1 00:00:00,000 --> 00:00:05,920 Hello everyone. 2 00:00:05,920 --> 00:00:09,560 Welcome back to another episode of the Stay Current podcast. 3 00:00:09,560 --> 00:00:13,720 I'm Cecilia Gigena, a research fellow at Cincinnati Children's Hospital. 4 00:00:13,720 --> 00:00:17,860 And along with Stay Current, we are sharing knowledge to improve child health around the 5 00:00:17,860 --> 00:00:18,860 globe. 6 00:00:18,860 --> 00:00:24,320 So today, we are talking about kidney transplants in pediatric patients. 7 00:00:24,320 --> 00:00:30,320 And for that, we have Dr. Jonathan Merola, a specialized transplant surgeon from Cincinnati 8 00:00:30,320 --> 00:00:31,900 Children's Hospital. 9 00:00:31,900 --> 00:00:37,380 The most common diagnosis for kidney failure in children includes congenital anomalies 10 00:00:37,380 --> 00:00:39,540 of the kidney and urinary tract. 11 00:00:39,540 --> 00:00:46,680 So this includes renal aplasia, hypoplasia, or dysplasia, as well as obstructive neuropathy 12 00:00:46,680 --> 00:00:50,040 from reflux and bladder obstruction. 13 00:00:50,040 --> 00:00:56,640 And together, they comprise 35 to 40% of pediatric patients undergoing kidney transplants. 14 00:00:56,640 --> 00:01:02,240 Other causes of kidney failure include focal segmental glomerular sclerosis, hereditary 15 00:01:02,240 --> 00:01:05,800 nephropathies, and chronic glomerulonephritis. 16 00:01:05,800 --> 00:01:12,000 In the US, approximately 800 kidney transplants are performed in children below 18 years old. 17 00:01:12,000 --> 00:01:18,240 And as Dr. Merola said, the main causes are congenital abnormalities, glomerulonephritis 18 00:01:18,240 --> 00:01:26,080 like FSGS or focal segmental glomerular sclerosis, and hereditary nephropathy. 19 00:01:26,080 --> 00:01:30,320 Transplant for all of those three conditions is really curative. 20 00:01:30,320 --> 00:01:36,000 And so survival for a living in deceased donor kidney transplant in children often exceeds 21 00:01:36,000 --> 00:01:37,560 30 years. 22 00:01:37,560 --> 00:01:43,360 And that is better than the weightless mortality, which is around 15 years. 23 00:01:43,360 --> 00:01:48,880 One of the major challenges, however, is supporting children with renal failure to the point where 24 00:01:48,880 --> 00:01:53,640 they can successfully obtain an adult kidney transplant. 25 00:01:53,640 --> 00:02:00,360 Neonates can then be supported with specialized hemodialysis known as Carpe Diem or Cardio-Renal 26 00:02:00,360 --> 00:02:07,480 Pediatric Dialysis Emergency Machine, which basically serves as a CRRT for infants as 27 00:02:07,480 --> 00:02:09,580 small as two and a half kilos. 28 00:02:09,580 --> 00:02:17,560 So Carpe Diem is an innovative continuous renal replacement therapy or CRRT as Dr. Merola 29 00:02:17,560 --> 00:02:18,640 said. 30 00:02:18,640 --> 00:02:26,720 This therapy is for small infants, specifically neonates where other CRRTs can't be used. 31 00:02:26,720 --> 00:02:33,040 After a short period on hemodialysis, we can then transition patients to perineal dialysis, 32 00:02:33,040 --> 00:02:38,560 which requires of at least a period of two to three weeks from the time of catheter insertion 33 00:02:38,560 --> 00:02:40,800 to when you can initiate it. 34 00:02:40,800 --> 00:02:45,720 That timeframe is really needed to mitigate the risk of perinitis. 35 00:02:45,720 --> 00:02:51,320 So for CRRT, we have hemodialysis and perineal dialysis. 36 00:02:51,320 --> 00:02:58,560 To initiate perineal dialysis safety, we need a period from the catheter insertion to dialysis 37 00:02:58,560 --> 00:03:02,360 initiation of at least two to three weeks. 38 00:03:02,360 --> 00:03:07,240 And are there any other technical tips that help with catheter insertion? 39 00:03:07,240 --> 00:03:12,680 We found that if you do an omentectomy in these small babies, there's a much greater 40 00:03:12,680 --> 00:03:15,600 success of catheter insertion. 41 00:03:15,600 --> 00:03:16,600 Awesome. 42 00:03:16,600 --> 00:03:19,760 So when do we consider a kidney transplant? 43 00:03:19,760 --> 00:03:25,040 For all patients with stage four or five chronic kidney disease, we would recommend referral 44 00:03:25,040 --> 00:03:27,060 for kidney transplant. 45 00:03:27,060 --> 00:03:32,800 So patients with kidney disease, stage four or five, should be referred for kidney transplant. 46 00:03:32,800 --> 00:03:37,640 And here Dr. Merola explains the considerations on size and age. 47 00:03:37,640 --> 00:03:41,880 Unlike adults, however, size can limit successful transplant. 