rejection
Urol Int 2014;92:323–327 DOI: 10.1159/000354277
1 1 1 1 1
325
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Single Pediatric Kidneys in Adults
1
0
Discussion
Renal transplantation is the treatment of choice for patients with end-stage renal disease, with superior quality of life and patient survival compared to dialysis [14– 16]. In order to reduce the shortage of possible donors, transplantation of kidneys with ‘expanded criteria’, the Eurotransplant Senior Program and LDRT have been established. For recipients for whom the allocation of an organ remains difficult due to their risk profile, DPDRT may be acceptable. This raises the question whether a pediatric graft is sufficient for adequate renal function in adults. The published rates of graft function are far better than was to be expected [11, 17, 18]. Bresnahan et al. [17] published a large study of data between 1988 and 2005 (United Network of Organ Sharing database) where 12,838 DPDRTs were performed to adult recipients. The pediatric donors were subdivided into three age groups, the largest being 12–17 years. The 1-year graft survival was 81.5% and thus differed significantly from organs from adult donors. The 2-, 3-, 4- and 5-year graft survival also differed significantly. In our study the 1-year graft survival was slightly lower with 75.0% and a 3-year graft survival of 62.5%. The study by Bresnahan et al. did not state whether an ‘en-bloc’ transplantation was performed. Satterthwaite et al. [11] compared the outcome of ‘en-bloc’ and single kidney transplantation of very young donors (5 years of age. Single graft DPDRT increases the number of possible recipients and should be performed wherever feasible. The study by Satterthwaite et al. [11] also showed ureteral leakage in 11% of cases. In our smaller study group, no ureteral complication was observed. An interesting finding by Satterthwaite et al. [11] was that 10 out of 91 transplants developed vascular complications leading to graft loss. Two stenoses of the renal artery were successfully treated with percutaneous angioplasty. In our study one graft also developed arterial stenosis. The recipient (50 years of age) was transplanted a single kidney of a 5-yearold donor. The stenosis was treated by arterial stenting. The creatinine levels were 1.2 mg/dl at 24 months followup. Especially with young donors the vascular risk seems to be higher. This might be explained by higher arterial pressure in adults, leading to arterial stenosis of the graft. A retrospective Italian study was able to show comparable results of DPDRT on adult recipients compared to conventional DDRT [18]. One-year survival in the pediatric group was 76% and patient survival was 96%. Complications rates did not differ either [18]. Overall, several studies found a higher complication rate for pediatric organs transplanted to an adult than in conventional DDRT [17, 19–22]. The most common complications are vascular (venous thrombosis/arterial stenosis) or ureteral (stenosis/leakage) in nature. In our small group, vas-
cular risk was also present. Vascular risk may be explained by the small size of the donor vessels and the organ size. Brenner et al. [23] established a hyperfiltration hypothesis, where a lack of nephron mass may lead to renal injury and nephrosclerosis with the development of FSGS. The primary form of FSGS is of great relevance in renal transplantation since it can recur within the graft and lead to graft loss within months to years after transplantation. In our study group, two patients experienced graft loss due to a recurrence of FSGS. Possibly transplantation of a pediatric kidney may have increased the risk of hyperfiltration and thus the recurrence of FSGS. Thus, recipients with FSGS as the underlying cause for end-stage renal disease may not be suitable for DPDRT.
Conclusion
Renal transplantation of a deceased single pediatric donor to an adult recipient can be performed safely and shows a good outcome. Wherever feasible, single pediatric kidney transplantation can double the number of recipients over an ‘en-bloc’ transplantation. The price for a single pediatric kidney transplant may be a higher vascular complication rate and a higher risk of rejection. Also, the risk of FSGS recurrence has to be taken into account. Despite the higher risks, transplantation of a single pediatric donor kidney should be performed when accomplishable.
References
326
Urol Int 2014;92:323–327 DOI: 10.1159/000354277
5 Ichimaru N, Takahara S: Japan’s experience with living-donor kidney transplantation across AB0 barriers. Nat Clin Pract Nephrol 2008;4:682–692. 6 Giessing M, Deger S, Roigas J, et al: Cross-over kidney transplantation with simultaneous laparoscopic living donor nephrectomy: initial experience. Eur Urol 2008;53:1074–1078. 7 Gröschl I, Wolff T, Gürke L, et al: Intermediate-term outcome of single kidney grafts from pediatric donors weighing 10–14 kg in adult recipients. Clin Transplant 2013; 27:E302– E307. 8 Sharma A, Fisher RA, Cotterell AH, et al: En bloc kidney transplantation from pediatric donors: comparable outcomes with living donor kidney transplantation. Transplantation 2011;92:564–569.
