Analysis of Risk Factors Affecting the Pediatric Renal Allograft Survival in Cyclosporine Era: A Single Center Study Based on 113 Renal Transplants

Kim, Pyung Kil; Kim, Ji Hong; Yook, Jin Won; Kim, Yu Seun; Kim, Soon Il; Park, Ki Il

Abstract

Renal transplantation is now a well established mode of optimal therapy for children with end-stage renal disease. A total of 119 pediatric renal transplantations were performed during last 20 years but 6 cases (early 3 cases treated with azathioprine and most recent 3 cases) were excluded for this study. A total of 113 pediatric renal transplants out of total 1,906 kidney transplantation recipients receiving cyclosporine A and low dose prednisone as the main immunosuppressive agent were the subjects of this study to find out the risk factors which might influence the pediatric renal allograft survival in a single center. When the potential donor was living related, at least the HLA 1-haplotype matched relative was selected, but, when unrelated, at least DR-1/2 or A+B 2/4 matching was required for selection. Living related donation from parent, brothers, sisters (n=82), and unrelated donation (n=31) through the swap program or from fully motivated healthy volunteers were the major source of kidney for allograft. The mean age of the recipient was 14.1 years ranging from ages 2.1 to 19.9. During a mean follow-up of 68.1 months, there were 21 cases of graft loss, and 3 recipient deaths. The major causes of graft loss were acute and/or chronic rejection, poor compliance and patients death. The 1-, 3- and 5-year graft survival were 94.6%, 88.9% and 79.2% respectively. There was no significant difference between children and adult in graft survival rate. No significant graft survival difference between the related and unrelated donors (73.3 vs 77.2% at 5-year, p>0.05) was found. The significant risk factors for the outcome were the ABO compatibility (p=0.0001) and development of more than 1 episode of acute rejection within 6 month (p=0.01) and 1 year (p=0.0016). Graft survival decreased with increasing number of rejection episode within 6 month (p=0.009) and 1 year (p=0.002). Other factors such as recipients age, original kidney diseases, type and duration of dialysis before transplantation, combined native kidney removals did not influence the outcome of graft. And because of presence of only 2 cadaveric donor in this analysis, we could not demonstrate any benefit of living donor transplantation. In conclusion, pediatric renal transplantation in at least older children (>5 years) is encouraging. The outcome of pre- emptive renal transplantation is also promising. More aggressive ABO matching and effort for reducing the rejection episode within 6 months and 1 year might be important factors for the successful outcome of pediatric renal transplantation. So development and application of more effective immunosuppressive agents such as mycophenolate mofetil or rapamycin to reduce the rejection episodes is to be needed in near future.