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• W2315094284 abstract "Kidney transplantation is currently the best treatment option for children with end-stage renal disease and offers the best hope to avoid detrimental perturbations in both physical and cognitive developments in these children when compared with dialysis (1). However, although children are given priority in receiving grafts, the severe shortage of organ donors limits the number of pediatric transplants. To increase organ use, one approach that our center has adopted has been transplantation of kidneys from small pediatric donors (weight < 15 kg) into the pediatric recipients. Kidney transplantation from small pediatric donors may be performed as single or en bloc. The en bloc transplants technique could avoid small anastomotic vessel size and provide greater renal mass. More recently, our report of successful outcomes of pediatric en bloc transplantation from infant donors (weight < 5 kg) into pediatric recipients has provided evidence of its efficacy (2). However, the en bloc pediatric transplants halve the number of potential recipients and result in a high risk of vascular and urinary complications. Forced by the extreme shortage of organs, we have adopted some more aggressive approaches to expand the donor pool, including single use of kidneys from small pediatric donors. In this study, we reviewed our recent experience with single kidney transplantation of small pediatric donors less than 15 kg to pediatric recipients. From March 2013 to March 2014, 15 pediatric patients received single kidney transplants from pediatric donors less than 15 kg in our center. The single allograft was implanted extraperitoneally in the right iliac fossa. The donor artery with a Carrel patch was anastomosed end-to-end to the internal iliac artery using continuous 6-0 absorbable suture. The donor renal vein was anastomosed (end-to-side) to the external iliac vein using continuous 6-0 absorbable suture. The ureter was anastomosed to the bladder using separate extravesical ureteroneocystostomies, and double-J stent (4 French, 12 cm) was placed. In all cases, the stents were removed 6 weeks postoperatively. To prevent thrombosis, prophylactic anticoagulation was preceded by using a continuous intravenous infusion of heparin, at a dose of 5 U/kg/h for the first week after transplantation, after which aspirin with or without clopidogrel was given daily. For the first week, the activated partial thromboplastin time was maintained to less than 1.5 times as high as the normal value. All patients were given basiliximab as induction therapy at a dose of 1 mg/kg intravenously for a total of three doses. Intravenous methylprednisolone was started on the day of transplant at an initial dose of 10 mg/kg per day and gradually tapered off in the first week after transplantation. Maintenance immunosuppression consisted of tacrolimus and enteric-coated mycophenolate sodium (Myfortic). Considering the increased clearance of tacrolimus in children, pediatric patients were given higher initial dosage of tacrolimus in this study. To achieve a therapeutic level of tacrolimus early after transplantation, intravenous tacrolimus was started by postoperative day 2 at 0.05 mg/kg/day (target level of 10–12 ng/mL) and switched to oral tacrolimus (0.15 mg/kg/dose twice daily) on postoperative day 10. Enteric-coated mycophenolate sodium was started by postoperative day 3 at 540 mg/m2 per day in two divided doses. The hospital records of these patients were retrospectively reviewed, and the parameters recorded were demographic characteristics of the recipients and donors, serum creatinine levels at discharge and at last follow-up, complications, and the overall outcome of patient and graft. GFR was estimated with the Schwartz formula (3). Kidney graft sizes were evaluated by ultrasonography at 1 week and 3, 6, and 12 months postoperatively. Graft loss was defined as a permanent return to dialysis, graft nephrectomy, or recipient death. Delayed graft function (DGF) was defined as the need for dialysis during the first week after transplantation with eventual graft function. Continuous variables with normal distribution were expressed as mean ± SD, whereas continuous variables with non-normal distribution were expressed as median (range). Demographic data are shown in Table 1. Of these 15 pediatric recipients, six were boys and nine were girls. Median age was 9.5 years (range, 5.4–16.0 years), and their median pretransplant weight was 24 kg (range, 15–37.5 kg). Median duration of dialysis was 15 months (range, 1–72 months). Kidneys from eight small pediatric donors (Maastricht Category III) were recovered by local organ procurement organizations and allocated to our center by the China Organ Transplant Response System. The causes of death included brain injury, drowning, congenital heart disease, viral encephalitis, severe diarrhea, and diaphragmatic paralysis. Donor age ranged from 5 to 30 months with weight ranging from 5.5 to 14 kg. Cold ischemic times ranged from 7 to 14 hr, whereas the warm ischemic times (revascularization time) were 38 to 52 min. All kidneys initially arrived as en bloc, and they were split into two single grafts in our center. One single kidney was discarded because of severe vascular damage.TABLE 1: Demographic data on patientsFollow-up data are shown in Table 2. Patient and graft survivals were 100% and 93.3%, respectively during the follow-up period. One graft was lost early from vascular thrombosis on postoperative day 6. A dialysis-related hypotension in the previous day may be a potential cause. The median follow-up was 6.5 months (range, 3 to 16 months). Delayed graft function was present in seven patients (46.7%), which were managed by peritoneal dialysis for 1 to 2 weeks postoperatively. All patients recovered without long-term consequences. Acute rejection occurred in one patient (6.7%), who responded well to steroid bolus treatment. There was one reoperation for ureteral stenosis occurring in one patient. After surgical revision, this