Indian Pediatrics 2001; 38: 1171-1173
Pre-emptive Kidney Transplant: A Rational Therapeutic Approach
Pre-emptive kidney transplant (PKT) is now considered by most nephrologists as a safe and cost effective procedure and associated with better survival, especially in children(1-4). Also dialysis, especially hemodialysis, is technically more difficult to perform in the pediatric age group. In developing countries like ours where facilities for dialysis are not only scarce but also expensive, PKT is of special relevance. Despite these facts, PKT remains uncommon in children. We describe here a 14-year-old boy who successfully underwent PKT.
A 14-year-male child, first presented to us in June 1997 with complaints of swelling over feet and face since one year along with increase in the frequency of micturition. He was investigated by the local physician, who detected proteinuria with urine albumin 4+ and 4 to 6 RBCs/HPF. He subsequently developed increased swelling all over body along with fever, anorexia and vomiting and was referred to us. At presentation, he was hypertensive and had moderate renal failure with serum creatinine of 3.9 mg/dl. An ultrasound was done which revealed unequal sized kidneys (RK 9 cm and LK 7.3 cm in length). A probable diagnosis of acute on chronic renal failure was entertained. In view of unequal kidney sizes and hypertension, renal angiography was done to investigate for renal artery stenosis which however was normal. A micturating cystourethrogram was also done which again did not reveal any vesicoureteric reflux. He was managed conservatively and inspite of strict control of blood pressure, his renal functions did not improve and serum creatinine stabilized at around 3.8 mg/dl (GFR 24 ml/min). Patient was kept on conservative management for CRF and regular follow up with close watch on his blood pressure and renal functions. Diuretics were used to manage edema and fluid over load. Over a period of 15 months, on conservative treatment, his GFR decreased from 24 ml/min to 14 ml/min and the serum creatinine increased to 7.2 mg/dl. Meanwhile his mother was identified as the prospec- tive donor and a premptive transplant was planned. A live related renal transplant was done on 29 October 98. Triple drug immuno-suppression was given which included azathioprine, prednisolone and cyclosporine. However, patient had biopsy proven acute vascular rejection on the 4th post operative day. Anti-rejection therapy using anti thymocyte globulin (2 mg/kg ATG ´ 4 doses) was given and the patient responded. His renal functions normalized and patient was discharged. At the time of discharge his serum creatinine was 1 mg/dl. Presently, the patient is on regular follow up and is doing well (35 months post transplant) and has resumed attending his school regularly.
We present this case as a successful preemptive kidney transplant in a 14 year male child. PKT, i.e., renal transplant without or at most 1 week of prior dialysis treatment has caused controversy in past. The main arguments against this procedure are: (i) Fluid overload and uremia in non dialyzed patients could impair the immediate outcome of renal transplant, (ii) Patient who had never undergone dialysis before transplant would be less compliant after transplant, and (iii) a higher rate of acute rejection partly due to absence of immunosuppressive effect of uremic state(1-4).
However, recent studies have shown that successful renal transplantation is optimal treatment for children with ESRD and that it should be performed as early as possible(2). OKT is one way of achieving this goal because it keeps uremic period as short as possible minimizing the adverse effect of uremia especially malnutrition. Pre-emptive transplantation signifies the use of trans-plantation as a primary renal replacement therapy in the absence of any (or at most 1 week) of pre-operative dialysis. Patients require dialysis once GFR falls to 5-10 ml/min. Thus we have to follow the patient’s creatinine clearance and symptomatology and it is advisable the pre-emptive transplant may be undertaken when patients begins to have the initial uremic symptoms and/or the GFR falls to a value of below 15-20 ml/min.
Studies have shown that PKT is associated with equal or even better graft and patient survival(4). Furthermore, it was shown by Offner et al. that not only survival rates of patients and grafts but also functional para-meters, renal function, bone disease, anemia, hypertension and growth rates yielded better functional values in PKT group(2). It has also been shown, as a consequence of the improved results with PKT, 20% fewer transplant recipients would undergo long term graft failure and would require retransplant as compared to patients who received dialysis followed by transplant. This would help in cutting down the waiting lists for trans-plants(4). In the 1995 Annual Report of the North American Pediatric Renal Transplant Cooperative Study, accounted for 24.4% of all pediatric transplants(5). In our country, 43 preemptive transplants were conducted at CMC Vellore over a period ranging from 1989-1996. Out of these, only 3 recipients (7%) were below 16 years(6). In another large series of pediatric transplants from our country, 22% were pre-emptive(7). At our own center there have been a total of 22 transplants below 18 years in last 10 years and this particular case was the first PKT(4,5). Thus PKT as a primary approach to ESRD remains uncommon in children.
Kidney transplants remain uncomon in children in our country(8,9). The reasons are manifold – delayed diagnosis, paucity of centers with expertise in pediatric dialysis and above all economic constraints. The outcome of such transplants also is inferior compared to western data as these patients are often referred late and have many complications of uremia including malnutrition. PKT is of special relevance to our country not only because of paucity of dialysis centers but also because it is a more economical alternative in view of cost saving due to non-requirement of dialysis(6). In a study it was found that PKT was 20-30% more economical is compared to routine procedure of dialysis and transplanta-tion(1). Moreover, the child is also much better preserved and is preempted from developing complications of uremia by an early transplant. Despite these advantages, PKT in children remains uncommon. The predominant reason is the lack of awareness amongst the patients as well as their treating physicians. Moreover, most of the times a diagnosis of chronic renal failure is made only once the child has become severely uremic and reached end stage renal disease(9). Early diagnosis and prompt referral to pediatric nephrology centres with appropriate expertise is crucial for the success of this approach.
AM and SG were involved in the pre- and post-transplant care and
preparation of the manuscript. AK was the transplant surgeon. RK and AK
critically reviewed the manuscript. SG will act as the guarantor for the