48 00:03:41,880 --> 00:03:47,680 And here at Cincinnati, we prefer children to be about 10 kilos or 80 centimeters in 49 00:03:47,680 --> 00:03:50,280 height to accommodate an adult kidney. 50 00:03:50,280 --> 00:03:52,520 And that's typically at two years of age. 51 00:03:52,520 --> 00:03:53,520 Okay. 52 00:03:53,520 --> 00:03:59,640 So to be able to be transplanted with an adult size kidney, they need to reach 10 kilograms 53 00:03:59,640 --> 00:04:02,560 or 80 centimeters of height. 54 00:04:02,560 --> 00:04:08,560 We have a close partnership with Urology, particularly for managing patients with posterior 55 00:04:08,560 --> 00:04:12,080 ureteral valves or a neurogenic bladder. 56 00:04:12,080 --> 00:04:17,160 Partnering with Urology is key so that they can follow the patients assessing the need 57 00:04:17,160 --> 00:04:21,840 for complementary surgeries or treatment and bladder cycling. 58 00:04:21,840 --> 00:04:28,800 And so they work up these patients by performing voiding systo urethrograms and neurodynamics 59 00:04:28,800 --> 00:04:35,960 study and closely evaluate them prior to transplant and use the results of those studies to guide 60 00:04:35,960 --> 00:04:38,080 a bladder cycling and conditioning. 61 00:04:38,080 --> 00:04:39,080 Perfect. 62 00:04:39,080 --> 00:04:44,600 So wait until they are at least eight to 10 kilos and follow them with Urology to check 63 00:04:44,600 --> 00:04:49,940 on the bladder size to see if they're need an augmentation or not. 64 00:04:49,940 --> 00:04:55,040 So what are the considerations we should have for these patients? 65 00:04:55,040 --> 00:05:00,760 Some of the unique considerations for pediatric population include size. 66 00:05:00,760 --> 00:05:07,480 So an adult size kidney should ideally be less than 10 or 12 centimeters to comfortably fit. 67 00:05:07,480 --> 00:05:08,480 Great. 68 00:05:08,480 --> 00:05:13,800 So the ideal size of a transplanted kidney should be less than 10 to 12 centimeters. 69 00:05:13,800 --> 00:05:19,360 And what type of organs are considered for pediatric kidney transplant? 70 00:05:19,360 --> 00:05:23,380 Living in deceased donor kidney transplants can be considered for children. 71 00:05:23,380 --> 00:05:28,180 Living donor kidney transplants are the preferred grafts because they have a lower rejection 72 00:05:28,180 --> 00:05:30,800 risk and a longer overall survival. 73 00:05:30,800 --> 00:05:35,540 Living donors can be from a family member or a friend who comes forward and donates 74 00:05:35,540 --> 00:05:38,520 their kidney as an elective operation. 75 00:05:38,520 --> 00:05:43,720 Advantages to this include that there's less delayed graft function, that there's more 76 00:05:43,720 --> 00:05:48,800 rapid organ access, particularly to patients who are not yet on dialysis. 77 00:05:48,800 --> 00:05:49,920 Great. 78 00:05:49,920 --> 00:05:57,160 So living donor recipients have better graft survival rates and less delayed graft function. 79 00:05:57,160 --> 00:06:03,760 Ten year graft survival is 75% for living donor kidneys and 65% in deceased donor kidney 80 00:06:03,760 --> 00:06:05,080 transplants in kids. 81 00:06:05,080 --> 00:06:07,400 So a very good outcomes overall. 82 00:06:07,400 --> 00:06:11,200 And we have to check if they have multiple vessels in the graft. 83 00:06:11,200 --> 00:06:16,000 Additionally, kidneys with multiple vessels are more challenging to implant on the aorta 84 00:06:16,000 --> 00:06:21,200 and IVC and therefore those are considered higher risk grafts. 85 00:06:21,200 --> 00:06:22,200 Great. 86 00:06:22,200 --> 00:06:29,400 So again, check the donor's kidney size and vasculature. 87 00:06:29,400 --> 00:06:31,520 And how is the surgery performed? 88 00:06:31,520 --> 00:06:36,280 So children typically receive kidney transplant through a retroperitoneal incision and the 89 00:06:36,280 --> 00:06:40,680 vascular andastomoses are performed to the common iliac vessels. 90 00:06:40,680 --> 00:06:48,320 And smaller patients, the aorta or IVC, inferior vena cava, allow for better vascular inflow 91 00:06:48,320 --> 00:06:55,280 and they both can be exposed using an intraperitoneal or extraperitoneal approach. 92 00:06:55,280 --> 00:06:59,220 Extraperitoneal is the preferred option at Cincinnati Children's. 93 00:06:59,220 --> 00:07:02,400 So let's hear the reason for that with Dr. Merola. 94 00:07:02,400 --> 00:07:08,040 Here in Cincinnati, we prefer the extraperitoneal approach both to minimize the risk of bowel 95 00:07:08,040 --> 00:07:13,600 injury and allow for contained space in the setting of any required biopsy of the kidney 96 00:07:13,600 --> 00:07:14,600 allograft. 