This document discusses renal transplantation in children. It provides an overview of the indications, contraindications, pretransplant evaluation and preparation of both the recipient and donor. Surgical techniques and perioperative management are described, including vascular access, ureteral anastomosis techniques, and postoperative monitoring in the intensive care unit with a focus on graft perfusion and fluid management. Goals for hospital discharge are also mentioned.

1. RENAL TRANSPLANTATION IN
CHILDREN
Dept of Urology
Govt Royapettah Hospital and Kilpauk Medical College
Chennai
1

2. Moderators:
Professors:
• Prof. Dr. G. Sivasankar, M.S., M.Ch.,
• Prof. Dr. A. Senthilvel, M.S., M.Ch.,
Asst Professors:
• Dr. J. Sivabalan, M.S., M.Ch.,
• Dr. R. Bhargavi, M.S., M.Ch.,
• Dr. S. Raju, M.S., M.Ch.,
• Dr. K. Muthurathinam, M.S., M.Ch.,
• Dr. D. Tamilselvan, M.S., M.Ch.,
• Dr. K. Senthilkumar, M.S., M.Ch.
Dept Of Urology, KMC and GRH, Chennai 2

3. INTRODUCTION
• Kidney transplantation is the preferred
treatment for end-stage renal disease (ESRD)
in children .
• It confers improved survival, skeletal growth
heath-related quality of life and
neuropsychological development compared to
dialysis.
Dept Of Urology, KMC and GRH, Chennai 3

4. • Goals:
• (1) Normal urinary drainage from the kidney into
a reservoir
• (2) A reservoir that permits low-pressure storage
for a socially acceptable time
• (3) Volitional emptying of the reservoir
• (4) Absence of infection
• (5) All with the fewest surgical procedures and
patient trauma.
Dept Of Urology, KMC and GRH, Chennai 4

5. INDICATIONS
Dept Of Urology, KMC and GRH, Chennai 5

6. Dept Of Urology, KMC and GRH, Chennai 6

7. ACCESS TO TRANSPLANTATION
• For pediatric recipients in the developing world is limited
by healthcare access.
• Donor sources depend on the availability of an organ
allocation program within the country.
• The majority of transplants in the developing world are
from living donors.
• The age range of recipients varies by country, with most
performing transplants in children over 7 years of age.
• In general, the countries that perform transplants in
children under 7 years of age also have access to deceased
donor sources, suggesting a more developed healthcare
delivery system.
Dept Of Urology, KMC and GRH, Chennai 7

8. TIMING FOR TRANSPLANTATION
• Due to increased risk of graft loss and
mortality in infants and children under 2 years
of age, most pediatric centers perform
transplants in children once they achieve a
weight above 10–15 kg.
• Children with ESRD frequently have delayed
growth, so a child will be greater than2 years
old before achieving the threshold size and
weight for the transplant center.
Dept Of Urology, KMC and GRH, Chennai 8

9. CONTRAINDICATION
• Active or untreated malignancy
• Active or untreated infection
• Multiple or progressive medical conditions
with overall poor prognosis for recovery (e.g.,
severe brain injury or multiorgan failure)
Dept Of Urology, KMC and GRH, Chennai 9

10. PRETRANSPLANT EVALUATION
• DONOR EVALUATION
• The ideal situation would be donation from an
HLA-identical sibling.
• Most live kidney donations for pediatric
recipients come from haplo-identical parents.
Dept Of Urology, KMC and GRH, Chennai 10

11. PRETRANSPLANT EVALUATION
• RECIPIENT SCREENING
• A large fraction of children in need of renal
replacement will have some type of uropathy—
congenital obstruction, vesicoureteral reflux, or
neuropathic bladder dysfunction.
• Younger boys will typically have obstructive
uropathy:posterior urethral valves.
• The reflux and neuropathic bladder patients will
be older, including young adults.
Dept Of Urology, KMC and GRH, Chennai 11

12. • A detailed history
Renal
ultrasonography(PVR)
Voiding
cystourethrogram(VCUG)
• History of a specific urologic
disease
• Febrile or recurrent urinary
tract infection (UTI)
• Hydronephrosis
• Clinically abnormal voiding
• Urodynamic testing
• To assess bladder capacity,
compliance, and emptying,
as well as sphincter
function.
• A known neuropathic
bladder abnormality
• Prior severe posterior
urethral valves
• Any ongoing voiding
dysfunction
• Hydronephrosis
• Recurrent UTI
Dept Of Urology, KMC and GRH, Chennai 12

