Expanding donor numbers for paediatric transplantation is an urgent, difficult issue. The use of non-heart-beating donor renal transplants has seen a revival in adult practice, with encouraging results. The authors present the first two cases in the UK of paediatric renal transplant from non-heart-beating donors.
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The global shortage of donated kidneys for transplantation has led to interest in the use of organs recovered from donors who have suffered cardiac death, so called non-heart-beating donors (NHBDs). UK Transplant has invested in programmes to recover organs from such donors, with some success: these organs accounted for almost 12% of all renal transplants in 2005–2006.1 However, these programmes have not influenced paediatric practice. We present here the UK's first cases of paediatric non-heart-beating (NHB) renal transplantation.
A boy aged 3 years, 3 months had end-stage renal failure secondary to renal dysplasia and posterior urethral valves. He was maintained on peritoneal dialysis and was oxygen dependent secondary to pulmonary hypoplasia.
Having been listed for transplantation at the age of 2 years, 9 months he was transplanted 5 months later, as no suitable organs from brain stem dead donors had been offered. At the time of transplant, he weighed 15 kg.
The donor was a 12-year-old patient with a fatal head injury. This was a NHBD, Maastricht category III (table 1), with withdrawal of treatment occurring in the intensive treatment unit. In situ perfusion and cooling was achieved by insertion of a catheter directly into the aorta at the time of retrieval. The total warm ischaemic time was 10 min and the cold ischaemic time 19 h 15 min. The kidney was a 1,1,1 human leucocyte antigen (HLA) mismatch. An extra-peritoneal transplant was performed, with anastomosis onto the external iliac vessels, by surgeons from the local transplant unit, who run a successful NHBD programme for adults.
Postoperatively, he received blood pressure support with dopamine for 7 days to maintain renal perfusion. There was delayed graft function with peritoneal dialysis being performed on day 4 after which there was improved urine output. He received low molecular weight heparin until fully mobile and aspirin for 3 months.
Initial immunosuppression consisted of basiliximab (an interleukin 2 receptor monoclonal antibody). Mycophenolate mofetil, prednisolone and tacrolimus were also used as per the regional policy, although the dose of the latter had to be altered due to delayed graft function.
He was discharged on day 14 and was no longer oxygen dependent.
He had one episode of biopsy proven acute rejection 4 months post-transplant, which was successfully treated with oral prednisolone.
On follow-up his creatinine levels have remained stable (creatinine 40–45 µmol/l) 18 months post-transplantation.
The second case was that of a 15-year-old boy with end-stage renal failure secondary to renal dysplasia with vesicoureteric reflux. He had been dialysis dependant since the age of 9. Age 11, he received a kidney from a brain stem dead donor that had failed after 3 days due to renal artery thrombosis. He had been on the waiting list for 4 years.
At the time of transplantation he was maintained on haemodialysis via a tunnelled line having previously had a failed fistula.
The donor was a 59 kg, 59-year-old female who had suffered a non-recoverable subarachnoid haemorrhage. This donor was managed surgically in the same manner as the first case. The warm ischaemic time was 18 min and the cold ischaemic time 16 h 12 min. The kidney was a 1,1,1 HLA mismatch and was transplanted in the same manner as the first. Intraoperative dopamine was required to maintain adequate blood pressure.
The graft functioned immediately, with a fall of creatinine from 900 to 275 μmol/litre over the first 48 h. He developed two episodes of suspected acute rejection that were successfully treated with steroids and anti-thymocyte globulin. One year post-transplant he is dialysis independent with a baseline creatinine of 150 µmol/litre.
Analysis of the UK Transplant activity reports since the establishment of programmes to retrieve organs from NHBDs demonstrates that these two cases are the first of their kind in the UK.1 This report highlights that in units with successful programmes of NHBD in adults, NHBD transplantation into paediatric recipients should be seriously considered (organs retrieved from units with NHBD programmes tend to stay in these units using local allocation protocols, rather than entering the national allocation scheme). The increased warm ischaemic time in NHB organs means that delayed graft function is far more common than when using organs from brain stem dead donors, so levels of immunosuppression need to be closely monitored and manipulated accordingly.
There is evidence to support the use of kidneys from paediatric donors in paediatric recipients.2 For this to occur, the reluctance in the UK to approach the topic of NHBD with parents in paediatric intensive care unit (PICU) needs to be overcome. In brain stem dead donors, the family can say their goodbyes on the PICU and then the patient is taken to theatre. In NHBD treatment is withdrawn on the PICU in the presence of the family, who then wait for asystole to occur. Once it does, death is confirmed and the patient is quickly taken to theatre for retrieval. Therefore, NHBD allows the parents to be with the child at the time of death, although they have to wait for it to occur. Problems arise when asystole does not occur within a specified time, (from 90 min to 5 h for kidneys, depending on which unit is retrieving) as the lungs, kidneys and livers will not be retrieved. This is painful for the parents, who then have to wait on the unit for asystole to occur. However, corneas, skin and heart valves can still be donated in this situation.
Until this time there has also been a reluctance to transplant organs from NHBD into paediatric recipients, largely due to a lack of outcome data in both children and adults.3
Recently, a case matched comparison of long-term results of NHBD and heart beating donor renal transplants in adults was published.4 The analysis demonstrated a comparable graft function and survival up to 10 years in the two groups, with the organs from NHBD having slightly inferior function and survival rates beyond this time. However, the data from this UK centre was based largely on the use of organs from uncontrolled donors, which are those from Maastricht categories I and II. Currently in the UK, only one unit retrieves organs from category II donors and due to the need of having a theatre team available immediately, the logistics of retrieving from this category of donors is difficult. In addition patients arriving in the emergency department in cardiac arrest often have an uncertain history and duration of arrest; such organs are considered less suitable for use in paediatric recipients.
Regarding paediatric outcome data there have been previous reports of similar cases in the international literature with the biggest series coming from the USA. The united network for organ sharing published data on paediatric kidney transplants from NHBDs.5 Over a 10-year period 26 (0.6%) renal transplants performed in children under the age of 18 used allografts from NHBDs. One-year graft survival was 82.5% and 74.3% at 5 years, compared to 89.6 and 64.8% for organs from deceased donors (p=0.7). While the numbers in this series are small these organs appear to have comparable graft survival in paediatric recipients.
However, the paucity of paediatric outcome data raises important issues about informed consent as it is impossible to give parents accurate figures from a single unit. Therefore, the possibility of using these organs should be discussed with parents early in the transplantation journey so that they have time to consider the implications of their use.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.
Patient consent Obtained.
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