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PEDIATRIC RENAL TRANSPLANTATION

Department of Anaesthesia, The Hospital For Sick Children, 555 University Avenue, Toronto M5G 1X8, Ontario, Canada.

INTRODUCTION

Renal transplantation is the treatment of choice for children with end stage renal failure. The results of pediatric renal transplantation are inferior to those in adults due to the higher incidence of acute tubular necrosis and graft loss from vascular thrombosis and primary nonfunction. Infants are at highest risk for graft loss and mortality of any group undergoing renal transplantation^{1, 2}. The aim of this study was to assess the incidence and predisposing factors of graft failure and to define optimal anesthetic management for pediatric renal transplantation.

METHODS

After Institutional Review Board approval, 34 patients who underwent renal transplantation at our institution between January 2001 and August 2003 were reviewed retrospectively.

RESULTS

The mean age and weight of the 34 patients at transplantation were 11 years and 36 kg respectively. The etiology of renal failure was obstructive uropathy (13), glomerulonephritis (10), renal dysplasia (4) and others (7). Live-donor grafts were used in 56% of patients, 35% received a cadaveric adult kidney and 9% received a cadaveric pediatric kidney. Crystalloids, 5 % Albumin or packed red cells were given at 22–55 mls/kg (mean= 53 mls/kg) to maintain intravascular volume and achieve a CVP of 11–19 mmHg (mean= 14 mmHg) prior to release of aortic and caval cross clamps. Mannitol (0.5 – 1.0g/kg) and furosemide (1mg/kg) were also given intravenously prior to release of cross-clamps to ensure a brisk diuresis. Venous thromboses occurred in two living related recipients (weight < 20 kg) resulting in early graft loss.

DISCUSSION

Anesthetic, surgical, and immunological advancements have contributed to improved pediatric renal transplantation graft survival. The 2 cases of early graft loss were both the result of venous thrombosis, a known risk factor in smaller renal transplant recipients². Recent studies have suggested a correlation between perioperative donor kidney ischemia and increased graft immunogenic activation, making donor grafts with prolonged ischemia more vulnerable to host immune attack ³. Our results demonstrate a trend towards attaining supraphysiologic intravascular volume at time of donor kidney revascularization and successfully minimizing graft ischemia. Aggressive perioperative fluid administration to attain supraphysiologic vascular volume is recommended to improve graft survival in pediatric renal transplantation patients.

REFERENCES

1 Salvatierra O et al. Transplantation, 66: 819, 1998.[Medline]

2 Sarwal M et al. Transplantation, 70:1728, 2000.[Medline]

3 Tilney et al. Transplantation, 64: 945, 1997.[Medline]

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