9 Borboroglu PG, Foster CE 3rd, Philosophe B, et al: Solitary renal allografts from pediatric cadaver donors less than 2 years of age transplanted into adult recipients. Transplantation 2004;77:698–702. 10 Hayes JM, Novick AC, Streem SB, et al: The use of single pediatric cadaver kidneys for transplantation. Transplantation 1988; 45: 106–110. 11 Satterthwaite R, Aswad S, Sunga V, et al: Outcome of en bloc and single kidney transplantation from very young cadaveric donors. Transplantation 1997; 63:1405–1410. 12 Modlin C, Novick AC, Goormastic M, et al: Long-term results with single pediatric donor kidney transplants in adult recipients. J Urol 1996;156:890–895.
Friedersdorff/Fuller/Werthemann/Cash
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1 Mange KC, Joffe MM, Feldman HI: Effect of the use or nonuse of long-term dialysis on the subsequent survival of renal transplants from living donors. N Engl J Med 2001;344:726–731. 2 Meier-Kriesche HU, Kaplan B: Waiting time on dialysis as the strongest modifiable risk factor for renal transplant outcomes: a paired donor kidney analysis. Transplantation 2002; 74:1377–1381. 3 Frei U, Noeldeke J, Machold-Fabrizii V, et al: Prospective age-matching in elderly kidney transplant recipients – a 5-year analysis of the Eurotransplant Senior Program. Am J Transplant 2008;8:50–57. 4 Uchida J, Machida Y, Iwai T, et al: Clinical outcome of ABO-incompatible living unrelated donor kidney transplantation. Urol Int 2011;86:307–314.
Single Pediatric Kidneys in Adults
17 Bresnahan BA, McBride MA, Cherikh WS, et al: Risk factors for renal allograft survival from pediatric cadaver donors: an analysis of united network for organ sharing data. Transplantation 2001;72:256–261. 18 Pugliese MR, Ridolfi L, Nanni Costa A, et al: A comparison of pediatric and adult kidney donors for adult recipients. Transplant Int 1999;12:122–126. 19 Gourlay W, Stothers L, McLoughlin MG, et al: Transplantation of pediatric cadaver kidneys into adult recipients. J Urol 1995; 153: 322– 325. 20 Ratner LE, Cigarroa FG, Bender JS, et al: Transplantation of single and paired pediatric kidneys into adult recipients. J Am Coll Surg 1997;185:437–445.
Urol Int 2014;92:323–327 DOI: 10.1159/000354277
21 El-Sheikh MF, Gok MA, Buckley PE, et al: En bloc pediatric into adult recipients: the Newcastle experience. Transplant Proc 2003; 35: 786–788. 22 Praz V, Leisinger HJ, Pascual M, et al: Urological complications in renal transplantation from cadaveric donor grafts: a retrospective analysis of 20 years. Urol Int 2005; 75: 144– 149. 23 Brenner BM, Meyer TW, Hostetter TH: Dietary protein intake and the progressive nature of kidney disease: the role of hemodynamically mediated glomerular injury in the pathogenesis of progressive glomerular sclerosis in aging, renal ablation, and intrinsic renal disease. N Engl J Med 1982; 307: 652–659.
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13 Schröter K, Lindemann G, Fritsche L: TBase2 – a Web-Based Electronic Patient Record. Fundamenta Informaticae 43. Amsterdam, IOS Press, 2000, p 343. 14 Port FK, Wolfe RA, Mauger EA, et al: Comparison of survival probabilities for dialysis patients vs cadaveric renal transplant recipients. JAMA 1993;270:1339–1343. 15 Wolfe RA, Ashby VB, Milford EL, et al: Comparison of mortality in all patients on dialysis, patients on dialysis awaiting transplantation, and recipients of a first cadaveric transplant. N Engl J Med 1999;341:1725–1730. 16 Oniscu GC, Brown H, Forsythe JL: Impact of cadaveric renal transplantation on survival in patients listed for transplantation. J Am Soc Nephrol 2005;16:1859–1865.
Urologia Internationalis
Received: March 22, 2013 Accepted after revision: July 4, 2013 Published online: November 22, 2013
Urol Int 2014;92:323–327 DOI: 10.1159/000354277
Outcome of Single Pediatric Deceased Donor Renal Transplantation to Adult Kidney Transplant Recipients Frank Friedersdorff Tom Florian Fuller Peter Werthemann Hannes Cash Department of Urology, Charité – Universitätsmedizin Berlin, Campus Mitte, Berlin, Germany
Key Words Kidney transplantation · Pediatric donors · Adult recipients · Complications · Risks
number of recipients over an ‘en-bloc’ transplantation. The price for a single pediatric kidney transplant may be a higher vascular complication rate and a higher rejection risk. Despite the higher risks, transplantation of a single pediatric donor kidney should be performed when accomplishable.