13. PRETRANSPLANT PREPARATION
• BLADDER PREPARATION
• The most common bladder
abnormality associated with ESRD is a
low-capacity, hypertonic bladder with
poor compliance.
• Recurrent pyelonephritis is a
potential hazard for the transplant ,
associated with graft loss.
• Initiating CIC in preparation for
transplantation serves an assessment
purpose and facilitating bladder
emptying.
• Bladder refunctionalization is often
best accomplished by bladder cycling
to increase capacity, determine
bladder wall compliance, and assess
the family’s ability to perform CIC.
• There is no evidence that bladder
augmentation increases the risk of
transplant.
• Indications for augmentation before
transplantation include :
• Capacity less than 75% of expected
for age
• Pressures below 30 cm H2O
• Catheterization every 3 hours
• Maximal anticholinergic medications
• The ability to empty spontaneously
will affect the decision regarding the
need for a continent catheterizable
stoma.
Dept Of Urology, KMC and GRH, Chennai 13

14. Dept Of Urology, KMC and GRH, Chennai 14

15. • RECONSTRUCTIVE STRATEGIES
• In general, any major urologic
reconstruction should be
undertaken well before
anticipated transplantation.
• Dialysis issues : For patients on
peritoneal dialysis,
intraperitoneal surgery will
likely require temporary
transition to hemodialysis.
• Graft placement
• In the very small child in
whom the graft will be placed
intraperitoneally on the aorta.
• Careful movement of any
mesenteric pedicles away
from the midline is advisable,
as is trying to avoid a
transureteroureterostomy.
• A psoas hitch for ureteral
reimplantation of the native
kidney, if it is to be salvaged,
can make ipsilateral iliac graft
placement difficult.
Dept Of Urology, KMC and GRH, Chennai 15

16. • Native nephrectomy is indicated for patients with the following:
• Malignant hypertension
• Profound nephrotic syndrome with malnutrition
• Recurrent upper tract infection
• Massive reflux
• In the absence of specific indications for nephrectomy, leaving the
native kidneys offers the advantage of having a potential source of
water excretion if the graft fails.
• Active prevention of infection
• High-grade reflux.
• Persisting hydronephrosis with or without reflux.
Dept Of Urology, KMC and GRH, Chennai 16

17. • When nephrectomy is to be performed, ureteral
preservation should be considered.
• If the ureter is normal, it should always be left to
limit surgical dissection near the iliac vessels.
• To have proximal transplant to native
ureteroureterostomy for distal ureteral stenosis .
• Preserving the ureter for use as a continent
stoma is advisable. This is best performed
pretransplant.
Dept Of Urology, KMC and GRH, Chennai 17

18. • VASCULAR EVALUATION
• The abdominal vasculature should be assessed for patency in
preparation for transplant surgery.
• Children with a prior history of femoral lines or inflammatory
conditions of the abdomen are at increased risk of thrombosis of
the inferior vena cava (IVC) or iliac vessels thereby complicating
vascular anastomosis of the graft.
• Magnetic resonance venogram and computed tomography
angiography are sensitive techniques
• For assessing IVC patency
• Detailed anatomic survey of abdominal vasculature.
• In patients at lower risk of thrombosis, Doppler ultrasound is useful
to screen for IVC and iliac vein patency.
Dept Of Urology, KMC and GRH, Chennai 18

19. • NEURODEVELOPMENT
• Developmental delay
• Children with CKD have
higher rates of
neurocognitive delays.
• Factors associated with
increased risk for
neurocognitive deficits:
• Longer duration of CKD
• Increased severity of
disease
• Younger onset of disease.
• In the absence of
structural brain
abnormalities,
psychomotor delay can
improve following
transplant, with many
infants regaining normal
developmental
milestones.
Dept Of Urology, KMC and GRH, Chennai 19

20. • PSYCHOSOCIAL ISSUES
• Psychoemotional status
• Pharmacotherapy for
depression, bipolar
disorder, and attention
deficit hyperactivity
disorder are important
adjunctive therapies.
• Most selective serotonin
reuptake inhibitors do not
interfere with
immunosuppressive
medications.
• Seizures : Seizure disorder
requiring anticonvulsant
therapy ( about 5% of
pediatric transplant
recipients).
• Adequate seizure control
should be obtained prior
to transplantation.
Dept Of Urology, KMC and GRH, Chennai 20

