Transplantation of adultsized kidneys into infants and small children

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Transplantation of adult-sized kidneys into
infants and small children

• Hemodynamic influences and management

Intern ??? 2003/01/06
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Case(1)

• 2 year-old girl, 10 Kg, a renal recipient
• Her father, 70 Kg, a living donor
• Operation on 91-12-13 Aorta?kidney?IVC

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Case(2)
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History(1)

• Before 1980s outcomes of kidney transplantation
  in infants and small children was to be inferior
• vascular thrombosis, ATN, rejection, recipient
  death

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History(2)

• Kidney int. 1996 S53 S99-S102
• The University of Minnesota protocols they began
  living donor transplants for infants and children
  under age 4 since 1972.
• The transplant aggressive volume replacement,
  CVP from 15 to 18 cmH2O
• Early post-transplant IVF are administered on a
  milliliter-by-milliliter basis to match urine
  output.

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Adequate hydration

• Renal perfusion in infant recipients of
  adult-sized kidneys is a critical risk factor
• Quantitative of the hemodynamic changes?

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Adequate hydration

• Salvatierra O. et. al. Transplantation 1998 66
  819-823
• Nine hemodynamically stable infants (mean weight
  12.1/-2.6 kg range 9.3-16 kg)
• After transplantation, tube feeding was carried
  out for greater than 4 months and was targeted to
  achieve a total daily fluid intake of 2500
  ml/cm2/day plus a minimum sodium intake of 8-10
  mEq/kg/day
• Aortic and renal Blood flow measurements, Renal
  volume measurements

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Adequate hydration
Mean in situ donor renal artery blood flow prior
to donor nephrectomy was 618/-130 ml/min.
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Adequate hydration

• A 26 reduction in renal volume (P0.003)
  occurred between the two postoperative time
  periods (six months).
• Shrinkage with time as part of a functional
  adaptation and reverse "work hypertrophy
• One-year graft and patient survival in the nine
  infants was 100. The mean serum creatinine
  levels at 3, 6, and 12 months were 0.43/-0.10,
  0.48/-0.15, and 0.49/-0.16 mg/dl.

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Adequate hydration

• Arch. Surg. 20001351063-1069
• We became more aggressive in optimizing infants
  intravascular volume through nasogastric or
  gastrostomic tube feeding of at least 2500 to
  3000 ml/m2 per day.

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Adequate hydration

• Salvatierra O. et. al. Transplantation
  200070412-413
• long-term maintenance of optimum intravascular
  volume can enhance the quality of the adult-sized
  allograft

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Adequate hydration

• Healey PJ. et.al. Arch. Surg. 20001351035-1041
• Expansion of recipient intravascular volume is
  also critical to a prompt complete reperfusion of
  the donor kidney.
• Postoperatively, continued aggressive fluid
  support is necessary to maintain intravascular
  volume output and adequate renal graft blood flow.

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Adequate hydration

• Minnie M. et. al. Transplantation
  2000701728-1736

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Heart

• Kidney int. 1996S53S99-S102
• Hypertension and left ventricular hypertrophy are
  possible complications in pediatric patients
  after renal transplantation
• Pediatr. Nephrol. 200116843847
• The results suggest that hypertension is not
  always associated with cardiac hypertrophy
  following pediatric renal transplantation.

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Case(3)
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Case(4)

• Adequate IVF hydration
• CVP still 3-8 mmHg
• Urine output?diurectic phase, kidney size?
• One week after operation, urine output return to
  normal level adaptation, renin-angiotensin-aldos
  teron system
• Heart tolerable

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• Successful transplantation of adult-sized kidneys
  into infants requires maintenance of high aortic
  blood flow
• 
  Salvatierra O.

Thank you for your attention