Abstract Introduction: In times of organ shortage more kidneys were transplanted in ‘expanded criteria kidney’ programs. This study examines the outcome of adult kidney recipients from pediatric donors. Materials and Methods: This single-center retrospective analysis evaluated eight adult patients who received a kidney from a deceased pediatric donor (age 5–17) between 06/2000 and 09/2011. Results: The median donor age was 14 years (range 5–17). The median recipient age was 49 years (range 25–57). The median cold ischemia time was 13.3 h (range 4.3–20.1), while the median warm ischemia time was 53 min (range 42–60). The median follow-up was 35.8 months (range 7–142). Acute rejection was observed in 50.0% of cases. The median HLA mismatch was 2.0. The median 1-year creatinine level was 0.95 mg/dl, the uncensored 1-year graft survival was 75.0% and the 3-year graft survival 62.5%, respectively. No recipient died within the follow-up period. As severe surgical complications, one stenosis of the renal artery and one lymphocele needing surgical revision were observed. Conclusions: Renal transplantation of a deceased single pediatric donor to an adult recipient can be performed safely and shows a good outcome. Wherever feasible, single pediatric kidney transplantation can double the
© 2013 S. Karger AG, Basel
E-Mail [email protected] www.karger.com/uin
There is still disparity between the demand for and the supply of organs for renal transplantation. For a patient on the waiting list for deceased donor renal transplantation (DDRT), prolonged renal dialysis in associated with a higher mortality and reduced quality of life [1, 2]. Constant efforts have been made in recent years in order to increase the donor pool. Especially the transplantation of kidneys with ‘expanded criteria’ and the Eurotransplant Senior Program have increased the number of older organs for DDRT [3]. Programs for AB0-incompatible living donor renal transplantation (LDRT) and cross-over LDRT have widened the possibility for LDRT [4–6]. Due to the shortage of organs, kidneys of deceased pediatric donors have been transplanted to adult recipients, although this remains a rare option. The organs are either transplanted as ‘en-bloc’ kidneys or as solitary organs [7– 9]. Published studies on deceased pediatric donor renal transplantation (DPDRT) showed a higher vascular and Dr. Frank Friedersdorff Charité – Universitätsmedizin Berlin, Campus Mitte Charitéplatz 1 DE–10117 Berlin (Germany) E-Mail frank.friedersdorff @ charite.de
Downloaded by: NYU Medical Center Library 128.122.253.228 - 5/29/2015 5:22:38 PM
© 2013 S. Karger AG, Basel 0042–1138/13/0923–0323$38.00/0
Introduction
Materials and Methods In our retrospective study we analyzed the cases of adult recipients of DPDRT who were transplanted between June 2000 and September 2011 at Charité, Campus Mitte. Overall eight cases were transplanted in this constellation. During the same time period more than 1,000 DDRTs were performed at our center. With regard to the acceptance of pediatric kidneys for adult recipients our center does not follow a strict profile and decisions are made on an individual basis. In all cases single kidneys were transplanted; no ‘en-bloc’ transplantation was performed. Data were acquired using an electronic database (TBase) [13]. We analyzed demographic data as well as complications, rejection rates, graft and patient outcome. DPDRT was performed in a standard extraperitoneal fashion using a Gibson incision without further adjustments. The vascular anastomosis was performed by the urologist as an end-to-side anastomosis between the renal vessels and the external iliac vessels. For the vascular anastomosis we used Polydioxanon sutures. Ureteroneocystostomy was accomplished using the extravesical Lich-Gregoir technique or the Politano technique. A ureteral double-J stent was routinely used. The stent was typically removed 6 weeks post transplantation. Graft function was monitored by Doppler ultrasound, serum creatinine and urine output measurements. Delayed graft function was defined as the need for at least 1 hemodialysis session during the first 7 days after transplantation. Delayed graft function and elevated (>0.8) resistance indices upon repeat measurements as well as a 20% rise in serum creatinine were indications for renal biopsy around postoperative day 7 to rule out rejection. Immunosuppression consisted of prednisone, mycophenolate mofetil and a calcineurin inhibitor. Oral prednisone was tapered to a dose of 10 mg during the first 6 months. Cyclosporine and tacrolimus target serum levels were between 150 and 250 ng/ml and between 10 and 12 ng/ml, respectively. Induction therapy with antilymphocyte agents or CD25 antibodies was applied in patients with a high immunologic risk. Rejection episodes were treated with high-dose steroids.
