Kidney transplantation is the preferred treatment for children with chronic renal failure, as it has better outcomes than dialysis. However, kidney transplantation in children faces unique challenges compared to adults. These include higher rates of donor-recipient mismatch due to differences in size, higher risks of rejection due to greater HLA mismatch with deceased donors, and issues associated with a child's development and transition to adulthood. Effective long-term management requires minimizing immunosuppression side effects, monitoring adherence, and preparing patients to transition successfully to adult care.

2. Kidney transplantation in children
challenges and hopes
Fahimeh Asgarian; MD
Children’s Medical Center
TUMS

3. ✦In children and adolescents affected by chronic renal failure the
treatment of choice is kidney transplant.
✦Globally, all-cause mortality rates for children on dialysis are
significantly higher than what is experienced by the transplant
population

4. ✦Dialysis is more disruptive to family lifestyle, schooling, and social
interactions.
✦Avoidance of dialysis preserves vascular and peritoneal access sites for
future use if the transplant should fail.
✦Dietary and fluid restrictions are necessary on dialysis.
✦Dialysis is associated with an increased risk of cardiovascular disease
and vascular calcification, which occur at a proportionately earlier age.

5. Kidney transplant differs between pediatric patients and adults in
several aspects.
✦Causes of ESRD
✦Types of complications
✦Optimal donor selection
✦Problems associated with growth
✦Comorbidities associated with the lower
urinary tract
✦Nonadherence to medication regimens
✦Child’s transition to adulthood

6. Causes of ESRD

7. Donor-recipient size mismatch
✦The following factors must be considered in pediatric KT recipients:
✦Renal function of the donor kidney
✦Age of the donor
✦Donor criteria
✦Matching degree of human leukocyte antigen (HLA)

8. ✦Donor-recipient size mismatch commonly results in graft hypoperfusion
and delayed graft function (DGF)
✦Kidneys obtained from very young donors can be associated with graft
thrombosis owing to small-sized anastomotic vessels

9. HLA mismatch
✦Most pediatric recipients require retransplantation.
✦Therefore, kidneys from HLA-mismatched donors are not preferred
✦Studies reinforce the fact that higher HLA mismatches limit long-term
graft survival.

10. The majority of pediatric recipients of a deceased donor kidney, 84%,
had four or more HLA mismatches compared with only 27% of living
donor recipients

11. UROLOGIC ISSUES
✦Urological disorders related to anomalies of the lower urinary tract
are a significant difficulty encountered in pediatric KT
✦Treatment of urological disorders may necessitate additional
procedures such as open vesicostomy and bladder augmentation

12. Surgical Issues
✦Small children (<20 kg)
✦Intraperitoneal/intra abdominal placement of graft
✦Anastomosis of the renal vein and artery to the recipient’s inferior
vena cava and aorta

13. Immunosuppression
✦Steroid therapy side effects:
✦Growth retardation
✦Glucocorticoids interfere with the width of the growth plate, increase
the apoptosis of chondrocytes, and reduce VEGF expression.

14. ✦Several different strategies to minimize steroid doses have been
attempted in pediatric KT
✦Early steroid withdrawal
✦Late steroid withdrawal
✦Complete steroid avoidance

16. PTLD and malignancy
✦PTLD is an abnormal proliferation of lymphocytes observed in
immunocompromised patients receiving transplantation.
✦Histopathological findings range from an infectious mononucleosis-
like presentation to that of non-Hodgkin lymphoma.

17. PTLD and malignancy
✦PTLD risk factors:
✦Epstein-barr virus (ebv)-seronegative status of recipients
✦Use of calcineurin inhibitors and antilymphocyte antibodies
✦The number of methylprednisolone pulses administered
✦Cytomegalovirus infection
✦ Younger age
✦Acute graft rejection episodes
✦Renal cell carcinoma was the most common type of non-PTLD
malignancy observed

18. Nonadherence & transition into adulthood
✦Nonadherence to medical recommendations is widespread
✦It rates as high as 75% in adolescents.

19. ✦Primary risk factors of nonadherence include:
✦Poor family functioning
✦Poor psychological functioning of the child
✦Poor family functioning includes poor family cohesion and
dysfunctional family dynamics

20. ✦Nonadherence should be monitored using objective methods:
✦Pill counts
✦Medication refill rates
✦Blood levels of medications
✦Thorough use of electronic devices
✦Effective health education that includes imparting behavioral skills
and using motivational strategies is warranted to assist such
adolescents.

21. ✦In general, a child’s transition into adulthood is a critically vulnerable
period
✦Successful transition of care requires that age-appropriate practices
be adopted by patients, their parents, and the staff involved with
performing pediatric and adult transplantations.

22. ✦Pediatric transplant patients should be instructed as to their medical
condition, its treatments, the need for treatment during childhood
and adolescence, and optimal self- care practices
✦They should understand and accept the eventual need for transfer of
care