eMedicine Specialties > Pediatrics: Surgery > Transplantation
Kidney Transplantation: Follow-up
Updated: Mar 24, 2009
Outcome and Prognosis
Graft survival
Kidney transplant survival increased dramatically with the use of cyclosporine A in the late 1980s. Since that time, a steady increase in kidney and patient survival has followed the advent of new immunosuppressive medications and modifications in the way immunosuppressive drugs are used. Actual kidney transplant survival as reported by US Renal Data Systems is illustrated in Media file 15.
Actual kidney transplantation survival in North American children. Data from US Renal Data Systems, 2008.
Actual kidney transplantation survival in North American children. Data from US Renal Data Systems, 2008.
The most recent report from North American Pediatric Renal Trials and Collaborative Studies (NAPRTCS) demonstrates that kidney transplant survival rates in very young children (aged 0-1 y) is approximately 10 percentage points lower than that for older children. This difference is due to graft losses within the first year following transplantation. As in the adult population, black children experience graft loss at a higher rate than people of other races. Children who receive kidney transplants from pediatric donors appear to have more capacity to increase their glomerular filtration rate as they grow compared with children who receive adult kidneys.52
Cause of graft loss
The most common etiology of allograft loss among children and adolescents is rejection. Acute and chronic rejection caused almost half of the kidney transplant losses reported by members of the NAPRTCS. This was true for both initial and second kidney transplant failures. Other causes in order of decreasing frequency include technical complications including thrombosis, death with a functioning kidney, recurrent or de novo kidney diseases, primary nonfunction, noncompliance with immunosuppression, and others (see Media file 16).
Etiology of kidney transplant loss in children. Data from US Renal Data Systems, 2008.
Patient survival
Patient survival for pediatric recipients of kidney transplants reported by the US Renal Data System is illustrated in Media file 17.16
Pediatric patient survival following kidney transplantation. Data from US Renal Data Systems, 2008.
Patient survival is significantly lower for very young (<1 y) recipients. Infant recipients of cadaveric kidneys have the highest mortality rate.
Etiology of patient death
The NAPRTCS report from 2007 lists cardiopulmonary event as the most common cause of death among children with kidney transplants. Infection (bacterial more common than viral) was the second most common cause of mortality. Other causes are illustrated in Media file 18.
Cause of death among pediatric recipients of kidney transplantation. Data from US Renal Data System, 2008.
Currently, of any of the options for treatment, renal transplantation offers children with end-stage renal disease (ESRD) the best opportunity for growth and development. Allograft and patient survival both have demonstrated consistent improvement in the 5 decades during which renal transplantation has been available. This has been the result of improved understanding of the immune response to allografting and the development of increasingly specific strategies to protect a kidney transplant from the body's natural defenses while leaving a recipient protected from infection.
Future and Controversies
General
The greatest challenges facing those who treat children with end-stage renal disease (ESRD) are to provide more organs for children waiting for transplant and to prevent acute and chronic rejection without increasing the complications of immunosuppressive drugs.
Non–heart-beating cadaver donors
In the United States and Europe, most cadaver organs used in transplantation come from heart-beating cadavers. In some countries that have no legal recognition of brain death, transplant surgeons use organs from non–heart-beating cadavers, patients who experienced nonsurvivable injury (but did not meet the criteria for brain death), and those for whom life support systems did not preserve life. Within the last decade, several US and European centers have reported success in this technique. In general, graft survival rates are not as high and renal function is somewhat poorer when kidneys from non–heart-beating cadavers are used. Ongoing research in preservation and harvesting techniques may improve outcomes for transplantation with such organs.
Newer immunosuppressive agents
In the 1990s, several new immunosuppressive drugs became available. This explosion in transplant pharmacology has left transplant physicians wondering how these new medications should be used. In addition, new techniques in dosing and monitoring of older immunosuppressive regimens have improved graft survival. With the dramatic improvements in graft survival observed in the past decade, proving superiority of newer immunosuppressive agents is more difficult, especially in the short term (1-3 y). Lower rates of chronic rejection are expected as acute rejection rates decrease. Therefore, comparison of long-term graft survival likely is necessary to determine the best combination of immunosuppressive drugs.