Results
From June 2000 to September 2011 eight adult patients received single renal grafts from pediatric donors. The median donor age was 14 years (range 5–17). The 324
Urol Int 2014;92:323–327 DOI: 10.1159/000354277
Table 1. Demographic data
Median donor age, years (range) Median recipient age, years (range) Graft distribution, left/right Recipient gender, female/male Median HLA mismatch Underlying cause of ESRD Polycystic kidney disease FSGS Chronic glomerulonephritis Previous bilateral RCC Nephrolithiasis in single kidney Median follow-up, months (range)
14 (5–17) 49 (25–57) 5 (62.5%)/3 (37.5%) 5 (62.5%)/3 (37.5%) 2.0 3 2 1 1 1 35.8 (7–142)
ESRD = End-stage renal disease; RCC = renal cell carcinoma.
youngest donor was 5 years old, the oldest 17 years. The 17-year-old donor was included because of growth pattern in the lower percentiles of the Centers for Disease Control and Prevention growth chart and thus comparable to a 15–16-year-old donor (www.cdc.gov/ growthcharts). Four donors were female and four male. Overall five right kidneys and three left organs were donated. Seven recipients had had no previous renal transplantation, for one patient is was the second organ. One patient had previously been transplanted and had received a LDRT from her mother at the age of 6 years. The renal function was preserved for 18 years. The median recipient age was 49 years (range 25–57). Five recipients were male, three female. The underlying caused for end-stage renal disease were polycystic kidneys in three cases, bilateral renal cell carcinoma with bilateral nephrectomy in one case, one case of nephrolithiasis in a functional single kidney, two patients with focal segmental glomerulosclerosis (FSGS) and one patient with chronic glomerulonephritis. The demographic data are shown in table 1. The median cold ischemia time was 13.3 h (range 4.3– 20.1). While the median warm ischemia time was 53 min (range 42–60), the overall median operating time was 217.5 min (range 195–257). The median HLA mismatch was 2.0. The kidney was transplanted in the right iliac fossa in six cases and the right iliac fossa in two cases. The median follow-up was 35.8 months (range 7–142). Six out of eight patients (75.0%) experienced complications. A summary of complications is shown in table 2. One patient developed a graft failure due to recurrence of a focal sclerosing glomerulosclerosis 6 months postoperatively. Another patient (32 years of age) also developed graft failFriedersdorff/Fuller/Werthemann/Cash
Downloaded by: NYU Medical Center Library 128.122.253.228 - 5/29/2015 5:22:38 PM
urinary complication rate [10, 11]. Also an increased risk for acute rejection and a higher rate of delayed graft function were noted [12]. An inferior outcome of DPDRT may be explained by the lesser nephron mass of the small kidneys, which would favor ‘en-bloc’ transplantation. For ‘en-bloc’ transplantation a higher vascular risk may have to be taken into account. The aim of our study was to evaluate the outcome of adult recipients of DPDRT (age ≤17 years) at our center.
2 Mean creatinine (mg/dl)
1.02
0.89 0.91
0.75
0.89
0.70
0.87 0.82
w ee k m on th 6 m on th 12 s m on th 24 s m on th 36 s m on th 48 s m on th 60 s m on th 72 s m on th s 1
Fig. 1. Creatinine follow-up.
100
80 Graft survival (%)
+
+ +
+ +
+
60
40
20
Survival function
+ Censored
0 0
20
40 60 Follow-up (months)
80
Fig. 2. Kaplan-Meier curve for graft survival.
