Laboratory Studies
The following studies are indicated in kidney transplantation candidates:
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Complete blood cell count (CBC)
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Comprehensive metabolic panel, plus serum phosphorus and magnesium
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Parathyroid hormone
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Liver function tests
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Coagulation studies - These should include prothrombin time with International Normalized Ratio (INR) and activated partial thromboplastin time
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Human leukocyte antigen (HLA) and panel reactive antibody (PRA) testing
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Viral titers
In PRA testing, recipient serum is incubated with white blood cells 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. 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 include the following:
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Cytomegalovirus (CMV)
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Herpes simplex virus (HSV)
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Varicella-zoster virus (VZV)
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Epstein-Barr virus (EBV)
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Hepatitis B virus (HBV)
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Hepatitis C virus (HCV)
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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.
One must therefore closely monitor such recipients following transplantation and provide appropriate antiviral therapy (agents that prevent viral proliferation or antibodies directed against a specific virus). One should ensure that all children receive routine childhood immunizations, including pneumococcal 13-valent conjugate vaccine and hepatitis B vaccine. In addition, children age 2 years and older should also receive the 23-valent pneumococcal vaccine, given at least 8 weeks after the child has received the final dose of the 13-valent vaccine. All live vaccines should be given at least 2 months prior to transplantation. See Pediatric Hepatitis B for complete information on this topic.
Imaging Studies
Imaging studies include chest radiography and abdominal ultrasonography. Additional studies depend on the child's urologic pattern, as revealed by a thorough medical history. 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 and cystoscopy.
Urodynamic Evaluation
Urodynamic evaluation should be performed in children with a history of voiding dysfunction (eg, incontinence) or major reconstruction of the lower urinary tract. A urodynamic study is a functional evaluation of the bladder that measures the following:
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Bladder capacity
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Bladder storage pressures
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Voiding function and pressure
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Coordination of the components of the lower urinary tract
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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Etiology of end-stage renal disease in North American children. Data from Annual Report North American Pediatric Renal Trials and Collaborative Studies (NAPRTCS), 2007.
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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.
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Management of end-stage renal disease in US children aged 0-19 years by age group. Data from US Renal Data Systems, 2008.
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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.
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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.
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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.
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Incisions used for kidney transplantation. (A) Gibson incision used for large children and adults. (B) Midline abdominal incision used for small children.
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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.
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Anastomosis of kidney transplant ureter to bladder.
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Anastomosis of kidney transplantation. Ureter to (A) bladder augmented with a patch of bowel and (B) urinary conduit constructed from a segment of ileum.
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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.
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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.
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Digital subtraction angiogram showing renal artery stenosis. Image provided by David A. Hatch, MD, copyright 1998, used with permission.
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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.
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Actual kidney transplantation survival in North American children. Data from US Renal Data Systems, 2008.
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Etiology of kidney transplant loss in children. Data from US Renal Data Systems, 2008.
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Pediatric patient survival following kidney transplantation. Data from US Renal Data Systems, 2008.
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Cause of death among pediatric recipients of kidney transplantation. Data from US Renal Data System, 2008.
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Donor source of kidneys transplanted into children. Data from North American Pediatric Renal Trials and Collaborative Studies (NAPRTCS) annual report, 2007.
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Probability of first rejection at 12 months following transplantation. Data from North American Pediatric Renal Trials and Collaborative Studies (NAPRTCS) annual report, 2007.
Tables
Patient Characteristic |
Percentage |
Age < 1 y |
0.3 |
Age 1-5 y |
20.9 |
Age 6-10 y |
17.0 |
Age 11-17 y |
61.9 |
White |
37.1 |
Black |
26.5 |
Hispanic |
31.8 |
Asian |
3.0 |
Other or unknown |
1.5 |
Cause of Kidney Failure |
Percentage |
Focal segmental glomerulosclerosis |
7.4 |
Glomerulonephritis |
5.1 |
Congenital anomalies |
38.3 |
Other or unknown |
49.2 |