Xenotransplantation
Since the infancy of human kidney transplantation, physicians have sought to use organs from animals. Early experimentation with sheep and primate organs were unsuccessful because of immunologic barriers. More is being learned about such impediments; however, currently xenotransplantation remains an unrealized dream. The two approaches under investigation are (1) immunologic blockade to the antigen-initiated response to interspecies transplantation and (2) genetic engineering to produce animals that lack the antigens against which human recipients mount an immunologic response.
For further information, see Mayo Clinic - Kidney Transplant Information.
More on Kidney Transplantation |
| Overview: Kidney Transplantation |
| Workup: Kidney Transplantation |
| Treatment: Kidney Transplantation |
 Follow-up: Kidney Transplantation |
| Multimedia: Kidney Transplantation |
| References |
| « Previous Page | Next Page » |
References
Ullman E. Experimentelle nierentransplantation. In: Wien Klin Wochenschr. Vol 14. 1902:281.
Carrel A. La technique operatoire des anastomoses vasculaires et la transplantation des visceres. Lyon Med. 1902;98:859.
Jaboulay M. Greffe de reins au pli du coude par soudure arte. Bull Lyon Med. 1906;107:575.
Unger E. Nierentransplantation. In: Berlin Dlin Wochenschr. Vol 1. 1909:1057.
Medawar PB. The behaviour and fate of skin autografts and skin homografts in rabbits: A report to the War Wounds Committee of the Medical Research Council. J Anat. Oct 1944;78:176-99. [Medline].
Hume DM, Merrill JP, Miller BF, Thorn GW. Experiences with renal homotransplantation in the human: report of nine cases. J Clin Invest. Feb 1955;34(2):327-82. [Medline].
Murray JE, Merrill JP, Harrison JH. Kidney transplantation between seven pairs of identical twins. Ann Surg. Sep 1958;148(3):343-59. [Medline].
Calne RY, Alexandre GP, Murray JE. A study of the effects of drugs in prolonging survival of homologous renal transplants in dogs. Ann N Y Acad Sci. Oct 24 1962;99:743-61. [Medline].
Goodwin WE, Mims MM, Kaufman JJ. Human renal transplantation III. Technical problems encountered in six cases of kidney homotransplantation. Trans Am Assoc Genitourin Surg. 1962;54:116-25. [Medline].
Starzl TE, Marchioro TL, Waddell WR. The reversal of rejection in human renal homografts with subsequent development of homograft tolerance. Surg Gynecol Obstet. Oct 1963;117:385-95. [Medline].
Terasaki PI, Vredevoe DL, Porter KA, Mickey MR, Marchioro TL, Faris TD, et al. Serotyping for homotransplantation. V. Evaluation of a matching scheme. Transplantation. Nov 1966;4(6):688-99. [Medline].
Cranford RW. Brain death. In: Organ Procurement, Preservation and Distribution in Transplantation. Richmond, Va: UNOS; 1991:23-31.
Banowsky LH. Current results and future expectations in renal transplantation. Urol Clin North Am. May 1983;10(2):337-46. [Medline].
Ting A, Morris PJ. Matching for B-cell antigens of the HLA-DR series in cadaver renal transplantation. Lancet. Mar 18 1978;1(8064):575-7. [Medline].
Calne RY, White DJ, Thiru S, et al. Cyclosporin A in patients receiving renal allografts from cadaver donors. Lancet. Dec 23-30 1978;2(8104-5):1323-7. [Medline].
USRDS. United States Renal Data System. Available at http://www.usrds.org/. Accessed December 12, 2008.
Traum AZ, Ko DS, Kawai T. The potential for tolerance in pediatric renal transplantation. Curr Opin Organ Transplant. Oct 2008;13(5):489-94. [Medline].
Shapiro R, Scantlebury VP, Jordan ML, et al. Tacrolimus in pediatric renal transplantation. Transplantation. Dec 27 1996;62(12):1752-8. [Medline].
Hocker B, John U, Plank C, et al. Successful withdrawal of steroids in pediatric renal transplant recipients receiving cyclosporine A and mycophenolate mofetil treatment: results after four years. Transplantation. Jul 27 2004;78(2):228-34. [Medline].
