Pediatric Kidney Transplantation Workup

  • Author: David Hatch, MD; Chief Editor: Stuart M Greenstein, MD   more...
 
Updated: Nov 22, 2011
 

Laboratory Studies

The following studies are indicated in kidney transplantation:

  • CBC count
  • Complete metabolic panel
  • Coagulation studies: These should include prothrombin time, activated partial thromboplastin time, and international normalized ratio (INR).
  • Panel reactive antibody (PRA): Recipient serum is incubated with WBCs pooled from a group of blood donors with human leukocyte antigen (HLA) types representative of the community. Cell kill indicates that the recipient has antibodies against the donor cells. PRA, the percentage of the donors against which the recipient reacts, is used as a predictor of the likelihood of a positive cross-match that would prevent transplantation.
  • Viral titers (ie, cytomegalovirus [CMV], herpes simplex virus [HSV], varicella-zoster virus [VZV], Epstein-Barr virus [EBV], hepatitis B virus [HBV], hepatitis C virus [HCV], HIV)
    • Children who demonstrate no antibody to CMV, VZV, and EBV are at increased risk of posttransplant primary infection, especially if they receive kidneys from donors who are seropositive for these viruses.
    • Closely monitor such recipients following transplantation and provide appropriate antiviral therapy (agents that prevent viral proliferation or antibodies directed against a specific virus).
    • Ensure that all children are immunized against HBV prior to transplantation.
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Imaging Studies

  • Imaging studies include chest radiography and abdominal ultrasonography.
  • The medical history should provide a thorough evaluation of the child's urologic pattern. A history of congenital urologic anomaly, recurrent urine infections, and/or voiding abnormalities (eg, incontinence, frequency, urgency) identifies children who should undergo further urologic imaging or evaluation, including voiding cystourethrography and possible urodynamic studies.
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Other Tests

  • A urodynamic study is a functional evaluation of the bladder that measures bladder capacity, bladder storage pressures, voiding function and pressure, and coordination of the components of the lower urinary tract.
  • In children with a history of voiding dysfunction (eg, incontinence) or major reconstruction of the lower urinary tract, perform urodynamic evaluation to determine bladder capacity and compliance and also to evaluate competence of the continence mechanisms.
  • If low bladder capacity, high storage pressure, incomplete emptying, or high voiding pressure is found on urodynamic testing, instituting intervention prior to transplantation to prevent urine infection, urinary obstruction, or incontinence may be appropriate.
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Contributor Information and Disclosures
Author

David Hatch, MD  Chief, Section of Pediatric Urology, Professor of Urology & Pediatrics, Departments of Urology and Pediatrics, Foster G McGaw Hospital and Loyola University of Chicago

David Hatch, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, American Society of Transplant Surgeons, and American Urological Association

Disclosure: Nothing to disclose.

Coauthor(s)

Rekha Agrawal, MD  Director, Division of Pediatric Nephrology, Professor, Department of Pediatrics, Loyola University Medical Center

Rekha Agrawal, MD is a member of the following medical societies: American Society of Pediatric Nephrology and International Society of Nephrology

Disclosure: Nothing to disclose.

Specialty Editor Board

Casimir F Firlit, MD, PhD  Director of Reconstructive Urology, Department of Neuro-Urology and Fetal Urology, SSM Cardinal Glennon Children's Medical Center

Casimir F Firlit, MD, PhD is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, American Medical Association, American Society of Transplant Surgeons, American Urological Association, and Illinois State Medical Society

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Brian F Gilchrist, MD  Surgeon-in-Chief of Pediatric Surgery, The Floating Hospital for Children at Tufts-New England Medical Center; Associate Professor, Department of Surgery, Tufts University School of Medicine

Brian F Gilchrist, MD is a member of the following medical societies: American College of Surgeons, American Pediatric Surgical Association, and Society for Surgery of the Alimentary Tract

Disclosure: Nothing to disclose.

Ron Shapiro, MD  Professor of Surgery, Robert J Corry Chair in Transplantation Surgery, Director, Kidney, Pancreas, and Islet Transplantation, Thomas E Starzl Transplantation Institute, University of Pittsburgh Medical Center

Ron Shapiro, MD is a member of the following medical societies: American College of Surgeons, American Society of Transplant Surgeons, Association for Academic Surgery, Central Surgical Association, and Society of University Surgeons

Disclosure: Astellas Honoraria Speaking and teaching; Brystol Meyer Squibb StemCell Data Monitoring Committee Consulting fee Review panel membership; Wyeth Honoraria Speaking and teaching; Stem Cells, Inc Consulting fee Review panel membership; Up To Date contracted Author

Chief Editor

Stuart M Greenstein, MD  Professor of Surgery, Albert Einstein College of Medicine; Consulting Surgeon, Department of Surgery, Division of Transplantation, Montefiore Medical Center

Stuart M Greenstein, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Surgeons, American Society of Transplant Surgeons, American Society of Transplantation, Association for Academic Surgery, International College of Surgeons, Medical Society of New Jersey, National Kidney Foundation, New York Academy of Sciences, and Southeastern Surgical Congress

Disclosure: Nothing to disclose.

