Pediatric renal transplantation

Abstract

Chronic dialysis and renal transplantation are both very good treatments for end-stage renal disease (ESRD). The majority of adults with ESRD are receiving dialysis rather than undergoing renal transplantation. The number of adults seeking renal transplantation is rising, but the number performed has been limited by the lack of appropriate donors [1]. There is a survival advantage of transplantation for virtually all candidates [2]. Renal transplantation was recognized as the better form of treatment for children with ESRD almost three decades ago [3] and has repeatedly shown to provide a survival benefit for children [4, 5]. Both peritoneal dialysis, delivered as CAPD or CCPD, and hemodialysis provide a worse quality of life, unsatisfactory growth rate, as well as ongoing complications as compared to renal transplantation. Data from the dialysis component of the North American Pediatric Renal Trials and Collaborative Studies (NAPRTCS) registry [6] show that the overall height deficit of −1.8 S.D. became more negative reaching a value of −2.16 S.D. at 24 months after initiation of dialysis. Additionally children do not tolerate being “dependent” on any modality, and maintenance dialysis induces loss of self-esteem and emotional maladjustment [7]. Cognitive achievement testing may diminish with prolonged time on dialysis [8]. In contrast, the mobility and freedom from dietary restrictions afforded by a functioning renal transplant enable children to live nearly normal lives. Renal transplantation has not lived up to the promise of normal growth for all children, but dramatic short-term improvements in height can be seen in many and final adult height is improving after transplantation [9–13]. Importantly, successful transplantation permits the child to attend school and to develop normally, and school function testing improves dramatically following transplantation [14, 15]. Importantly, young children have the best long-term outcomes of all age groups of transplant recipients, verifying the utility of transplantation in this age group [16–18]. For all of these reasons, successful renal transplantation remains the primary goal of programs that care for children with ESRD [5, 19]. Pediatric recipients of kidney transplants have high percentages of living donors, and they receive substantial preference on the deceased-donor transplant waiting list in many countries [20, 21], leading to potentially short waiting times [22]. Thus, pediatric patients with ESRD should not have substantial delays in undergoing renal transplantation after they develop ESRD, although the goal of rapid progression to kidney transplantation has not been universally achieved [23].