IMPROVING RESULTS OF PEDIATRIC RENAL-TRANSPLANTATION

BACKGROUND: Outcome after renal transplantation in children has been v ariable. We undertook a retrospective study of our experience over the past five years. STUDY DESIGN: From January 1, 1988, to October 15, 1 992, 60 renal transplantations were performed upon 59 children at the Children's Hospital of Pittsburgh. Twenty-eight (47 percent) of the ki dneys were from cadaveric donors, and 32 (53 percent) were from living donors. The recipients ranged in age from 0.8 to 17.4 years, with a m ean of 9.8 +/- 4.8 years. Forty-six (77 percent) recipients were under going a first transplant, while 14 (23 percent) received a second or t hird transplant. Fight (13 percent) of the patients were sensitized, w ith a panel reactive antibody of more than 40 percent. Eleven of the 1 4 patients undergoing retransplantation and seven of the eight patient s who were sensitized received kidneys from cadaveric donors. Thirty-t hree (55 percent) patients received cyclosporine-based immunosuppressi on, and 27 (45 percent) received FK506 as the primary immunosuppressiv e agent. RESULTS: The median follow-up period was 36 months, with a ra nge of six to 63 months. The one- and four-year actuarial patient surv ival rate was 100 and 98 percent. The one- and four-year actuarial gra ft survival rate was 98 and 83 percent. For living donor recipients, t he one- and four-year actuarial patient survival rate was 100 and 100 percent; for cadaveric recipients, it was 100 and 96 percent. Correspo nding one- and four-year actuarial graft survival rates were 100 and 9 5 percent for the living donor recipients and 96 and 69 percent for th e cadaveric recipients. Patients on cyclosporine had a one- and four-y ear patient survival rate of 100 and 97 percent, and patients on FK506 had a one- and three-year patient survival rate of 100 and 100 percen t. Corresponding one- and four-year actuarial graft survival rates wer e 100 and 85 percent in the cyclosporine group, while one- and three-y ear actuarial graft survival rates were 96 and 84 percent in the FK506 group. The mean serum creatinine level was 1.24 +/- 0.64 mg per dL; t he blood urea nitrogen level was 26 +/- 13 mg per dl;. The incidence o f rejection was 47 percent; 75 percent of the rejections were steroid- responsive. The incidence of cytomegalovirus was 10 percent. The incid ence of post-transplant lymphoproliferative disorder was 8 percent. No ne of the patients on cyclosporine were able to be taken off prednison e; 56 percent of the patients receiving FK506 were taken off prednison e successfully. Early growth and development data suggest that the pat ients receiving FK506 off prednisone had significant gains in growth. CONCLUSIONS: These results support the idea that renal transplantation is a successful therapy for endstage renal disease in children. They also illustrate the potential benefits of a new immunosuppressive agen t, FK506.