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Etiology of end-stage renal disease in North American children. Data from Annual Report North American Pediatric Renal Trials and Collaborative Studies (NAPRTCS), 2007.
Etiology of end-stage renal disease in children aged 0-18 years by age group. Data from North American Pediatric Renal Trials and Collaborative Studies (NAPRTCS) Annual Report, 2007.
Management of end-stage renal disease in US children aged 0-19 years by age group. Data from US Renal Data Systems, 2008.
Simplified diagram of the immune response to nonidentical major histocompatability complex (MHC) antigens. Foreign antigens are processed by macrophages or dendritic cells (antigen-presenting cell) and then presented to T-helper lymphocytes. Release of interleukin-1 from macrophages activates T-helper lymphocytes. Thus activated, these T-helper lymphocytes produce cytokines (interleukin-2) that stimulate production of cytotoxic T lymphocytes, antibody-producing B lymphocytes, and natural killer cells. Diagram provided by David A. Hatch, MD, copyright 2001, used with permission.
Simplified diagram illustrating the points of action of immunosuppressive drugs. Corticosteroids inhibit production of interleukin-1. Macrolides (ie, cyclosporine, tacrolimus, sirolimus) inhibit production of or use of interleukin-2, thus inhibiting stimulation of a clone of cytotoxic T lymphocytes directed against specific human lymphocyte antigen types. Antimetabolites (ie, mycophenolate mofetil, azathioprine) inhibit purine production, thus impairing cell proliferation. Antibodies impair normal function of cell surface markers, thus inhibiting stimulation of T-lymphocyte clones directed against foreign antigens. Diagram provided by David A. Hatch, MD, copyright 2001, used with permission.
Comparison of imaging techniques for a living kidney donor. (A) Digital subtraction angiogram showing lower pole artery. (B) Three-dimensional CT scan depicting 2 left renal arteries. Images provided by David A. Hatch, MD, copyright 1999, used with permission.
Incisions used for kidney transplantation. (A) Gibson incision used for large children and adults. (B) Midline abdominal incision used for small children.
Vascular anastomoses used in a kidney transplantation in a 5-year-old patient, renal artery to common iliac artery and renal vein to common iliac vein. Image provided by David A. Hatch, MD, copyright 2001, used with permission.
Anastomosis of kidney transplant ureter to bladder.
Anastomosis of kidney transplantation. Ureter to (A) bladder augmented with a patch of bowel and (B) urinary conduit constructed from a segment of ileum.
Kidney transplantation ultrasonograms. (A) Normal kidney. (B) Color Doppler ultrasonogram documenting normal perfusion to the kidney. (C) Color Doppler ultrasonogram showing absence of perfusion in a patient with thrombosis. (D) Hydronephrosis. (E) Lymphocele. (F) Stone in a kidney transplant. Images provided by David A. Hatch, MD, copyright 1998, used with permission.
Nuclear renograms of kidney transplantations. (A) Normal perfusion. Note that the isotope is observed in the aorta, iliac vessels, and the kidney in the first image (0-5 s). (B) Normal tubular function and drainage. Note that the isotope is rapidly excreted and drained. The highest concentration of isotope (darkest image) is observed in the first image (0-3 min). (C) Delayed perfusion in a patient with acute rejection. Note that the isotope is observed in the aorta and iliac vessels in the first frame (0-5 s), but the kidney first shows uptake of the isotope in the second frame (6-10 s). (D) Decreased tubular function in a cadaver kidney transplant with acute tubular necrosis. Image provided by David A. Hatch, MD, copyright 2001, used with permission.
Digital subtraction angiogram showing renal artery stenosis. Image provided by David A. Hatch, MD, copyright 1998, used with permission.
Histology of percutaneous kidney transplantation biopsy. (A) Normal kidney. (B) Acute rejection. Note the infiltration of lymphocytes. Images provided by David A. Hatch, MD, copyright 1999, used with permission.
Actual kidney transplantation survival in North American children. Data from US Renal Data Systems, 2008.
Etiology of kidney transplant loss in children. Data from US Renal Data Systems, 2008.
Pediatric patient survival following kidney transplantation. Data from US Renal Data Systems, 2008.
Cause of death among pediatric recipients of kidney transplantation. Data from US Renal Data System, 2008.
Donor source of kidneys transplanted into children. Data from North American Pediatric Renal Trials and Collaborative Studies (NAPRTCS) annual report, 2007.
Probability of first rejection at 12 months following transplantation. Data from North American Pediatric Renal Trials and Collaborative Studies (NAPRTCS) annual report, 2007.
 
 
 
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