Paediatric renal transplantation: moving forward in the field

Excerpt

The field of renal transplantation is becoming more complicated, with both clinicians and academics needing to know the latest advances. Although we learn from adult practice how to treat children, children are not small adults. There are inherent differences in anatomy, physiology, pathophysiology, and immunology between infants, children, and adolescents regarding their developing immune systems, making patient management complex for both physicians and surgeons. As children may require multiple renal transplants, subsequent sensitization is a key issue. Although close HLA matching is the goal, there is uncertainty about when poorer matching is outweighed by the detrimental effects of longer wait time on the deceased-donor list. Should we enter antibody-incompatible donor–recipient pairs into national kidney sharing schemes, and should we include compatible pairs to achieve better matching? Some children will receive an organ from an altruistic living donor, but many will remain on the deceased-donor waiting list. Should we consider donation after cardiac death (DCD; nonbeating heart) and marginal donors for some prospective paediatric renal transplant recipients (pRTR)? What is the role of ex vivo normothermic perfusion for such cases? Should we accept neonatal and infant en bloc donors for prospective pRTR, although it may entail increased thrombotic risk? Which children should receive induction agents for their first transplant when they may receive multiple transplants during their childhood? Should we use monoclonal and polyclonal antibodies more readily in adolescents at risk of losing their renal allografts due to nonadherence? Would monthly infusions of belatacept help such patients adhere to conventional immunosuppression regimes? …