Live donor kidney transplantation in children - invaluable by virtue of necessity

Renal transplantation is the treatment of choice for paediatric patients wi th end-stage renal failure. Living donor transplantation (LDT) has become a n important therapeutic option due to the shortage of cadaver donors and in creasingly long waiting times. Methods: Between 1992 and 1999, a total of 48 paediatric and adolescent pat ients underwent renal transplantation in Zurich. Of these, 21 patients (44% ) received a kidney from a living related donor. 11 patients had been dialy sed before LDT over a period of 0.2-5.7 years (median 0.6), and 10 were tra nsplanted preemptively. Triple immunosuppression consisted of cyclosporine A, azathioprine or mycophenolate mofetil (MMF; since 1998), and prednisone. The observation period was 0.5-7.3 years (median 2). Results: Recipients were 2-18 (median 10.5) years old at transplantation. O ne third had either a congenital malformation, an inherited disease, or an acquired disorder. One patient died of an associated cardiac disease at 4 m onths with functioning graft, and one functional graft loss occurred after 2.8 years. 9 patients were switched from cyclosporine to tacrolimus, 7 for biopsy-proven rejection and 2 for cosmetic reasons (hypertrichosis). No ant ibody preparations were used. Median glomerular filtration rate (Cr-51-EDTA ), measured after one year in 11 donor/recipients, was 64 (55-95) and 54 (3 2-82) ml/min/1.73 m(2), respectively. The most recent estimated renal funct ion (Schwartz formula) of 19 functioning grafts was 37-79 ml/min/1.73 m2 (m edian 63). Median body height of 16 patients with no associated extrarenal disease was -0.9 SDS (standard deviation score); the remaining 3 with serio us extra-renal disease - were considerably growth retarded. Main complicati ons were reversible rejection episodes in 19 (90%), arterial hypertension ( 16), CMV disease (2) and asymptomatic CMV infection (3), pyelonephritis (3) , and recurrence of the primary renal disease, seizures, diabetes mellitus and non-compliance (one each). Actuarial patient and graft survival (Kaplan -Meier) after 3 years was 95 and 83% respectively. This was not statistical ly different from the cadaveric donor group (n = 27) with 100 and 80% survi val respectively. Overall rehabilitation was excellent. The donors were 12 mothers, 8 fathers and one grandmother aged 31 to 50 (median 39) years; non e of them experienced serious postoperative problems. Conclusions: The paediatric transplantation programme would no longer be fe asible in Switzerland without LDT The results are very encouraging; preempt ive transplantation makes it possible to avoid dialysis in half of the pati ents. The risk for the donor is small, and careful evaluation without putti ng pressure on the family is essential.