Challanges in Pediatric Renal Transplant 2

8/9/2019 Challanges in Pediatric Renal Transplant 2

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One year old child 6 Kg

Performing hemodialysis.


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It is not Easy to Get Along that Early

without Kidneys


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Because children are constantly

growing and developingtechnical, metabolic,

immunologic, and psychological

factors exist that are unique to

children having kidney

transplantation, and must be

considered.


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Aplastic, hypoplastic, or dysplastic kidneys

Obstructive uropathy

Reflux nephropathy

Focal segmental glomerulosclerosis

Systemic immunological disease

Chronic glomerulonephritis

Hemolytic uremic syndrome


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Polycystic kidney disease

Congenital nephrotic syndrome

Medullary cystic disease

MPGNType II

MPGNType I

OTHER DISEASES

Diabetic glomerulonephritis

Sickle cell nephropathy

Unknown


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Growth retardation.Infections.

Non adherence to therapy.

Renal allograft dysfunction.

Long term kidney allograft

survival.

Immune suppression regimen.

Some technical aspects.Side effects .

Long term out come.


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Growth retardation is common in childrenand adolescents with chronic kidney disease

(CKD).

The etiology is multifactorial and includes: malnutrition due to uremic anorexia,

acidosis, alterations in calcium and phosphate

metabolism,

and alteration in the growth hormone-insulin-like growth factor axis


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One of the goals of successful pediatric renal

transplantation is the attainment of optimalfinal adult height.

Although height standard deviation scores of

pediatric renal transplant recipients have

steadily improved over the past 2 decades,

growth in many children despite targeted

therapeutic efforts remains suboptimal aftertransplantation


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Several factors have been shown to affect the

growth rates of children after renaltransplantation, but the most important are

Age at time of transplantation,

Allograft function,

And corticosteroid therapy.

Age: younger recipients exhibitthe greatest immediate catch-up growth

; catch-up growth occurs primarily

in recipients < 6 years of age at transplantationGraft function: elevated SCr concentration

and decreased GFR have been correlated with

a reduction in height and growth velocity.

Corticosteroids:

are known to adversely affect growth in children


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Infection now exceeds rejection as a causeof hospitalization of pediatric renal

transplant recipients in the first 2 years

post-transplantation.

The youngest children (aged 0-1 years) at

time of transplantation had significantly

higher rates of infection requiring

hospitalization , for bacterial and viral

infection compared with children > 12

years


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Infection-related hospitalization rates were

highest for pediatric kidney transplantrecipients.

Urinary tract infection (UTI) is a major causeof morbidity .

graft function deteriorated at a significantly

faster rate in patients with recurrent UTIs thanin those without recurrent UTIs at 4 years

post-transplantation


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Adolescents have the highest rate of 1-yeargraft survival of any age group, but long-term

transplant outcomes in this age group aredisappointing.

The most important challenge to long-term

survival in children following transplantationis the management of non adherence andother adolescent issues.

A major cause of late graft failure inadolescents is medication noncompliance.Medication noncompliance has been shownto be more than 4 times greater in adolescents

than in adults.


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Important milestones during the transition fromchildhood to adulthood include:

Becoming autonomous and eventually fullyindependent.

But almost paradoxically the cognitive skillsand intellectual maturation of adolescents arelimited, particularly in those with chronicdiseases .

Adolescents struggle with abstract thinking,including conceptualization of futureconsequences of present actions, which leads torisk-taking behaviors, including non adherence

with medications.


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A

s a group, the immunosuppressiveagents used to prevent acute rejection

and preserve kidney function in renal

Alter physical appearance,

Cause serious mental and psychosocial

problems,

Compromise quality of life

side effects


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Corticosteroids

CSA

TAC


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Gingival overgrowth in a transplant recipient taking CSA.

The accumulation of collagen seen in gingival overgrowth,

thought to occur as a result of CSA-induced inhibition of

collagenolytic activity within the gingival tissues, is disfiguring

and contributes to periodontal disease.


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Medication noncompliance is a leading cause

of morbidity in pediatric transplant recipients.

Stopping or markedly under dosing

immunosuppression even once for anextended period of time may allow the

irreversible process of chronic rejection to

begin.

Once this process begins, even if compliance

is perfect thereafter, the process is not likely

to be reversible


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Although the age group most commonlyassociated with increased risk for graft failure

is infancy, a less recognized high-risk age

group is adolescence.