97 00:07:14,600 --> 00:07:21,640 Usually, an ipsilateral nephrectomy is performed to allow an adequate space for the graft. 98 00:07:21,640 --> 00:07:28,120 But also in the setting of polyuria or proteinuria or in the case of FSGS, where urine protein 99 00:07:28,120 --> 00:07:32,720 is an important marker for disease recurrence to be detected early. 100 00:07:32,720 --> 00:07:39,160 So apart from graft space, prior diuresis and proteinuria has to be assessed in case 101 00:07:39,160 --> 00:07:42,600 patients need bilateral nephrectomies. 102 00:07:42,600 --> 00:07:48,040 In patients that require bilateral nephrectomy, like those with Wilms tumor or those who have 103 00:07:48,040 --> 00:07:53,120 FSGS where you really want to closely monitor proteinuria as a neural design, the disease 104 00:07:53,120 --> 00:07:58,960 recurrence, we usually take the contralateral kidney out in a separate setting from that 105 00:07:58,960 --> 00:08:03,480 transplant. 106 00:08:03,480 --> 00:08:07,680 Let's talk about complications after kidney transplant. 107 00:08:07,680 --> 00:08:12,960 Surgical complications include vascular thrombosis and urine leak and those can occur in about 108 00:08:12,960 --> 00:08:14,440 5% of patients. 109 00:08:14,440 --> 00:08:19,920 Rejection and infection are the two most significant non-surgical long-term complications in children 110 00:08:19,920 --> 00:08:22,020 following kidney transplant. 111 00:08:22,020 --> 00:08:26,280 So as in other transplants, these patients have to be immunosuppressed. 112 00:08:26,280 --> 00:08:31,300 But we have to carefully regulate it to avoid other complications that the immunosuppressors 113 00:08:31,300 --> 00:08:40,520 can cause, such as obesity for steroids or B-cell malignancies for T-cell suppressors. 114 00:08:40,520 --> 00:08:46,240 Immunosuppression is required lifelong, but may predispose patients to viral infections, 115 00:08:46,240 --> 00:08:51,200 malignancies, and long-term can cause toxicity to the transplanted kidney. 116 00:08:51,200 --> 00:08:54,400 So kids have to be monitored very closely for all of these post-transplant. 117 00:08:54,400 --> 00:08:59,240 But how can we improve outcomes in our patients? 118 00:08:59,240 --> 00:09:05,280 For the past 5 decades, many of the advances in transplant have relied on better ways to 119 00:09:05,280 --> 00:09:07,200 treat and protect the host. 120 00:09:07,200 --> 00:09:12,120 But one of the areas I'm very interested in is actually in treating the graft. 121 00:09:12,120 --> 00:09:17,400 Normothermic perfusion is a technique that circulates a warm perfusion solution through 122 00:09:17,400 --> 00:09:23,240 the renal vasculature, enabling the organ to recover from the ischemic injury. 123 00:09:23,240 --> 00:09:26,760 That also enables the opportunity to treat the organ. 124 00:09:26,760 --> 00:09:36,240 So taking care of the graft and not only the host seems to be the future in transplant. 125 00:09:36,240 --> 00:09:43,880 Congenital kidney and urinary tract malformations are the top causes of pediatric kidney transplant. 126 00:09:43,880 --> 00:09:50,480 Teamwork is key with neonatologists, pediatric nephrologists, and pediatric urologists joining 127 00:09:50,480 --> 00:09:52,040 forces for success. 128 00:09:52,040 --> 00:09:59,520 Done right, a single donated kidney survival can exceed 25 to 30 years, especially if it 129 00:09:59,520 --> 00:10:02,640 is from a living donor. 130 00:10:02,640 --> 00:10:08,960 Specific consideration in kids includes graft to child size, the need for a concurrent uni- 131 00:10:08,960 --> 00:10:15,480 or bilateral nephrectomy, and a careful regulation between immunosuppression and risk of infection 132 00:10:15,480 --> 00:10:16,480 or malignancy. 133 00:10:16,480 --> 00:10:22,760 Also, cutting-edge technologies like organ perfusion offers a promising way to treat 134 00:10:22,760 --> 00:10:31,260 organs outside the body to potentially extend their lifespan. 135 00:10:31,260 --> 00:10:33,480 And that was everything for today. 136 00:10:33,480 --> 00:10:37,200 Don't forget to subscribe to the Stay Current MD YouTube channel. 137 00:10:37,200 --> 00:10:41,400 Follow our social media channels and download the Stay Current MD app for tons of content 138 00:10:41,400 --> 00:10:44,440 in pediatric surgery. 139 00:10:44,440 --> 00:10:50,080 Global Cast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child 140 00:10:50,080 --> 00:11:16,880 health around the globe.