Kahan BD, Rajagopalan PR, Hall M. Reduction of the occurrence of acute cellular rejection among renal allograft recipients treated with basiliximab, a chimeric anti-interleukin-2-receptor monoclonal antibody. United States Simulect Renal Study Group. Transplantation. Jan 27 1999;67(2):276-84. [Medline].
Kim FJ, Ratner LE, Kavoussi LR. Renal transplantation: laparoscopic live donor nephrectomy. Urol Clin North Am. Nov 2000;27(4):777-85. [Medline].
Slakey DP, Wood JC, Hender D, et al. Laparoscopic living donor nephrectomy: advantages of the hand-assisted method. Transplantation. Aug 27 1999;68(4):581-3. [Medline].
Barry JM. Unstented extravesical ureteroneocystostomy in kidney transplantation. J Urol. May 1983;129(5):918-9. [Medline].
Lich R. Recurrent urosepsis in children. Journal of Urology. 1961;86:554.
Gill IS, Hayes JM, Hodge EE, Novick AC. Clean intermittent catheterization and urinary diversion in the management of renal transplant recipients with lower urinary tract dysfunction. J Urol. Nov 1992;148(5):1397-400. [Medline].
Hatch DA, Koyle MA, Baskin LS, et al. Kidney transplantation in children with urinary diversion or bladder augmentation. J Urol. Jun 2001;165(6 Pt 2):2265-8. [Medline].
Whitaker RH. Clinical assessment of pelvic and ureteral function. Urology. Aug 1978;12(2):146-50. [Medline].
Renoult E, Buteau C, Lamarre V, Turgeon N, Tapiero B. Infectious risk in pediatric organ transplant recipients: is it increased with the new immunosuppressive agents?. Pediatr Transplant. Aug 2005;9(4):470-9. [Medline].
Silkensen JR. Long-term complications in renal transplantation. J Am Soc Nephrol. Mar 2000;11(3):582-8. [Medline].
Sia IG, Paya CV. Infectious complications following renal transplantation. Surg Clin North Am. Feb 1998;78(1):95-112. [Medline].
Bock GH, Sullivan EK, Miller D, et al. Cytomegalovirus infections following renal transplantation--effects on antiviral prophylaxis: a report of the North American Pediatric Renal Transplant Cooperative Study. Pediatr Nephrol. Dec 1997;11(6):665-71. [Medline].
Granger DK, Burd RS, Schmidt WJ, et al. Incidence and timing of infections in pediatric renal transplant recipients in the cyclosporine era. Transplant Proc. Feb 1994;26(1):64. [Medline].
Cox KL, Lawrence-Miyasaki LS, Garcia-Kennedy R, et al. An increased incidence of Epstein-Barr virus infection and lymphoproliferative disorder in young children on FK506 after liver transplantation. Transplantation. Feb 27 1995;59(4):524-9. [Medline].
Newell KA, Alonso EM, Whitington PF, et al. Posttransplant lymphoproliferative disease in pediatric liver transplantation. Interplay between primary Epstein-Barr virus infection and immunosuppression. Transplantation. Aug 15 1996;62(3):370-5. [Medline].
Green M, Michaels MG, Webber SA, et al. The management of Epstein-Barr virus associated post-transplant lymphoproliferative disorders in pediatric solid-organ transplant recipients. Pediatr Transplant. Nov 1999;3(4):271-81. [Medline].
Ho M, Jaffe R, Miller G, et al. The frequency of Epstein-Barr virus infection and associated lymphoproliferative syndrome after transplantation and its manifestations in children. Transplantation. Apr 1988;45(4):719-27. [Medline].
Broyer M, Tete MJ, Guest G, et al. Varicella and zoster in children after kidney transplantation: long-term results of vaccination. Pediatrics. Jan 1997;99(1):35-9. [Medline].
Furth SL, Sullivan EK, Neu AM, et al. Varicella in the first year after renal transplantation: a report of the North American Pediatric Renal Transplant Cooperative Study (NAPRTCS). Pediatr Transplant. Aug 1997;1(1):37-42. [Medline].
Broyer M, Boudailliez B. Varicella vaccine in children with chronic renal insufficiency. Postgrad Med J. 1985;61 Suppl 4:103-6. [Medline].
Hardy I, Gershon AA, Steinberg SP, LaRussa P. The incidence of zoster after immunization with live attenuated varicella vaccine. A study in children with leukemia. Varicella Vaccine Collaborative Study Group. N Engl J Med. Nov 28 1991;325(22):1545-50. [Medline].
