Transplantation of adult living donor kidneys into infants and small children

Hypothesis: We hypothesized that improved outcomes following renal transpla ntation in high-risk infants and small children primarily are due to advanc es in immunosuppression and accurate diagnosis of rejection. Optimizing ren al allograft perfusion is critical to achieving good early graft function a nd decreasing early graft loss. Design: Twenty-eight consecutive recipients (weighing <20 kg) of adult livi ng donor kidneys transplanted at our center from 1984 to 1999 were reviewed . Two groups were identified based on differing immunosuppression protocols and clinical surveillance. Actuarial graft and patient survival reported a t 1, 3, and 5 years were compared for group 1 (1984-1991) and group 2 (1992 -1999). Graft losses, categorized as immunologic or nonimmunologic, and the incidences of delayed graft function, vascular thrombosis, and rejection w ere compared. Results: Graft and patient survival in group 1 (n=13) at i, 3, and 5 years was 77% and 92%, 54% and 85%, and 54% and 85%, respectively. In group 2, al l 15 patients are alive with functioning grafts to date. Immunologic graft loss occurred in 5 of 13 patients in group 1 who developed chronic rejectio n. Nonimmunologic causes (vascular thrombosis [2 patients]) and patient dea th [1]) resulted in early graft failure within 2 weeks in 3 of 13 patients in group 1. The overall incidences of delayed graft function (10.7%) and th rombosis (7.1%) were low and did not differ between groups. Percutaneous re nal biopsy was used more frequently in group 2 to evaluate graft dysfunctio n and guide treatment. Conclusions: We conclude that improved overall graft and patient survival i n group 2 is owing to advances in immunosuppression and better treatment of rejection. Percutaneous renal biopsy allows prompt and accurate histologic al diagnosis of graft dysfunction. Surgical technique and aggressive fluid management aimed at maximizing renal allograft perfusion is critical in opt imizing early graft function and decreasing vascular complications.