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Successful paediatric en bloc renal transplant into a 15 year-old child: a tale of two kidneys
  1. HE Jones1,
  2. M Drage2,
  3. G Koffman2,
  4. SD Marks1
  1. 1Paediatric Nephrology Department, Great Ormond Street Hospital for Children, London, UK
  2. 2Department of Renal Transplant Surgery, Guys' Hospital, London, UK

Abstract

Aims We report a case and follow-up data of a 15 year-old black African female who presented with end stage renal disease secondary to dysplasia aged 13 years and subsequently received an en-bloc renal transplant two years later.

Methods A retrospective case-note and laboratory results review was performed, including clinical assessment, post-transplantation complications, results and renal growth.

Results The recipient (15 year, weight 55 Kg, CMV and EBV positive) received an en bloc donation after cardiac death (DCD) transplant (HLA mismatch 111) from a 23 month old who'd suffered an intra-cerebral bleed. The kidneys were transplanted into the right iliac fossa, the donor aorta and vena cava being anastomosed onto the common iliac artery and vein, with the ureters connected to the bladder with ureteric stents in-situ. Prophylactic anticoagulation with subcutaneous heparin was given for two weeks. There were no surgical complications and no delayed primary function (creatinine falling to 110 umol/L by day 6).

Initial immunosuppression was prednisolone, azathioprine and tacrolimus. On day 11 new-onset diabetes after transplant was diagnosed. She commenced insulin. Prednisone was weaned more rapidly, tacrolimus stopped and ciclosporin A introduced. By 6 weeks follow-up the creatinine rose above its baseline of 100 umol/L to 178 umol/L. A renal biopsy revealed grade 1b acute T cell mediated rejection, treated with methylprednisolone and mycophenolate mofetil. Despite a fall in the creatinine back to baseline it increased again at 2 months with a concurrent renal biopsy showed no significant rejection. To date her creatinine has remained stable since though due to side effects of ciclosporin, she restarted tacrolimus with good diabetic control.

During the follow-up period, serial ultrasounds have shown progressive renal growth with the superiorly positioned kidney increasing in length from 73 to 92 mm and the inferiorly positioned kidney increasing from 74 mm to 91 mm over three months. A DMSA scan showed no evidence of focal scarring in either kidney.

Conclusions At three-month follow-up despite the complications of a rejection episode and developing diabetes, the recipient is well, normotensive without proteinuria, viral loads for CMV, EBV and BK virus remain undetected and she has an eGFR of 55 ml/min/1.73 m2. Her transplant kidneys continue to demonstrate linear growth.

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