21. PERIOPRATIVE MANAGEMENT
• PRE OP MANAGEMENT
• Intravascular volume status is important prior to
transplant surgery
• Children with hypovolemia (especially those with high
urine output) are at increased risk of graft thrombosis
and graft hypoperfusion, leading to ATN.
• If dialysis treatment is indicated prior to
surgery,excessive fluid removal should be avoided.
• Children with residual urine output should receive
intravenous fluids to maintain intravascular volume while
oral intake is restricted awaiting surgery.
Dept Of Urology, KMC and GRH, Chennai 21

22. • Subclinical infections of skin, dialysis access site, peritoneal fluid, and urinary tract
should be screened
• History
• Physical exam
• Urinalysis, and urine culture
• Peripheral white blood cell count with differential, blood cultures (for those with
indwelling venous catheters)
• Peritoneal cell count and culture (for those maintained on peritoneal dialysis).
• A recent episode of peritonitis or peritoneal dialysis catheter exit site infection
does not preclude transplantation.
• The child should complete 10–14 days of antibiotics and have a negative
peritoneal fluid culture off antibiotics prior to transplant.
• CMV and EBV serologies should be repeated if previous results revealed
immunological naiveté.
• Final crossmatch is performed within 1 week prior to living donor kidney
transplant or in the hours preceding deceased donor transplant.
Dept Of Urology, KMC and GRH, Chennai 22

23. INRA-OP MANAGEMENT
• Children weighing over 30 kg are often treated
surgically as small adults with graft placement in the
standard extraperitoneal pelvic location and vascular
anastomoses to the common iliac artery and vein.
• In small children (usually less than 20 kg), intra-
abdominal placement may be preferable with vascular
anastomoses to the infrarenal aorta and IVC.
• The surgical approach should be individualized with
• appropriate matching of blood vessel size
• attention to expected circulatory volume requirements.
Dept Of Urology, KMC and GRH, Chennai 23

24. • URETER ANASTOMOSIS
• Extravesical ureteroneocystostomy is the
preferred ureteral anastomosis.
• After the vascular anastomoses have
been performed and hemostasis has been
achieved, the bladder is partially filled
with saline or a dilute antibiotic solution.
• The anterolateral aspect is cleared and
traction sutures are placed to mobilize the
lateral aspect upward and to provide
tension on the vesical wall.
• The ureter is sized to ensure it will reach.
• The detrusor is incised to the level of the
mucosa for a length of about 3 to 3.5 cm
in a horizontal direction.
• Flaps of detrusor are elevated away from
the mucosa and a small disc of mucosa is
excised at the distal aspect of the trough.
• The ureter is trimmed loosely to length and
spatulated for 4 to 5 mm.
• An interrupted, mucosa-to-mucosa
anastomosis is performed using a fine
absorbable suture.
• A monofilament is preferred.
• The detrusor flaps are then brought over the
ureter.
• No advancement stitch is used.
• Two stitches are placed through the
detrusor and the adventitia of the terminal
ureter to prevent eversion of the ureter.
• The detrusor is closed with interrupted
absorbable suture.
Dept Of Urology, KMC and GRH, Chennai 24

25. • Alternatively, Barry technique may be used.
• A 4-cm tunnel is created between parallel incisions through which the ureter is
passed.
• Transplant to native ureteroureterostomy is an effective option.
• Ureteral Stenting
• The role of routine ureteral stenting in pediatric transplant is debated, but there
are no data to demonstrate its routine usefulness.
Dept Of Urology, KMC and GRH, Chennai 25

26. • Typically, a central venous catheter is inserted for
close monitoring of central venous pressures.
• Central venous pressures should be maintained at 8–
12 cm H2O and mean arterial pressures above 70
mm Hg via infusion of crystalloid or 5% albumin prior
to clamp release to ensure adequate perfusion to the
adult-sized transplanted kidney.
Dept Of Urology, KMC and GRH, Chennai 26

27. • Continuous dopamine infusion at 2–3 μg/kg/min is
often necessary in infants.
• To maintain higher mean arterial pressure
• Continued for 24–48 hours postoperatively to allow
the graft to accommodate slowly to lower mean
arterial pressure in the recipient.
• Mannitol (1 g/kg) with or without furosemide (1
mg/kg) is often administered prior to clamp removal
to facilitate diuresis.
Dept Of Urology, KMC and GRH, Chennai 27