patient suffered no further complications. There were no complications of the anticoagulation therapy during the follow-up period. Of the remaining 14 recipients, all had excellent graft function with median serum creatinine of 0.97 mg/dL (range, 0.60–2.52 mg/dL) at discharge and 0.78 mg/dL (range, 0.43–1.75 mg/dL) at last follow-up. The estimated GFR was 72.9 mL/1.73 m2/min (range, 27.1–89.5 mL/1.73 m2/min) at discharge and 89.8 mL/1.73 m2 per min (range, 37.6–150.7 mL/1.73 m2/min) at last follow-up. All kidney grafts showed significant growth in length by ultrasonography. The median length of the grafts increased from 6.75 cm at 1 week after transplantation to 8.45 cm at last follow-up.TABLE 2: Follow-up dataThe results of the present study indicate that excellent short-term outcomes can be obtained from pediatric single transplantation from small pediatric donors if performed at experienced centers. However, kidneys from small pediatric donors have been traditionally considered suboptimal grafts (4, 5). Many centers are reluctant to transplant small pediatric donor kidneys into pediatric recipients because of a high risk of technical failure and complications (6, 7). According to the NAPRTCS 2010 annual report, only 1.4% of deceased donor sources came from donors younger than 24 months old (8). In our center, we are frequently faced with a donor who weighs less than 15 kg and, on the other hand, have hundreds of children waiting for a kidney. Because of recent improvements in surgical technique and immunosuppression, the transplantation of small pediatric donor kidneys into pediatric recipients has become an acceptable option. Our present data support the notion that recipients of single kidneys from small pediatric donors less than 15 kg do not represent a cohort with poorer short-term outcomes. Although the GFRs of patients receiving kidneys from the smallest donor were low at 3 months postoperatively, we believe their long-term outcomes would be favorable, given that pediatric grafts are able to increase GFR and adapt to the growing recipients (9). Despite the reported success with use of pediatric donor kidneys in pediatric recipients (10–13), the optimal use of kidneys from small pediatric donors is still unclear. Although en bloc pediatric transplants provide greater renal mass and theoretically reduce hyperfiltration injury, systematic application of en bloc technique may waste the scarce organ source for transplant. If equivalent outcomes can be achieved with single pediatric kidneys, their use offers the advantage of doubling the number of grafts available and decreasing the risk of complications associated with en bloc pediatric kidney transplants (14, 15). However, there is no consensus regarding when pediatric donor kidneys could be split and transplanted as single grafts without compromising outcomes. A balance should be reached between ensuring the success of the transplant and maximizing the number of potential grafts. In this study, we found that kidneys from a 5.5-kg weighting donor could be split and transplanted singly into two pediatric recipients without technical complications. However, our previous report has shown that kidneys from donors less than 5 kg should be transplanted as en bloc because of small anastomotic vessel size. From the aspects of surgical technique, we suppose 5 kg might be the minimum donor weight for single kidney transplantation. A larger number of cases with longer follow-up would be necessary to clearly address this question. Although the use of single kidneys (vs. en bloc) reduces the likelihood of vascular torsion, vascular thrombosis is still the major risk for graft loss when transplanting small pediatric kidneys. Small vessel size, hypotension, hypercoagulable state, acute rejection, and surgical complications are the major risk factors for graft thrombosis. In this study, there was a single case of graft thrombosis secondary to a dialysis-related hypotension; an incidence of 6.7% which is acceptable in comparison with other reports. We believe that transplantation of single pediatric kidneys to body weight-matched pediatric recipients is safe as long as a wide aortic carrel patch is present and prophylactic anticoagulation is used. In this study, we also noted that transplantation of single kidneys from pediatric donors less than 15 kg did yield an increased incidence of DGF. However, by treatment with continuous peritoneal dialysis, all patients with DGF recovered and currently have excellent graft function. Interestingly, we found that the mean donor/recipient weight ratio for the DGF group (0.318±0.072) was significantly lower than that of the non-DGF group (0.469±0.144). The donor-recipient weight ratio might be an independent risk factor for DGF in pediatric donor kidney transplantation. Conclusively, the main limitation in our study was the short-term follow-up and small number of patients. However, we have demonstrated satisfactory short-term outcomes with the use of single pediatric kidney transplants into pediatric recipients. More specifically, in line with recent reports from the literature and our own findings, we suggest the following graft usage scheme: kidneys from pediatric donors weighing greater than 5 kg could be transplanted as singles in pediatric recipients. Alternatively, kidneys from pediatric donors less than 5 kg are generally more safely transplanted en bloc. Wen-Yu Zhao 1 Lei Zhang1 You-Hua Zhu1 Fan-Yuan Zhu1 Yu Chen1 Qian Shen2 Hong Xu2 Li Zeng1 1 Organ Transplantation Institute of PLA Changzheng Hospital Second Military Medical University Shanghai, PR China 2 Department of Nephrology and Rheumatology Children’s Hospital of Fudan University Shanghai, PR China" @default.
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• W2315094284 date "2014-12-27" @default.
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• W2315094284 title "Single Kidneys Transplanted From Small Pediatric Donors Less Than 15 Kilograms Into Pediatric Recipients" @default.
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