IMMUNOLOGICAL AND PATIENT SELECTION-STRATEGIES FOR SUCCESSFUL UTILIZATION OF LESS-THAN 15 KG PEDIATRIC DONOR KIDNEYS - LONG-TERM EXPERIENCES WITH 40 TRANSPLANTS

Renal transplantation using infant donors is associated with significa ntly less graft survival (GS) and increased morbidity, especially from very young and small donors. We report our results using specific str ategies to determine which age and size donor require en bloc renal tr ansplant reconstruction and associated immunologic protocols for optim ization of subsequent GS. Forty cadaveric pediatric en bloc renal tran splants were performed. Mean donor age was 23.6+/-18.4 months with sub groups: 2-12 months, n=14; 13-24 months, n=19; and 25-60 months, n=7. Mean donor weight was 14.4+/-4.5 kg. All kidneys were placed in primar y, nonsensitized (peak PRA = 7.9+/-5.6%) adult (41.6+/-16 years) recip ients. Low weight was preferred (62.4+/-12.8 kg). Mean cold ischemia t ime was 26.9+/-8.6 hr. Immunosuppression consisted of quadruple immuno suppression (QI) with OKT3 induction. All patients had ureteral stents placed intraoperatively. Mean follow-up was 16.9 months. Actuarial GS at 12, 24, and 33 months were 100% (n=13), 85% (n=20), and 71% (n=7), respectively. Total GS was 35/40=88%. All grafts functioned immediate ly and there were no technical losses. Biopsy proven rejections occurr ed in 12 (30%) patients, developing at 16-167 days postoperatively (me an = 50.3 days). Mean serum creatinine at one week and 1, 6, 12, and 1 8 months were 2.1+/-2.0, 1.5+/-0.8, 1.3+/-0.5, 1.1+/-0.4, and 0.9+/-0. 4 mg/dl, respectively. Functional isotopic renography, as well as sono graphic monitoring reflected rapid initial and continued growth in the se kidneys. Mean BP at 12 and 24 months postoperatively were 145/83+/- 18/13 and 122/76+/-20/10 mmHg, respectively, with no significant prote inuria noted. Excellent results with minimal complications utilizing v ery small and young infant donors can be achieved with QI immunosuppre ssion, and selection of low immune reactive and noncomplicated adult r ecipients. Additionally, maximal renal dosing by minimizing recipient weight may prevent future hyperfiltration damage.