28. • Blood gases and lactate levels should be monitored
intraoperatively.
• Verapamil or papaverine are injected into the
arterial anastomosis to overcome arterial spasm that
impairs graft perfusion.
• For most immunosuppression protocols, intravenous
methylprednisolone sodium succinate (Solu-Medrol)
is administered at the beginning.
Dept Of Urology, KMC and GRH, Chennai 28

29. POST OP MANAGEMENT
Children are monitored in the intensive care unit.
• In the first 2–3 days, the postoperative management
focus primarily on
• optimizing graft perfusion.
• mitigating the effects of fluid overload (e.g., electrolyte
derangements and hypertension).
• small children often require dopamine infusion for 24–
48 hours posttransplant to maintain graft perfusion.
• allow gradual accommodation of the graft to the lower
mean arterial pressures of the recipient.
Dept Of Urology, KMC and GRH, Chennai 29

30. • Urinary losses are replaced in equal volumes with
intravenous 0.45% or 0.9% sodium chloride infusion for
the first 24–48 hours.
• Dextrose should be withheld from the initial
intravenous fluids given or urine replacement .
• Replacement of insensible water losses should be
administered as a separate infusion with dextrose-
containing crystalloid.
• Hypokalemia and hypophosphatemia may develop .
• Potassium and/or phosphate salts can be added to the
replacement fluids.
Dept Of Urology, KMC and GRH, Chennai 30

31. • Urine replacement with intravenous crystalloid can
be discontinued ,when graft gets its concentating
ability.
• Intake goals of 150–200% of calculated maintenance
needs should be started by mouth.
• Children with intra-abdominal graft placement are
susceptible to prolonged postoperative ileus due to
displacement of the colon and intestines with an
adult-sized graft occupying almost the entire right
side of the abdomen.
Dept Of Urology, KMC and GRH, Chennai 31

32. • Hypertension is commonly observed in children
following transplant,improve with adequate
analgesia.
• Fluid overload postoperative hypertension.
• Aggressive treatment of hypertension is typically not
recommended .
• Children who were on multiple antihypertensive
medications prior to transplant may need
reinstitution of their previous medications.
Dept Of Urology, KMC and GRH, Chennai 32

33. • Goals for hospital discharge of the pediatric
transplant recipient
• Adequate oral fluid intake to prevent hypovolemia
(and subsequent graft hypoperfusion)
• Stable immunosuppression regimen
• Completion of family and caregiver education, access
to medications
• Arrangement of outpatient follow-up.
Dept Of Urology, KMC and GRH, Chennai 33

34. COMPLICATIONS
• URINE LEAKS
• Urine leaks are typically identified in
the early postoperative period with
increasing fluid from the wound
drains.
• The fluid creatinine level can reveal if
this is a urine leak as opposed to
lymphatic drainage.
• At first presentation, it is critical to
assess all urinary drainage tubes,
particularly the Foley catheter. If the
catheter has been removed, it is
often best to replace it.
• A transplant sonogram is performed
to determine if there is
hydronephrosis, although its absence
does not rule out obstruction.
• If hydronephrosis is present,distal
ureteral obstruction should be
suspected.
• Consideration for a percutaneous
nephrostomy should be entertained.
• The level of the leak must then be
determined, and either a
mercaptoacetyltriglycine(MAG3) scan
(assuming adequate graft function)
or a computed tomography (CT) scan
can be effective.
• A cystogram may be useful to identify
a bladder leak from the site of the
anastomosis.
Dept Of Urology, KMC and GRH, Chennai 34

35. • The indications for intervention are
clinically based.
• If the leak is limited, an observational
approach is reasonable.
• Leaks in the setting of very high post-
transplant urine output in smaller
children caused simply by a small
bladder catheter.
• If there is significant urine leak despite
adequate bladder drainage,
exploration may be needed.
• Exploration is to identify the cause and
location of the leak and provide for
repair.
• If the leak is bladder based, the use of
simple repair and drainage is effective.
• If the leak is a result of distal ureteral
necrosis, ureteral replacement is
needed.
• For a short segment of necrosis,
bladder mobilization and
reimplantation is effective.
• If a long segment of ureter has been
lost,native ureter, either ipsilateral
contralateral, may be useful if
available.
• A psoas hitch or bladder flap may be
needed if the native ureter is not
present.
Dept Of Urology, KMC and GRH, Chennai 35

