Introduction to paediatric renal
transplantation
Martin Christian
Consultant Paediatric Nephrologist,
Nottingham Children’s Hospital
Benefits of transplantation
• Minimise disruption to family, school and
social life
• Facilitate physical and emotional growth
and development
• Improved survival
• Cost-effective
Consequences of a transplant
• Lifelong immunosuppression
• Expected lifespan of a transplant kidney
• Early complications
Preparation for a transplant
• Trends in eGFR
• Home visit
• CKD day
• Tests
• Transplant surgeon
Pre-emptive transplantation
• Misses out dialysis step
• Better outcomes?
• Timing of transplant
• Not suitable for all
Source of Organs
Deceased donors
• Donation after brain
death (DBD) donors
• Donation after
circulatory death
(DCD) donors
Living donors
• Usually living related
from parent or other
close family member
What is the demand for organs?
Data from NHSBT ODT
What is the supply of organs?
0
200
400
600
800
1000
1200
01/0202/0303/0404/0505/0606/0707/0808/0909/1010/11
DBDdonors
DCDdonors
Livedonors
Data from NHSBT ODT
National trends
Donor types
• More living donors
• DBD donors are older with more co-
existing conditions
• More DCD donors
Deceased and living paediatric
kidney only transplants
109101
139
110
128
96
114
85
10493
100
81 8374 71 71
6374
6269
5
1
1
1
2
1
1
1
1
2
1
2
10 13
11
22
19
26
19
25
31
33
34
4446
44 4651
50
64
64
68
0
20
40
60
80
100
120
140
160
1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Living
DCD
DBD
Nu
mb
er
of tr
an
sp
lants
Year of graft
Paediatric KAG NHSBT
Waiting times of deceased
paediatric kidney only transplants
0
100
200
300
400
500
600
700
800
900
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Q1
Median
Q3
Wa
itin
g tim
e (
da
ys)
Year of graft
Paediatric KAG NHSBT
% g
raft
su
rviv
al
0
10
20
30
40
50
60
70
80
90
100
years post-transplant0 5 10 15 20
Graft survival following first DBD
paediatric kidney only transplant
2006-2010 1yr survival 95% (92-97) N=308
2001-2005 5yr survival 81% (77-85) N=360
1996-2000 10yr survival 63% (58-68) N=411
1991-1995 15yr survival 45% (41-50) N=488
1986-1990 20yr survival 27% (23-31) N=442
p<0.0001
Paediatric KAG NHSBT
Graft survival following first DBD
paediatric kidney only transplant excluding failures within the first year
% g
raft
su
rviv
al
0
10
20
30
40
50
60
70
80
90
100
years post-transplant0 5 10 15 20
2001-2005 5yr survival 88% (84-91) N=328
1996-2000 10yr survival 73% (68-78) N=345
1991-1995 15yr survival 55% (50-60) N=392
1986-1990 20yr survival 38% (32-44) N=310
p<0.01
p=0.5 (1991 – 2005)
Paediatric KAG NHSBT
Graft survival following first living
paediatric kidney only transplant excluding failures within the first year
% g
raft
su
rviv
al
0
10
20
30
40
50
60
70
80
90
100
years post-transplant0 5 10 15 20
2001-2005 5yr survival 95% (90-97) N=173
1996-2000 10yr survival 78.0% (68-85) N=107
1991-1995 15yr survival 49% (34-62) N=60
1986-1990 20yr survival 37% (22-53) N=42
p=0.009
Paediatric KAG NHSBT
Life after transplant is a rollercoaster
Adolescents have the highest
rate of transplant loss
• Teenage brain
• Autonomy versus
responsibility
• Psychosocial and youth
work support
% g
raft
su
rviv
al
0
10
20
30
40
50
60
70
80
90
100
years post-transplant0 5 10 15 20
% g
raft
su
rviv
al
0
10
20
30
40
50
60
70
80
90
100
years post-transplant0 5 10 15 20
% g
raft
su
rviv
al
0
10
20
30
40
50
60
70
80
90
100
years post-transplant0 5 10 15 20
Graft survival following first DBD
paediatric kidney only transplant
<6 years 6-11 years 12-17 years
Paediatric KAG NHSBT
Transplant options - previously
Suitable
directed
donor
Deceased
donor list
Paired
donation
ABOi or
HLAi
Transplant
No No
Yes Yes Yes
Non-directed
(altruistic) donor
Transplant options - now
Suitable
directed
donor
Deceased
donor list
Paired
donation
ABOi or
HLAi
Transplant
No No
Yes Yes Yes
Non-directed
(altruistic) donor
Non-directed altruistic donation
• Individual donates a
kidney after medical/
psychological testing
• Allocated according
to national allocation
guidelines – those
<18yrs will get
preference
Deceased donor
DBD donor
• Fewer standard donors
• Extended criteria donor – higher risk donor (increased risk to organ and/or recipient)
• Use of both kidneys: En-bloc (suitable for donors 18m-5yrs); or dual (suitable for elderly donors)
DCD donor
• Long term outcomes for kidney equivalent to standard DBD donor, but 50% incidence of kidney initially slow to function
Implications
• Recognise that all transplants come with
some risks – as does dialysis
• Paediatric recipients get priority in national
allocation scheme and don’t give offered
kidneys from donors >50yrs
• Kidneys from DCD donors may be slow to
function initially and may prolong hospital
stay
• Every August
• Adults and children
• Charitable support to attend
• www.transplantsport.org.uk
Transplant Games
• www.emeesykidney.nhs.uk
• www.infokid.org.uk
• www.nhsbt.nhs.uk
Sources of information
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