Adolescents also had a significantly higher

percentage of late acute rejection episodes

and a lower rate of rejection reversal

compared with other age groups.


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There are many causes of renal dysfunction inpediatric renal transplant recipients. Likewise,the allograft can undergo a variety ofmorphologic changes during the progressionfrom injury to dysfunction.

Acute antibody-mediated and cell-mediated rejection,

Drug toxicity from CNIs,

Chronic allograft nephropathy (CAN),Viral infection,

And post-transplant lymphoproliferative

disease are


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Although short-term kidney allograft survivalrates have improved dramatically, long-term

survival has not kept pace due to the nearly

universal development of CAN.

Chronic allograft nephropathy (CAN) is

irreversible and is the single most important

factor for allograft dysfunction and loss in

children.


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Chronic allograft nephropathty

10 years

Immunologic Nonimmunologic

eg, rejection

, inadequate immunosuppression,

viral infection

eg, reperfusion injury,

increased ureteral pressure,

hypertension,

hyperfiltration,

ischemia,

proteinuria,

CNI toxicity


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Clinically, CAN is characterized by :

Worsening renal function (slowly

progressive decrease in the GFR),De novo or aggravated hypertension,

And worsening proteinuria .


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Reliance on SCr can underestimate the

severity and rate of decline in renal function,

particularly when the GFR is 30 to 70

mL/min (which is the case for most kidneytransplant recipients).

Proteinuria (new-onset, > 0.5 g/24 h, orworsening) should raise the suspicion of

CAN


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Investigators evaluated

transplant protocol biopsies

from 280 patients with stable SCr levels

and determined that

SCr and estimatedGFR are poor

predictors of early histopathologicchanges that precede CANinrenal allograft biopsies.


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A renal allograft affected by chronic allograft nephropathy shows loss of

normal architecture with interstitial chronic inflammation, tubular atrophy,glomerular collapse, and global sclerosis but without tubulitis or arteritis.


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Renal function within

the first year of

transplantation wasthe most important

predictor of kidney

graft survival


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Although the occurrence of acute rejection isthe strongest predictor for the development of

chronic rejection.

1-year SCr and delta creatinine values, not

clinical acute rejection episodes, predicted

long-term renal graft survival.


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In the setting of acute rejection,

it is thepreservation of renal function that

is more important for graft survival.

That recent improvements in graft half-life

can be attributed to better preservation of

renal function within the first year post-transplantation


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Conversion from a CSA-based to a TAC-based

immunosuppression regimen has been

associated with

Stabilization of renal function, compared with agradual deterioration of graft function in patients whoremained on CSA

Sustained reduction in systolic and diastolic bloodpressure

Sustained improvement in serum lipid profile (totalcholesterol, LDL-C, and triglycerides)

Reduced Framingham risk score


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RECURRENT RENAL DISEASEPrimary hyperoxaluria

IgA nephropathyMembranous glomerulonephritis

Diabetes mellitus

Cystinosis

Amyloidosis

Focal segmental glomerulosclerosis

Alports, crescentic glomerulonephritis, vasculitis

Haemolytic uraemic syndrome

Systemic lupus erythematosus

Mesangiocapillary glomerulonephritis


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As pediatric recipients

are likely to require

re-transplantation during their lifetime,every effort should be made

to minimize HLA mismatches

to reduce the risk of future sensitization


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The implantation of an adult kidney into a

paediatric recipient requires close cooperation

between the surgical and anaesthetic teams.

Meticulous attention needs to be paid to the

child's intravascular volume status.

When the aortic and inferior vena cava

clamps are released, the transplanted organ

and lower extremities fill with blood,potentially resulting in severe hypovolaemia

unless adequate volume loading has taken

place.


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Fluids and electrolyte balance

Urine output and insensible losses are replaced initiallywith 2.5% glucose/0.45% saline, volume for volume on an

hourly basis.

Plasma electrolytes are checked at 2-4 hourly intervals for

the first 12 to 24 hours and replacement fluids should be

adjusted according to these results.

Central venous pressure (CVP) monitoring is mandatory

and the CVP should be maintained at 5-10cmH2O in the

spontaneously breathing patient, with intravenous normal

saline or by the administration of an alternative colloid to

correct hypovolaemia.


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Challanges in Pediatric Renal Transplant 2

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