Introduction to paediatric renal transplantation€¦ · Introduction to paediatric renal transplantation Martin Christian Consultant Paediatric Nephrologist, ... Paired donation

Introduction to paediatric renal

transplantation

Martin Christian

Consultant Paediatric Nephrologist,

Nottingham Children’s Hospital

Benefits of transplantation

• Minimise disruption to family, school and

social life

• Facilitate physical and emotional growth

and development

• Improved survival

• Cost-effective

Consequences of a transplant

• Lifelong immunosuppression

• Expected lifespan of a transplant kidney

• Early complications

Preparation for a transplant

• Trends in eGFR

• Home visit

• CKD day

• Tests

• Transplant surgeon

Pre-emptive transplantation

• Misses out dialysis step

• Better outcomes?

• Timing of transplant

• Not suitable for all

Source of Organs

Deceased donors

• Donation after brain

death (DBD) donors

• Donation after

circulatory death

(DCD) donors

Living donors

• Usually living related

from parent or other

close family member

What is the demand for organs?

Data from NHSBT ODT

What is the supply of organs?

0

200

400

600

800

1000

1200

01/0202/0303/0404/0505/0606/0707/0808/0909/1010/11

DBDdonors

DCDdonors

Livedonors

Data from NHSBT ODT

National trends

Donor types

• More living donors

• DBD donors are older with more co-

existing conditions

• More DCD donors

Deceased and living paediatric

kidney only transplants

109101

139

110

128

96

114

85

10493

100

81 8374 71 71

6374

6269

5

1

1

1

2

1

1

1

1

2

1

2

10 13

11

22

19

26

19

25

31

33

34

4446

44 4651

50

64

64

68

0

20

40

60

80

100

120

140

160

1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Living

DCD

DBD

Nu

mb

er

of tr

an

sp

lants

Year of graft

Paediatric KAG NHSBT

Waiting times of deceased

paediatric kidney only transplants

0

100

200

300

400

500

600

700

800

900

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Q1

Median

Q3

Wa

itin

g tim

e (

da

ys)

Year of graft

Paediatric KAG NHSBT

% g

raft

su

rviv

al

0

10

20

30

40

50

60

70

80

90

100

years post-transplant0 5 10 15 20

Graft survival following first DBD

paediatric kidney only transplant

2006-2010 1yr survival 95% (92-97) N=308

2001-2005 5yr survival 81% (77-85) N=360

1996-2000 10yr survival 63% (58-68) N=411

1991-1995 15yr survival 45% (41-50) N=488

1986-1990 20yr survival 27% (23-31) N=442

p<0.0001

Paediatric KAG NHSBT

Graft survival following first DBD

paediatric kidney only transplant excluding failures within the first year

% g

raft

su

rviv

al

0

10

20

30

40

50

60

70

80

90

100

years post-transplant0 5 10 15 20

2001-2005 5yr survival 88% (84-91) N=328

1996-2000 10yr survival 73% (68-78) N=345

1991-1995 15yr survival 55% (50-60) N=392

1986-1990 20yr survival 38% (32-44) N=310

p<0.01

p=0.5 (1991 – 2005)

Paediatric KAG NHSBT

Graft survival following first living

paediatric kidney only transplant excluding failures within the first year

% g

raft

su

rviv

al

0

10

20

30

40

50

60

70

80

90

100

years post-transplant0 5 10 15 20

2001-2005 5yr survival 95% (90-97) N=173

1996-2000 10yr survival 78.0% (68-85) N=107

1991-1995 15yr survival 49% (34-62) N=60

1986-1990 20yr survival 37% (22-53) N=42

p=0.009

Paediatric KAG NHSBT

Life after transplant is a rollercoaster

Adolescents have the highest

rate of transplant loss

• Teenage brain

• Autonomy versus

responsibility

• Psychosocial and youth

work support

% g

raft

su

rviv

al

0

10

20

30

40

50

60

70

80

90

100

years post-transplant0 5 10 15 20

% g

raft

su

rviv

al

0

10

20

30

40

50

60

70

80

90

100

years post-transplant0 5 10 15 20

% g

raft

su

rviv

al

0

10

20

30

40

50

60

70

80

90

100

years post-transplant0 5 10 15 20

Graft survival following first DBD

paediatric kidney only transplant

<6 years 6-11 years 12-17 years

Paediatric KAG NHSBT

Transplant options - previously

Suitable

directed

donor

Deceased

donor list

Paired

donation

ABOi or

HLAi

Transplant

No No

Yes Yes Yes

Non-directed

(altruistic) donor

Transplant options - now

Suitable

directed

donor

Deceased

donor list

Paired

donation

ABOi or

HLAi

Transplant

No No

Yes Yes Yes

Non-directed

(altruistic) donor

Non-directed altruistic donation

• Individual donates a

kidney after medical/

psychological testing

• Allocated according

to national allocation

guidelines – those

<18yrs will get

preference

Deceased donor

DBD donor

• Fewer standard donors

• Extended criteria donor – higher risk donor (increased risk to organ and/or recipient)

• Use of both kidneys: En-bloc (suitable for donors 18m-5yrs); or dual (suitable for elderly donors)

DCD donor

• Long term outcomes for kidney equivalent to standard DBD donor, but 50% incidence of kidney initially slow to function

Implications

• Recognise that all transplants come with

some risks – as does dialysis

• Paediatric recipients get priority in national

allocation scheme and don’t give offered

kidneys from donors >50yrs

• Kidneys from DCD donors may be slow to

function initially and may prolong hospital

stay

• Every August

• Adults and children

• Charitable support to attend

• www.transplantsport.org.uk

Transplant Games

• www.emeesykidney.nhs.uk

• www.infokid.org.uk

• www.nhsbt.nhs.uk

Sources of information