Zamora I, Simon JM, Da Silva ME, Piqueras AI. Attenuated varicella virus vaccine in children with renal transplants. Pediatr Nephrol. Apr 1994;8(2):190-2. [Medline].
Chugh KS, Sakhuja V, Jain S, et al. High mortality in systemic fungal infections following renal transplantation in third-world countries. Nephrol Dial Transplant. 1993;8(2):168-72. [Medline].
Chugh KS, Sakhuja V, Jain S, et al. Fungal infections in renal allograft recipients. Transplant Proc. Oct 1992;24(5):1940-2. [Medline].
Tolkoff-Rubin NE, Rubin RH. Opportunistic fungal and bacterial infection in the renal transplant recipient. J Am Soc Nephrol. Jun 1992;2(12 Suppl):S264-9. [Medline].
Neu AM, Fivush BA. Recommended immunization practices for pediatric renal transplant recipients. Pediatr Transplant. Nov 1998;2(4):263-9. [Medline].
Enke BU, Bokenkamp A, Offner G, et al. Response to diphtheria and tetanus booster vaccination in pediatric renal transplant recipients. Transplantation. Jul 27 1997;64(2):237-41. [Medline].
[Best Evidence] Mathew JL, El Dib R, Mathew PJ, Boxall EH, Brok J. Hepatitis B immunisation in persons not previously exposed to hepatitis B or with unknown exposure status. Cochrane Database Syst Rev. Jul 16 2008;CD006481. [Medline].
American Academy of Pediatrics. Report of the committee on infectious diseases. Pickering LK, Baker CJ, McMillan M, Long S (Editors). Red Book. 27th Edition. 2006.
Penn I. Incidence and treatment of neoplasia after transplantation. J Heart Lung Transplant. Nov-Dec 1993;12(6 Pt 2):S328-36. [Medline].
Mongeau JG, Clermont MJ, Robitaille P, et al. Study of psychosocial parameters related to the survival rate of renal transplantation in children. Pediatr Nephrol. Oct 1997;11(5):542-6. [Medline].
Birk PE, Matas AJ, Gillingham KJ, et al. Risk factors for chronic rejection in pediatric renal transplant recipients--a single-center experience. Pediatr Nephrol. Aug 1997;11(4):395-8. [Medline].
Pape L, Offner G, Ehrich JH, et al. Renal allograft function in matched pediatric and adult recipient pairs of the same donor. Transplantation. Apr 27 2004;77(8):1191-4. [Medline].
Benfield MR, McDonald R, Sullivan EK, et al. The 1997 Annual Renal Transplantation in Children Report of the North American Pediatric Renal Transplant Cooperative Study (NAPRTCS). Pediatr Transplant. May 1999;3(2):152-67. [Medline].
Davis ID, Bunchman TE, Grimm PC, et al. Pediatric renal transplantation: indications and special considerations. A position paper from the Pediatric Committee of the American Society of Transplant Physicians. Pediatr Transplant. May 1998;2(2):117-29. [Medline].
Goldstein SL, Somers MJ, Lande MB, et al. Acyclovir prophylaxis of varicella in children with renal disease receiving steroids. Pediatr Nephrol. Apr 2000;14(4):305-8. [Medline].
Hatch DA, Belitsky P, Barry JM, et al. Fate of renal allografts transplanted in patients with urinary diversion. Transplantation. Oct 1993;56(4):838-42. [Medline].
Whitaker RH. Methods of assessing obstruction in dilated ureters. Br J Urol. Feb 1973;45(1):15-22. [Medline].
Further Reading
Keywords
kidney transplantation, transplant, kidney transplant, end-stage renal disease, ESRD, renal transplant, renal transplantation, kidney donation, dialysis, hemodialysis, glomerulonephritis, histocompatibility antigens, HLAs, kidney rejection, nephrectomy, systemic lupus erythematosus, Goodpasture syndrome, Goodpasture disease, focal segmental glomerulosclerosis, membranoproliferative glomerulonephritis, hemolytic-uremic syndrome, Henoch-Schönlein purpura, continuous ambulatory peritoneal dialysis, CAPD, treatment, kidney failure, renal failure
