Abstract
Renal transplantation (RT) is the optimal form of renal replacement therapy for children with end-stage renal disease (ESRD). Although in the previous textbooks and reviews there were several contra-indications to RT, most of which have been resolved to date. We discuss the contra-indications to pediatric RT and delineate the indications of RT through the recent literatures and our experiences.
Absolute contra-indications to RT include only uncurable malignacy and chronic HIV infection because the risk of immunosuppressive therapy definitely outweighs the benefits of RT in these cases.
Relative contra-indications include chronic infection of hepatitis B and hepatitis C virus, ABO blood type incompatibility, positive T cell crossmatch, mental retardation, the primary disease of focal segmental glomerulosclerosis and primary oxalosis, severe lower urinary dysfunction, severe cardiac dysfunction, and small children. However, recent advance in the pre-, intra- and post-operative treatment enables us to expand RT previously regarded as contraindication.
RT for patients with the primary disease of focal segmental glomerulosclerosis and primary oxalosis was a matter awaiting solution. In primary oxalosis, combined liver and renal transplantation may be a better solution to date. In recurrent focal segmental glomerulosclerosis, early use of plasmaphresis leads to prolonged allograft survival and prophylactic plasmaphresis reduces the incidence of recurrence. Successful RT across ABO barrier is possible with adequate pre- and post-transplant management and may be established as a standard procedure in Japan to settle a shortage of cadaveric allografts. The cardiac performance of an uremic patient is one of the most important determinant influencing the decision of putting on the waiting list. Nevertheless, RT itself eliminates several factors of cardiotoxicity and subsequently improves cardiac function. The recipients with hepatitis B and C infection have an increased risk of hepatic cirrhosis and hepatocellular carcinoma and interferon therapy after RT is contraindicated because of the high risk of triggering acute rejection. Therefore, sufficient treatment for hepatitis is required before RT.
According to a report from the NAPRTCS registry, the age under 2 years of the recipients was a significant risk factor for decreased graft survival because of kinking of redundant donor vessels and subsequent vascular thrombosis. Therefore, most of centers wait until children with ESRD grow enough to be recipients. Recently, a few leading centers attempted to perform RT from living donors for small pediatric children. RT may be successfully performed in children with ESRD caused by severe lower urinary tract dysfunction by making a practice of good urinary drainage using clean intermittent catheterization and augmentation cystoplasty prior to RT.
Many efforts to rescue children with ESRD by many pediatric nephrologists and transplant surgeons have resulted in remarkable accomplishments in pediatric RT.
