Hanan Fathy

One year old child 6 Kg

Performing hemodialysis.
It is not Easy to Get Along that Early
without Kidneys
Because children are constantly
growing and developing
technical, metabolic,
immunologic, and psychological
factors exist that are unique to
children having kidney
transplantation, and must be
considered.
♣Aplastic, hypoplastic, or dysplastic
kidneys
♣Obstructive uropathy
♣Reflux nephropathy
♣Focal segmental glomerulosclerosis
♣Systemic immunological disease
♣Chronic glomerulonephritis
♣Hemolytic uremic syndrome
♣Polycystic kidney disease

♣Congenital nephrotic syndrome

♣Medullary cystic disease

♣MPGN Type II
♣MPGN Type I
♣OTHER DISEASES
♣Diabetic glomerulonephritis
♣Sickle cell nephropathy
♣Unknown
 •Long term out come.
•Side effects .
Some technical aspects.
•Immune suppression regimen.
Long term kidney allograft
survival.
•Renal allograft dysfunction.
•Non adherence to therapy.
•Infections.
•Growth retardation.
• Growth retardation is common in children
and adolescents with chronic kidney disease
(CKD).

• The etiology is multifactorial and includes:

♣ malnutrition due to uremic anorexia,
♣ acidosis, alterations in calcium and phosphate
metabolism,
♣ and alteration in the growth hormone-insulin-
like growth factor axis
• One of the goals of successful pediatric renal
transplantation is the attainment of optimal
final adult height.

• Although height standard deviation scores of

pediatric renal transplant recipients have
steadily improved over the past 2 decades,
growth in many children despite targeted
therapeutic efforts remains suboptimal after
transplantation
• Several factors have been shown to affect the
growth rates of children after renal
transplantation, but the most important are
♠ Age at time of transplantation,
♠ Allograft function,
♠ And corticosteroid therapy.

Age: younger recipients exhibit

the greatest immediate catch-up growth
Corticosteroids:
; catch-up growth occurs primarily
Graft
are inknown function:
to adversely elevated
affect SCr concentration
growth in children
recipients < 6 years of age at transplantation
and decreased GFR have been correlated with
a reduction in height and growth velocity.
• Infection now exceeds rejection as a cause
of hospitalization of pediatric renal
transplant recipients in the first 2 years
post-transplantation.

• The youngest children (aged 0-1 years) at

time of transplantation had significantly
higher rates of infection requiring
hospitalization , for bacterial and viral
infection compared with children > 12
years
• Infection-related hospitalization rates were
highest for pediatric kidney transplant
recipients.

• Urinary tract infection (UTI) is a major cause

of morbidity .

• graft function deteriorated at a significantly

faster rate in patients with recurrent UTIs than
in those without recurrent UTIs at 4 years
post-transplantation
• Adolescents have the highest rate of 1-year
graft survival of any age group, but long-term
transplant outcomes in this age group are
disappointing.

• The most important challenge to long-term

survival in children following transplantation
is the management of non adherence and
other adolescent issues.

• A major cause of late graft failure in

adolescents is medication noncompliance.
Medication noncompliance has been shown
to be more than 4 times greater in adolescents
than in adults.
• Important milestones during the transition from
childhood to adulthood include:
Becoming autonomous and eventually fully
independent.

• But almost paradoxically the cognitive skills

and intellectual maturation of adolescents are
limited, particularly in those with chronic
diseases .

• Adolescents struggle with abstract thinking,

including conceptualization of future
consequences of present actions, which leads to
risk-taking behaviors, including non adherence
with medications.
• As a group, the immunosuppressive
agents used to prevent acute rejection
and preserve kidney function in renal

side effects

 Alter physical appearance,

 Cause serious mental and psychosocial
problems,
 Compromise quality of life
• Corticosteroids
• CSA
• TAC
Gingival overgrowth in a transplant recipient taking CSA.
The accumulation of collagen seen in gingival overgrowth,
thought to occur as a result of CSA-induced inhibition of
collagenolytic activity within the gingival tissues, is disfiguring
and contributes to periodontal disease.
• Medication noncompliance is a leading cause
of morbidity in pediatric transplant recipients.

• Stopping or markedly under dosing

immunosuppression even once for an
extended period of time may allow the
irreversible process of chronic rejection to
begin.

• Once this process begins, even if compliance

is perfect thereafter, the process is not likely
to be reversible
• Although the age group most commonly
associated with increased risk for graft failure
is infancy, a less recognized high-risk age
group is adolescence.

• Adolescents also had a significantly higher

percentage of late acute rejection episodes
and a lower rate of rejection reversal
compared with other age groups.
• There are many causes of renal dysfunction in
pediatric renal transplant recipients. Likewise, the
allograft can undergo a variety of morphologic
changes during the progression from injury to
dysfunction.