Table 2. Postoperative complications
Lymphocele requiring surgical treatment Asymptomatic lymphocele Seroma Renal artery stenosis Graft lost due to acute rejection
Urol Int 2014;92:323–327 DOI: 10.1159/000354277
1 1 1 1 1
325
Downloaded by: NYU Medical Center Library 128.122.253.228 - 5/29/2015 5:22:38 PM
Single Pediatric Kidneys in Adults
1
0
Discussion
Renal transplantation is the treatment of choice for patients with end-stage renal disease, with superior quality of life and patient survival compared to dialysis [14– 16]. In order to reduce the shortage of possible donors, transplantation of kidneys with ‘expanded criteria’, the Eurotransplant Senior Program and LDRT have been established. For recipients for whom the allocation of an organ remains difficult due to their risk profile, DPDRT may be acceptable. This raises the question whether a pediatric graft is sufficient for adequate renal function in adults. The published rates of graft function are far better than was to be expected [11, 17, 18]. Bresnahan et al. [17] published a large study of data between 1988 and 2005 (United Network of Organ Sharing database) where 12,838 DPDRTs were performed to adult recipients. The pediatric donors were subdivided into three age groups, the largest being 12–17 years. The 1-year graft survival was 81.5% and thus differed significantly from organs from adult donors. The 2-, 3-, 4- and 5-year graft survival also differed significantly. In our study the 1-year graft survival was slightly lower with 75.0% and a 3-year graft survival of 62.5%. The study by Bresnahan et al. did not state whether an ‘en-bloc’ transplantation was performed. Satterthwaite et al. [11] compared the outcome of ‘en-bloc’ and single kidney transplantation of very young donors (5 years of age. Single graft DPDRT increases the number of possible recipients and should be performed wherever feasible. The study by Satterthwaite et al. [11] also showed ureteral leakage in 11% of cases. In our smaller study group, no ureteral complication was observed. An interesting finding by Satterthwaite et al. [11] was that 10 out of 91 transplants developed vascular complications leading to graft loss. Two stenoses of the renal artery were successfully treated with percutaneous angioplasty. In our study one graft also developed arterial stenosis. The recipient (50 years of age) was transplanted a single kidney of a 5-yearold donor. The stenosis was treated by arterial stenting. The creatinine levels were 1.2 mg/dl at 24 months followup. Especially with young donors the vascular risk seems to be higher. This might be explained by higher arterial pressure in adults, leading to arterial stenosis of the graft. A retrospective Italian study was able to show comparable results of DPDRT on adult recipients compared to conventional DDRT [18]. One-year survival in the pediatric group was 76% and patient survival was 96%. Complications rates did not differ either [18]. Overall, several studies found a higher complication rate for pediatric organs transplanted to an adult than in conventional DDRT [17, 19–22]. The most common complications are vascular (venous thrombosis/arterial stenosis) or ureteral (stenosis/leakage) in nature. In our small group, vas-
cular risk was also present. Vascular risk may be explained by the small size of the donor vessels and the organ size. Brenner et al. [23] established a hyperfiltration hypothesis, where a lack of nephron mass may lead to renal injury and nephrosclerosis with the development of FSGS. The primary form of FSGS is of great relevance in renal transplantation since it can recur within the graft and lead to graft loss within months to years after transplantation. In our study group, two patients experienced graft loss due to a recurrence of FSGS. Possibly transplantation of a pediatric kidney may have increased the risk of hyperfiltration and thus the recurrence of FSGS. Thus, recipients with FSGS as the underlying cause for end-stage renal disease may not be suitable for DPDRT.
Conclusion
Renal transplantation of a deceased single pediatric donor to an adult recipient can be performed safely and shows a good outcome. Wherever feasible, single pediatric kidney transplantation can double the number of recipients over an ‘en-bloc’ transplantation. The price for a single pediatric kidney transplant may be a higher vascular complication rate and a higher risk of rejection. Also, the risk of FSGS recurrence has to be taken into account. Despite the higher risks, transplantation of a single pediatric donor kidney should be performed when accomplishable.
References
326
Urol Int 2014;92:323–327 DOI: 10.1159/000354277
5 Ichimaru N, Takahara S: Japan’s experience with living-donor kidney transplantation across AB0 barriers. Nat Clin Pract Nephrol 2008;4:682–692. 6 Giessing M, Deger S, Roigas J, et al: Cross-over kidney transplantation with simultaneous laparoscopic living donor nephrectomy: initial experience. Eur Urol 2008;53:1074–1078. 7 Gröschl I, Wolff T, Gürke L, et al: Intermediate-term outcome of single kidney grafts from pediatric donors weighing 10–14 kg in adult recipients. Clin Transplant 2013; 27:E302– E307. 8 Sharma A, Fisher RA, Cotterell AH, et al: En bloc kidney transplantation from pediatric donors: comparable outcomes with living donor kidney transplantation. Transplantation 2011;92:564–569.
9 Borboroglu PG, Foster CE 3rd, Philosophe B, et al: Solitary renal allografts from pediatric cadaver donors less than 2 years of age transplanted into adult recipients. Transplantation 2004;77:698–702. 10 Hayes JM, Novick AC, Streem SB, et al: The use of single pediatric cadaver kidneys for transplantation. Transplantation 1988; 45: 106–110. 11 Satterthwaite R, Aswad S, Sunga V, et al: Outcome of en bloc and single kidney transplantation from very young cadaveric donors. Transplantation 1997; 63:1405–1410. 12 Modlin C, Novick AC, Goormastic M, et al: Long-term results with single pediatric donor kidney transplants in adult recipients. J Urol 1996;156:890–895.
Friedersdorff/Fuller/Werthemann/Cash
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