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FOCUS POINTS
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Congenital and structural abnormalities are the leading causes of pediatric renal failure.
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The adult approach, curvilinear incision and retroperitoneal placement of the donor kidney, is the current surgical technique.
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Careful review of preoperative medications is warranted, especially angiotensin converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) that may affect cardiac hemodynamics intraoperatively.
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Vascular access can be a challenge and may require a preoperative placement in the interventional radiology suite for successful placement.
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Sugammadex has been proven to be safe and effective in patients with renal failure, perhaps with slower recovery compared with patients with normal renal function. Sugammadex and sugammadex-rocuronium complexes are cleared by hemodialysis.
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Providing optimal hemodynamics for graft reperfusion is extremely important; this goal can be accomplished with the administration of crystalloid, colloid, blood products, and/or inotropic infusions.
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Causes of graft loss in the immediate postoperative period include primary nonfunction of the new organ and thrombosis of vessels.
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Malignancy is a potential complication after transplant surgery with post-transplant lymphoproliferative disease (PTLD) being the most common, developed from latent Epstein–Barr virus (EBV).
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End-stage renal disease (ESRD) is a complex and difficult problem in pediatric medicine. It causes significant metabolic and physiological derangements as the disease progresses leading to growth retardation, chronic anemia, electrolyte abnormalities, and systemic hypertension. Dialysis can be a life-prolonging treatment; however, renal transplant is considered to be the therapy of choice for patients with ESRD. Transplantation has the advantages of better quality of life, increased survival, and decreased health cost over time. Younger patients who undergo transplantation tend to have greater benefit and survival.1,2
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The Organ Procurement and Transplant Network (OPTN) manages the national transplant registry of the United States. The 2017 OPTN data shows 1,022 patients ages 17 and under on the active waiting list. This represents 1.05% of the 96,628 patients on the active waiting list.3,4 The North American Pediatric Renal Trials and Collaborative Studies (NAPRTCS) group has been following a similar small cohort of patients since 1987 in order to better characterize the epidemiology and outcomes of this unique population. They have obtained voluntary participation from all U.S. and Canadian centers performing a minimum of four pediatric renal transplants per year.5 As of the 2014 Annual Report, 12,189 transplants have been reported for 11,186 patients (Table 24-1). Congenital and structural abnormalities account for a majority of cases of pediatric renal failure. In contrast, the leading causes of adult renal failure are diabetes mellitus, hypertensive nephrosclerosis, and glomerular disease.
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