Pediatric Renal Transplantation

A second lease of life for children with End Stage Renal Disease

Kidney transplantation is considered the treatment of choice for end stage renal disease (ESRD) in children, as it provides a much better quality of life, productivity, growth and longer patient survival than what can be achieved with any modality of dialysis. Graft survival has improved significantly in recent years, mainly due to improved immunosuppressive strategies.

Chronic Kidney Disease (CKD) in children

There are distinct geographic differences in the reported causes of CKD in children ; this is due to environmental, racial, genetic, and cultural (consanguinity) differences. A substantial proportion of children who develop CKD early in life have congenital anomalies of the kidney and urinary tract - obstructive uropathy , aplasia, hypoplasia, or dysplasia of kidneys . Although the best treatment modality for ESRD in children is renal transplantation, lack of high quality health care resources and expertise in many countries limits the widespread use of renal transplantation in young children.

Although the number of children with ESRD in need for renal transplantation is small compared with adults, the problem associated with renal transplant in children are numerous and varied. Children and adolescents with ESRD would be able to achieve normal growth, normal cognitive and psychological development following successful kidney transplantation..

Preemptive Transplantation

Preemptive transplantation (PET), which denotes transplantation prior to the initiation of dialysis, has recently been growing in popularity, as it is postulated that transplanting children before they develop symptoms of severe uremia avoids many of the associated long -term complications of ESRD and dialysis. Avoiding dialysis and all its hazards is one of the most important advantages of PET. Dialysis is regarded by most children and parents, as an inconvenient experience requiring frequent hospital visits for hemodialysis and frequent dialysate exchanges for peritoneal dialysis. Therefore, PET provides a better option for the prevention of short stature with all its co-morbidity and psychosocial implications. As most of the effects on cognitive development are related to uremia, it is postulated that PET will have further favorable effect over transplantation after a period of dialysis. Moreover, PET is also more cost effective. Therefore, decreasing the period on dialysis or even avoiding dialysis altogether whenever appropriate, has a significant effect on the cost of care in children with ESRD.

Types of Kidney Transplantation in Children

Deceased donor transplantation – The child can get a kidney from a healthy person who has suffered a brain death. To obtain a deceased donor kidney, the child must be registered with the Kerala Network for Organ Sharing (KNOS) and be on the waiting list.
Living donor renal transplantation - A healthy relative can donate one of his/her kidneys to the child. Donors for children are often their parents, siblings, or grandparents. Parents of a child with kidney disease are usually the best donors, because they often have the same blood group and are a good tissue match with the recipient.
Immunosuppression

Steroid free regimens may be tried in children to avoid steroid related adverse effects, especially related to growth and mineral metabolism. The other drugs used are similar to adult transplantation, namely Tacrolimus and Mycophenolate Mofetil.

Renal Allograft Survival

Renal allograft survival in children has improved substantially over the last two decades, with several large registry studies from abroad reporting graft survival approaching 80% at three years and 75% at five years. Renal allograft survival in infants is now similar to that in older children, and short term deceased donor allograft survival in children now approaches that of living donation.

Conclusion

Transplantation is currently the best option for children with ESRD. Surgery and modern immunosuppression have demonstrated excellent results, provided the children are managed in a center with experience in the management of all aspects of pediatric renal transplantation.

The Kidney transplant Unit at Aster Medcity has successfully done 30 paediatric transplantations . This includes very small children (aged 2 years and weighing around 10 kilograms) and children with complex urinary tract anomalies. Robot assisted kidney transplants in children are done at our institution with outstanding results. The graft survival in children after kidney transplantation at our centre has been 98% at the end of three years. This has been possible because of the surgical expertise at our centre, experienced Anaesthesiology and Nephrology teams at Aster Medcity ,which has an excellent infrastructure for health care.

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