Pediatric Transplants

Liver


The Liver transplant program includes pediatric patients affected with:

  • Cholestatic cirrhosis
  • Cirrhosis due to other causes
  • Metabolic diseases
  • Liver tumors
  • Acute liver failure

Transplants are performed using several techniques and grafts (whole liver, reduced-size liver, split liver, and living donor).

In case of need, liver transplants are performed in combination with other organs, such as kidney or intestine.

Kidney


Kidney transplantation is the optimal treatment for chronic renal failure in children, not only to treat uremia but also to improve the life of pediatric patients. The latter aspect has become predominant in the treatment strategy, and the actual goal is to transplant children electively in a period that in the past corresponded to dialysis. This, so-called pre-emptive, strategic approach, allows the child to avoid dialysis for a (sometimes long, difficult, and complicated) period of time. In order to achieve that, the best strategy for candidates who can benefit from it is the living-related kidney transplant, which can be planned by the team in terms of time and organization. On the other hand, a kidney transplant from a deceased donor cannot be scheduled, and the chances of performing it pre-emptively are very much reduced.

1) Kidney transplant: what is it?
2) Kidney transplant: why?
3) At what age can a child receive a transplant?
4) Pre-emptive kidney transplant: what does it mean?
5) Choosing a living or deceased donor.
6) Peritoneal dialysis or hemodialysis?
7) Kidney transplant results.
8) ISMETT’s experience with the pediatric kidney transplantation.


1) Kidney transplant: what is it?
The new kidney, procured from a (living or deceased) donor, is positioned in the recipient’s abdomen, near the pelvis, in an ideal place for the necessary reconnection of the kidney with the vessels (artery and vein) and the bladder. For technical purposes, in younger children the kidney can be positioned in the upper space of the peritoneal cavity. The recipient’s kidneys are generally left in their original position, and removed only for particular reasons. The ureter is connected directly with the bladder, and the patient will resume regular diuresis after the procedure.


2) Kidney transplant: why?
The transplant of a new kidney is indicated for children with chronic renal failure, a condition that prevents the kidneys from performing regular functions, such as ridding the blood of toxins, and balancing body fluids in a proper fashion.
In children younger than two years, the causes of kidney failure are mainly due to malformations, obstruction of the urinary tract (valves of the posterior ureter), or metabolic diseases (e.g., hyperoxaluria)
In older children, the causes can be hereditary, such as polycystic kidney disease, nephronophthisis, acquired diseases such as focal and segmental glomerulosclerosis, hemolytic-uremic syndrome (HUS), and glomerulonephritis.


3) At what age can a child receive a transplant?
Kidney transplantation is performed very rarely in children under 2 years of age who weigh less than 10 kg because overall management of them is quite difficult. From a technical viewpoint, transplants at this age and weight are much more complex. At that age, in fact, the recipients’ abdominal cavity has limited capacity, and the vessels are not sufficiently developed. Considering that most of the allocated kidneys come from adult donors, and that living donors are always adult, the transplant of a large kidney in a small stomach, even using alternative techniques (intra-peritoneal transplant, direct anastomosis on the main vessels), implies high risks of complications and major loss of the organ compared with transplants performed in older children.
Since very few children in this age group require chronic dialysis, though transplantation is feasible in such young children, if no factors justify the need to perform a transplant it is advisable to wait for the age of 2-3 years and a weight over 15-20 g to place a pediatric recipient on the organ waiting list and perform the transplant in better conditions.
It is certainly less harmful for a child to undergo dialysis for a few months instead of a kidney transplant in such difficult conditions.
For most children, the evolution towards chronic renal failure is slow, and dialysis is not usually necessary before 2-3 years of age. In this case a pre-emptive kidney transplant can be performed.


4) Pre-emptive kidney transplant: what does it mean?
A transplant is called pre-emptive when it is performed before dialysis. This allows the child to avoid a period of dialysis and its possible complications and psychological problems; this way all the procedures necessary to start peritoneal dialysis or hemodialysis, such as placement of a peritoneal catheter or ventral venous catheter, can be avoided.
The pre-emptive transplant gives better results, especially if performed with a graft from a living donor.


