OUTCOME OF EN-BLOC AND SINGLE KIDNEY-TRANSPLANTATION FROM VERY YOUNG CADAVERIC DONORS

Background. The optimal use of very young cadaveric kidneys (from dono rs less than 4 years old) remains controversial. High rates of technic al complications and poor functional results compared with adult donor kidneys have been reported. The use of en bloc transplantation to ove rcome these problems has been advocated, although en bloc transplantat ion halves the number of potential transplants from very young donors. Methods. We studied the technical and functional results of 91 transp lants from very young donors performed at our institution between 1984 and 1995. This included 59 single and 22 en bloc procedures involving first transplants and 7 single and 3 en bloc procedures involving ret ransplantation. Individual surgeon preference dictated the use of eith er the single or en bloc technique. Kidneys smaller than 6 cm tended t o be transplanted en bloc, and lighter patients were generally given p reference for receiving pediatric kidneys. Patients received sequentia l cyclosporine-based quadruple immunosuppression. Results. En bloc kid neys had a 1-year and 5-year graft survival of 82% and 70%, respective ly. Single kidneys had a 1-year and 5-year graft survival of 64% and 4 0%. Kidneys that avoided acute rejection episodes and that were transp lanted into heavier or male recipients had better long-term survival. Kidneys from donors less than 2 years old did poorly whether transplan ted en bloc or singly. Better HLA matching improved short-term, but no t long-term, graft survival, whereas cold ischemic time did not have s tatistically significant association with differences in graft surviva l. Eleven percent of the transplants had ureteral leaks, but only one kidney was lost. Ten transplants had vascular complications leading to graft loss, whereas two episodes of arterial stenosis were successful ly treated with percutaneous angioplasty. Conclusions. En bloc transpl antation optimizes the outcome of transplantation with very young kidn eys. We recommend induction therapy and cyclosporine immunosuppression with cyclosporine levels similar to adult target levels to minimize r ejection episodes and, thus, improve outcome. These kidneys should be distributed nationally, because better HLA matching is associated with improved short-term graft survival. Our high ureteral leak rate indic ates that alternatives to unstented ureteroneocystostomy should be con sidered.