Acute antibody-mediated and cell-

mediated rejection,
Drug toxicity from CNIs,
Chronic allograft nephropathy (CAN),
Viral infection,
 And post-transplant
lymphoproliferative disease are
• Although short-term kidney allograft survival
rates have improved dramatically, long-term
survival has not kept pace due to the nearly
universal development of CAN.

• Chronic allograft nephropathy (CAN) is

irreversible and is the single most important
factor for allograft dysfunction and loss in
children.
 Chronic allograft nephropathty

10 years

Immunologic
Nonimmunologic

eg, reperfusion injury,

eg, rejection increased ureteral pressure,
, inadequate immunosuppression, hypertension,
viral infection hyperfiltration,
ischemia,
proteinuria,
CNI toxicity
• Clinically, CAN is characterized by :

Ω Worsening renal function (slowly

progressive decrease in the GFR),
Ω De novo or aggravated hypertension,
Ω And worsening proteinuria .
• Reliance on SCr can underestimate the
severity and rate of decline in renal function,
particularly when the GFR is 30 to 70
mL/min (which is the case for most kidney
transplant recipients).

• Proteinuria (new-onset, > 0.5 g/24 h, or

worsening) should raise the suspicion of
CAN
 Investigators evaluated
transplant protocol biopsies
from 280 patients with stable SCr levels
and determined that

SCr
SCrand
andestimated
estimatedGFR
GFRareare
poor
poorpredictors
predictorsof
ofearly
early
histopathologic
histopathologicchanges
changesthat
that
precede
precedeCAN
CANin inrenal
renal
allograft
allograftbiopsies.
biopsies.
A renal allograft affected by chronic allograft nephropathy shows loss of
normal architecture with interstitial chronic inflammation, tubular atrophy,
glomerular collapse, and global sclerosis but without tubulitis or arteritis.
Renal
Renal function
function
within
within the
the first
first year
year
of
of transplantation
transplantation
was
was the
the most
most
important
important
predictor
predictor ofof kidney
kidney
graft
graft survival
survival
Although the occurrence of acute rejection is
the strongest predictor for the development of
chronic rejection.

1-year SCr and delta creatinine values, not

clinical acute rejection episodes, predicted
long-term renal graft survival.
• In the setting of acute rejection,
it is the preservation of renal function that
is more important for graft survival.

That recent improvements in graft half-life

can be attributed to better preservation of
renal function within the first year post-
transplantation
Conversion from a CSA-based to a TAC-based
immunosuppression regimen has been
associated with
• Stabilization of renal function, compared with a gradual
deterioration of graft function in patients who remained on CSA

• Sustained reduction in systolic and diastolic blood pressure

• Sustained improvement in serum lipid profile (total cholesterol,

LDL-C, and triglycerides)

• Reduced Framingham risk score

• Lower scores for distress related to side effects

RECURRENT RENAL DISEASE
Primary hyperoxaluria
IgA nephropathy
Membranous glomerulonephritis
Diabetes mellitus
Cystinosis
Amyloidosis
Focal segmental glomerulosclerosis
Alport’s, crescentic glomerulonephritis, vasculitis
Haemolytic uraemic syndrome
Systemic lupus erythematosus
Mesangiocapillary glomerulonephritis
 As pediatric recipients
are likely to require
re-transplantation during their lifetime,
every effort should be made
to minimize HLA mismatches
to reduce the risk of future sensitization
• The implantation of an adult kidney into a
paediatric recipient requires close cooperation
between the surgical and anaesthetic teams.

• Meticulous attention needs to be paid to the

child's intravascular volume status.

• When the aortic and inferior vena cava

clamps are released, the transplanted organ
and lower extremities fill with blood,
potentially resulting in severe hypovolaemia
unless adequate volume loading has taken
place.
 Fluids and electrolyte balance
• Careful monitoring and replacement of on-going
fluid loss is required, remembering that the urine
output from the adult kidney may be significant.

• In the early post-operative phase, particular

attention should be paid to fluid and electrolyte
balance because of the large volumes of urine that
can be passed.
 Fluids and electrolyte balance
• Urine output and insensible losses are replaced initially
with 2.5% glucose/0.45% saline, volume for volume on an
hourly basis.

• Plasma electrolytes are checked at 2-4 hourly intervals for

the first 12 to 24 hours and replacement fluids should be
adjusted according to these results.

• Central venous pressure (CVP) monitoring is mandatory

and the CVP should be maintained at 5-10cmH2O in the
spontaneously breathing patient, with intravenous normal
saline or by the administration of an alternative colloid to
correct hypovolaemia.