36. • INFECTION
• Is a long-term and often delayed
complication
• Reflects the status of bladder
function .
• Underlying urologic causes of
renal failure.
• Routine assessment of bladder
emptying,hydronephrosis, and
occasionally use of a VCUG will
usually identify the cause.
• Patient is on CIC and no specific
correctable cause is present,
prophylactic antibiotics and
bladder irrigation may be
effective.
• Aggressive management of
bladder dysfunction,which is
essential to preserve graft
function.
• If vesicoureteral reflux into the
graft and infection with fever and
altered renal function: Correction
of the reflux is warranted.
• Reflux in the absence of infection
with normal bladder function
observed.
Dept Of Urology, KMC and GRH, Chennai 36

37. • REFLUX
• Vesicoureteral reflux into the
transplant is entirely distinct
from routine reflux into an
otherwise normal renal unit.
• In a reimplanted ureter, the risk
to renal function of an episode
of pyelonephritis is greater in a
transplanted kidney, and the
patient is immunosuppressed.
• Febrile UTIs the presence of
transplant reflux justifies surgical
correction with an open ureteral
reimplantation.
• Intravesical, often with use of
extravesical mobilization.
• A transtrigonal technique is effective
if the contralateralnative ureter can
be avoided.
• Ureteral stenting is advisable.
Dept Of Urology, KMC and GRH, Chennai 37

38. HYDRONEPHROSIS
&
OBSTRUCTION
• A frequent urologic complication
in pediatric renal transplant is
hydronephrosis.
• A rising creatinine level and
hydronephrosis,obstruction and
rejection may be intermingled.
• If the hydronephrosis is mild and
other signs of rejection,biopsy is
the best first step.
• Ureter stenting may be
considered.
If the graft is not failing rapidly,
initial medical treatment of the
rejection is justified, with stenting
being reserved for lack of
improvement.
• Whether obstruction increases
the risk of rejection is unproven
but empirically suggested.
Dept Of Urology, KMC and GRH, Chennai 38

39. • The source of ureteral obstruction is
usually in the distal ureter, with stenosis at
the reimplantation site.
• Compression from a lymphocele or
adenopathy from post-transplant
lymphoproliferative disease (PTLD) are
possible causes.
• Focal ureteral narrowing on retrograde
imaging treated with balloon dilation and
stenting for 4 to 6 weeks.
• Bladder Dysfunction
• Bladder dysfunction may produce
infection, but may also create an
obstructive process that impairs renal
graft function.
• Combined stent and bladder drainage
followed by a recheck of the creatinine.
• Treating bladder dysfunction involves
measures to increase compliance using
• Anticholinergics
• An intermittent catheterization .
• Bladder augmentation may also be
needed,although only after aggressive
medical management has been tried.
• When intermittent catheterization per
urethra is difficult, creation of a continent
stoma may be needed.
Dept Of Urology, KMC and GRH, Chennai 39

40. • STONES
• Nephrolithiasis in a pediatric renal transplant is
uncommon,occurring in up to 5% of patients,more likely to
occur in less than 1%.
• Stone associated with renal graft dysfunction caused by
obstruction or infection should be managed with urgent
intervention to ensure drainage and prompt removal.
Dept Of Urology, KMC and GRH, Chennai 40

41. PEDIATRIC IMMUNOSUPPRESSIVE
PROTOCOLS
Many pediatric renal transplantation centers
have moved toward steroid avoidance or
withdrawal.
It has been estimated that approximately 60% of
children receive steroids.
Dept Of Urology, KMC and GRH, Chennai 41

42. Dept Of Urology, KMC and GRH, Chennai 42

43. Dept Of Urology, KMC and GRH, Chennai 43

44. Dept Of Urology, KMC and GRH, Chennai 44

45. Dept Of Urology, KMC and GRH, Chennai 45

46. AUTO TRANSPLANTATION
Combination of living nephrectomy and a
standard renal transplant in the same patient.
Dept Of Urology, KMC and GRH, Chennai 46

47. INDICATIONS
• Severe ureter stricture
• Renovascular hypertension
• Loin pain hematuria syndrome
• Complex nephrolithiasis
• Nut cracker syndrome
• Large renal artery aneurysm
• Renal injuries
• Extracorporeal nephron sparing surgery with
autotransplant in solitary kidney.
Dept Of Urology, KMC and GRH, Chennai 47

48. THANK YOU
Dept Of Urology, KMC and GRH, Chennai 48