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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.

Recipient Characteristics

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.

Type of Transplant

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.

Preemptive Transplant

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.

General issues regarding management of the pediatric transplant patient ...

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