5) Choosing a living or deceased donor
The kidney could come either from a deceased or living donor: in the latter case, almost always the donor is one of the child’s parents (very rarely, another adult family member).
In the case of a deceased donor, the kidney is procured after brain death has been ascertained, and after the donor’s desire to donate his or her organs for purposes of transplant is confirmed. In Italy, these organs are allocated to candidates included on a national organ waiting list on the basis of the best compatibility; the system is computerized and managed by the National Transplant Center, and allows for choosing the best possible donor/recipient match.
For safety reasons, donors are studied in advance to guarantee good organ functions, and minimize the risk of transmitting any diseases to the recipient.
In the case of a living donor, the donor candidate will be studied in detail to ascertain his/her excellent physical conditions, absence of contraindications to major surgery, and the possibility of removing a kidney without compromising renal functions.
In most cases, living donation is the chosen procedure for a pre-emptive kidney transplant, before dialysis becomes necessary.
At ISMETT, the kidney is procured from the living donor with minimally invasive and laparoscopic techniques, which allow a better and more rapid recovery of the patient after the procedure.


6) Peritoneal dialysis or hemodialysis?
Dialysis partially reproduces the functions of a kidney, gets rid of toxins, and balances fluids in the body. It is necessary when the renal functions are below a minimal threshold.
Peritoneal dialysis consists in the infusion of a fluid in the child’s belly through a catheter surgically positioned in the abdomen. After a period of time, necessary for the fluid to exchange several toxins (such as urea) and cleanse the child’s blood, the fluid is removed through the same catheter.
This procedure, which has been used for a long time, has now become simple, safe, and efficient. With modern and electronic devices, the parents can have the treatment done at night, at home. This method is not only very efficient for treating uremia, it also allows for the children to preserve their quality of life and psycho-physical state, thus necessitating less hospital stay.
Currently, the quality of peritoneal dialysis is such to allow young patients to grow older and gain weight without serious side effects, and most of them reach the optimal age and weight to undergo the transplant in the best possible conditions.
Hemodialysis is a more complex and demanding procedure. It requires one-day hospitalization several times a week, and has a serious impact on the child’s quality of life.
A permanent vascular access (silicon venous catheter) or arteriovenous fistula is necessary, and this implies careful management to prevent any possible complications.
Hemodialysis is the procedure of choice when peritoneal dialysis is not feasible, or when hemodialysis is much more efficient for removing some toxic substances.


7) Kidney transplant results
The survival rate of children undergoing kidney transplant in the age group between 6 and 10 is approximately 98% after 5 years. In the last 15 years, great improvements in terms of short and mid-term results have been obtained (reduced episodes of rejection and reduced side effects), and most children return to a normal life in the early months after the transplant.
Today, surgical teams are focused on preventing damages of different origins, including nephrotoxic medications, and ensuring long-term survival and functional quality of the transplanted organ.
For this purpose, transplant centers continue with therapy minimization projects, whenever possible, and prevention of side effects, with studies and research aimed at inducing immune tolerance.


8) The pediatric kidney transplant at ISMETT
In the last 20 years, ISMETT has acquired vast experience, and performed over 400 kidney transplants, 50% of which were living-related kidney transplants.
The first transplant on a pediatric patient was performed in 2000, the youngest children transplanted were three years old. In half of the cases, kidneys were procured from living donors. Over a period of 16 years, the survival rate for children is 94%, among the best results in Europe given the high complexity of cases (it also includes combined liver-kidney transplants).

Lung


ISMETT is the only lung transplant center in southern Italy. It is organized to provide for all the needs of patients who must undergo an evaluation for transplant, from diagnosis to surgery, and post-operative follow-up. Pediatric patients are also assessed and undergo transplantation.

A thoracic surgery program is available. In this unit, pediatric patients are also assessed – for the same surgeries and diseases as adult patients. As for adult patients, all procedures benefit from a minimally invasive surgical approach, and the support of dedicated specialties (e.g., pediatrics, pediatric intensive care).