Kidney Transplant with Dr. Merola

The most common diagnosis for kidney failure in children includes congenital anomalies of the kidney and urinary tract (renal aplasia, hypoplasia or dysplasia, obstructive neuropathy from reflux and bladder obstruction), comprising 35 to 40% of pediatric patients undergoing kidney transplants.

Other causes of kidney failure include focal segmental glomerulosclerosis, hereditary nephropathies, and chronic glomerulonephritis.

Survival for a living and deceased donor kidney transplant in children often exceeds 30 years.

Transplant survival (exceeding 30 years) is better than the waitlist mortality, which is around 15 years.

Neonates can be supported with specialized hemodialysis known as CARPEDIEM (cardiorenal pediatric dialysis emergency machine), which serves as CRRT for infants as small as 2.5 kg.

Peritoneal dialysis requires at least a period of 2 to 3 weeks from the time of catheter insertion to when dialysis can be initiated, to mitigate the risk of peritonitis.

Performing an omentectomy in small babies results in much greater success of peritoneal dialysis catheter insertion.

For all patients with stage 4 or 5 chronic kidney disease, referral for kidney transplant is recommended.

At Cincinnati Children's, children should be about 10 kg or 80 centimeters in height to accommodate an adult kidney, typically at 2 years of age.

An adult sized kidney should ideally be less than 10 or 12 centimeters to comfortably fit in a pediatric recipient.

Living donor kidney transplants are the preferred grafts because they have a lower rejection risk and a longer overall survival.

Advantages of living donor transplants include less delayed graft function and more rapid organ access, particularly to patients who are not yet on dialysis.

Kidneys with multiple vessels are more challenging to implant on the aorta and IVC and are considered high risk grafts.

Children typically receive kidney transplant through a retroperitoneal incision, and the vascular anastomosis are performed to the common iliac vessels.

In smaller patients, the aorta or inferior vena cava allow for better vascular inflow and can be exposed using an intraperitoneal or extraperitoneal approach.

At Cincinnati Children's, the extraperitoneal approach is preferred to minimize the risk of bowel injury and allow for a contained space in the setting of any required biopsy of the kidney allograft.

An ipsilateral nephrectomy is usually performed to allow adequate space for the graft, and also in the setting of polyuria or proteinuria, or in the case of FSGS where urine protein is an important marker for disease recurrence to be detected early.

In patients that require bilateral nephrectomy (such as those with Wilms tumor or FSGS where proteinuria monitoring is important for detecting disease recurrence), the contralateral kidney is usually taken out in a separate setting from that of transplant.

Surgical complications include vascular thrombosis and urine leak, occurring in about 5% of patients.

Rejection and infection are the two most significant non-surgical long-term complications in children following kidney transplant.

Immunosuppression is required lifelong but may predispose patients to viral infections, malignancies, and long-term can cause toxicity to the transplanted kidney.

Normothermic perfusion is a technique that circulates a warm perfusion solution through the renal vasculature enabling the organ to recover from ischemic injury and enables the opportunity to treat the organ.