Pre-emptive transplantation
| Registration of children for kidney transplantation | << Back.. |
| ANNEX A | Paediatric renal transplantation |
| ANNEX B | Listing for paediatric cadaveric renal transplantation |
| ANNEX C | Pre-emptive transplantation |
| ANNEX D | Living related paediatric renal transplantation |
1 Background
Transplantation without prior dialysis occurs in approximately 28% of children in N. America who undergo renal transplantation¹, and in 22% of children in the UK². Most, but not all of these children receive LRD grafts. There are potential benefits of pre-emptive transplantation: avoiding time spent on dialysis with disruption of family and school life; allowing more normal growth; avoiding the need for PD and HD access. Initial data suggested that there was no negative effect of pre-emptive transplantation on graft survival3,4 and indeed more recent data suggests a beneficial effect on graft survival1,5,6. No effect has been shown on rejection rates nor patient survival.
There are no published data regarding the timing of pre-emptive transplantation. Below are suggested criteria for proceeding with a pre-emptive transplant. Decisions need to be based on both laboratory and clinical parameters. At low levels of GFR (10-15 ml/min/1.73m²) some children have stable renal function and can be managed adequately with conservatively treatment only. In these children the need for renal replacement therapy tends to be made on the grounds of clinical symptoms.
- GFR < 10-15 ml/min/1.73m² and symptomatic ESRF
or - Rapidly declining GFR and inevitability of the need for dialysis within 6-12 months
2 Symptomatic ESRF
- despite adequate nutrition, fluid intake and correction of electrolyte abnormalities and acidosis, correction of anaemia, and treatment with phosphate binders and with activated vitamin D.
- Inability to take part in normal childhood activities - attend school, keep up with friends etc.
- Poor growth
- Uncontrolled renal osteodystrophy
3 Relative contra-indications
Some children will require (bilateral) nephrectomies prior to transplantation and unless these are performed at the time of transplantation, a short period of time on dialysis will be required. The persistence of the nephrotic state (despite a fall in GFR) may be considered a relative contra-indication to pre-emptive transplantation. Children who are hypertensive or fluid overloaded from renal failure may benefit from dialysis prior to transplantation.
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1Vats AN, et al. Pretransplant dialysis status and outcome of renal transplantation in North American children: A NAPRTCS study. Transplantation 2000;69:1414-1419
2 The Third Annual Report of the UK Renal Registry, Dec 2000
3 Nevins T et al. Prior dialysis does not affect the outcome of pediatric renal transplantation. Pediatr Nephrol 1991;5:211-214
4 Flom LS, et al. Favorable experience with pre-emptive renal transplantation in children. Pediatr Nephrol 1992;6:258-261
5 Mahmoud A, et al. Outcome of preemptive renal transplantation and pretransplantation dialysis in children. Pediatr Nephrol 1997;11:537-541
6 Ishitani M, et al. Predictors of graft survival in pediatric living-related kidney transplant recipients. Transplantation 2000;70:288-292
7 Schwartz
GJ, et al. A simple estimate of glomerular filtration rate
in children derived from body length and plasma creatinine.
Pediatrics 1976;58:259-26
