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Pediatric end-stage renal disease is successfully managed with
either chronic dialysis or renal transplantation (see Chapters 477 and 478). Because transplantation
promotes more normal growth and development compared with chronic
dialysis, it is now the preferred approach to management.1,2 However,
the required chronic immunosuppression exposes children to multiple
complications and side effects (see Chapter 128),
so management strategies attempt to minimize or eliminate immunosuppression
while assuring graft survival. Many factors determine the optimal
time for transplant in the individual patient, including the patient
age, primary renal disease, psychosocial status, family dynamics, availability
of a living donor versus deceased donor allograft,
optimal immunosuppressive therapy, and maximization of growth and
development.
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Recipient Characteristics
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The North American Pediatric Renal Trials and Cooperative Studies
(NAPRTCS) transplant registry shows that the annual number of renal
transplants performed in children under the age of 18 has been stable
over the past decade, ranging from 674 to 713.3 The
mean age of transplant is 12.3 years with 5.3 % of recipients
under age 2, 14.8% ages 2 to 5, 33.3% ages 6 to
12, 38.8% ages 13 to 17, and 7.8% ages 18 to 21.
The gender distribution of patients with renal transplants has remained
relatively constant over the past 15 years with males at approximately
60%. The percentage of Caucasian recipients is currently
61%, which has decreased from a high of 72% in 1987.
Seventeen percent of pediatric renal transplant recipients are African
American and 16% are Hispanic.
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There has been a steady increase in living donor recipients from
43% in 1987 to 60% in 2000 and beyond. Parents
represent the majority (81%) of living donors. The number
of unrelated living donors has increased over time from an average
of 3 per year in the period 1987–1995 to 17 per year since
then. There has been a corresponding decrease in the number of deceased
donors, from 57% in 1987 to 40% since 2002. Most
of the transplants in the infant age group are from living donors
(76%). In the other age groups, the percent of living donor
(LD) and deceased donor (DD) are relatively equal at 57%,
52%, and 48% LD in the 2 to 5, 6 to 12, and older
than 12 age groups, respectively.
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Morbidity is lower and graft survival is higher for children
who are transplanted before the need of dialysis therapy. Preemptive
transplants occur more frequently in children because of the parents’ and
patients’ desire to avoid dialysis when a living donor
is available. Children can also be listed for a preemptive deceased
donor transplant. The rate of preemptive transplant in children
is 25%. The rate of preemptive transplant is highest among Caucasians,
31% compared with 14% in African American and
16% in Hispanic recipients.
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General issues regarding management of the pediatric transplant
patient ...