Darras, FS

Hakala, TR

Jensen, CWB

Jordan, ML

Scantlebury, VP

Shapiro, R

Starzl, TE

Sundberg, R

English

D-Scholarship@Pitt

Transplantation of Pediatric En Bloc Kidneys Under·· FK 506 Immunosuppression F.S. Darras. M.L. Jordan. R. Shapiro. R. Sundberg, V.P. Scantlebury, C.W.B. Jensen, T.R. Hakala, and T.E. Starzl THE use of kidneys from pediatric donors has been controversial because of reponed high rates of graft loss from technical and immunologic complications. 1-3 FK 506 has been shown to be an effective immunosuppressive agent in clinical trials in liver transplantation and in recip· ients of adult cadaver kidneys.4.5 We repon herein our experience with FK 506 as primary immunosuppression in 39 patients transplanted with en bloc kidneys from young pediatric donors under 4 years of age. MATERIALS AND METHODS All kidneys were harvested en bloc with an intact segment of infrarenal aorta and vena cava. the cephalad ends of both closed with polypropylene suture. The inferior ends of the donor aorta and vena cava were anastomosed end-ta-side to the recipient's external iliac vessels. All ureters were reimplanted extravesically. Donors ranged in age from 4 to 48 months (mean 19.8 + 4.9 months, median 20 months). weighing 6.4 to 17.7 kg (mean 11.6 + 2.6 kg, median 1l.8 kg), with mean tenninal BUN/creatinine of 1110.4. All patients received FK 506 and steroids without lmman. RESULTS Overall patient and graft survival rates are 92% and 74%, respectively. with a mean follow-up of II months (range 6 From the DiviSion of Urologic Surgery/Renal Transplantation, Department of Surgery. University of Pittsburgh, Presbyterian University Hospital. Pittsburgh. Pennsylvania. Address repnnt requests to Mark L. Jordan. MD. Division of Urologic Surgery/Renal Transplantation, Department of Surgery. University of Pittsburgh. 4414 Presbyterian University Hospital. Pittsburgh, PA 15213. ~ 1991 by Appleton & Lange 0041-1345191/$3.00/ +0 Table 1. FK 506 and Pediatric En Bloc Kidneys: Patients With Functioning GI1Ifta PI8drilone' Date of Operabon Trll/'lllPlllllt No. PRA(%) Rejection Donor Age (montI\S) SCR' (mglCIL) FK 1508' (mgtl(g) (119'd) 10126189 2 23 No 20 1.5 .14B10 0 11119/89 92 Yes 30 1.1 .1e BID 20 2116190 0 Yes 18 2.1 .05 BID 5 2116190 23 No 16 0.9 .06 BID 0 2123190 0 Yes 21 1.2 .07 BID 7.5 2126/90 0 No 4 1.4 .15 BID 10 3/13190 7 No 20 1.9 .16 BID 0 4/20190 1 7 No 16 1.6 .15 BID 0 519190 2 7 Yes 24 1.7 .03 BID 0 6/3190 13 No 22 1.1 .16B10 0 7/13190 0 No 10 1.4 .04 BID 0 7/25190 0 Yes 30 0.9 .17 BID 10 8/16190 0 No 24 1.2 .08 BID 5 8/29190 3 Yes 30 1.6 .10 BID 10 8I30I9O 0 No 12 0.5 .13 BID 0 9/10190 0 Yes 18 1.1 .18 BID 0 9/14/90 0 No 36 1.5 .12 BID 0 1014190 0 Yes 22 1.7 .13 BID 10 10/10190 0 No 20 1.0 .18 BID 0 10118190 64 Yes 30 0.8 .24 BID 10 1117190 23 Yes 36 2.0 .10 BID 0 11/18190 1.5 Yes 31 1.7 .07 BID 7.5 11I20I90 1.7 No 17 1.2 .16B10 5 11126190 1 3 Yes 14 2.1 .12T10 5 12122J9O 1 59 No 9 1.4 .12 BID 7.5 12129190 2 57 Yes 17 1.6 .18 BID 7.5 1131191 0 No 7 2.0 .15 BID 5 1/4191 0 Yes 12 2.3 .14B10 7.5 1120/91 3 No 8 1.7 .17 BID 0 • Aliall foUow.up (median 11 monIhI). Transplantation Proceedings. \/01 23, No 6 (December). 1991: pp 3089-3090 3089 j ~I ! :' i ::\ I, I j I I ;1 l .. :, >.1 ~i:i Jj ::1 ! , ~ , ;1. K~ 3090 Table 2. CompllClltlons and cau ... of Graft Lo .. • Death (n = 3) Cardiac arrest (n = 2) TB • Anatomic complications (n = 3) Acute technical venous thrombosis (n = 1) Venous thrombosis from severe rejection (n = 1) Mycotic arterial anastomotic aneurysm (n = 1) • Irreversible acute rejection (n = 1) • Chronic rejection (n = 2) • Withdrawal of immunosuppression (TB) (n = 1) • Urologic complications (n = 0) to 21). There were 3 patient deaths. 2 due to cardiac arrest. and 1 due to TB. The clinical characteristics of the 29 patients who have functioning grafts are summarized in Table 1. Thirteen of these 29 patients (45%) are currently on FK S06 monotherapy, taking no prednisone. Neither prior transplantation. degree of HLA matching or mis-matching, nor PRA altered graft survival. Donor age did not affect graft survival or function. In a subgroup of grafts from donors under 1 year of age (n = 9), graft survival is 78% without any technical complications, and the mean serum creatinine I.S mgldL. Table 2 summarizes the complications and causes of graft loss. There were no urologic complications. Twenty-one patients were diag-nosed with rejection. Two were not treated because of tuberculosis, 2 grafts were lost to early acute rejection. and 2 were lost to chronic rejection at 12 months. The other 15 patients had successful reversal of rejection, and have a mean serum creatinine of 1.6 ± 0.6. " DARRAS. JORDAN, SHAPIRO ET AL DISCUSSION This report demonstrates satisfactory earty results using kidneys en bloc from young pediatric cadaver donors with FK S06 and low-dose steroids. The 29 functioning grafts continue to provide renal function with mean follow-up approaching 1 year. Significant is the absence of any urologic complications using en bloc kidneys from even the smallest donors. The rapid taper of prednisone may be an important advantage of FK S06 in recipients of kidneys from small donors where problems with healing could lead to significant technical complications. We conclude that transplanting kidneys en bloc from young donors under age 4 can provide excellent renal function with good rates of graft survival and acceptable complication rates. Use of these small kidneys may be an important factor toward increasing the donor pool. In addition. FK S06 appears to be an appropriate immuno-suppressive agent in this setting. permitting excellent renal function with minimal toxicity. and the ability to use little or no steroids. REFERENCES I. Wengenen K. Matas AJ. Tellis VA, etal: Ann Surg 204:173. 1986 2. Gruessner RWG. Matas AJ. L10veras G. et aI: Clin Trans-plantation 3:209. 1989 3. Ratner LE. Flye MW: Transplantation 51:273.1991 4. Starzi TE. Todo S. Fung JJ. et aI: Lancet ii:l000. 1989 5. Starzi TE. Fung JJ, Jordan M. et al: JAMA 264:63. 1990 ~ I 1 I I ! , 

Transplantation of pediatric en block kidneys under FK 506 immunosuppression

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Transplantation of pediatric en bloc kidneys under FK 506 immunosuppression

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Transplantation of pediatric en block kidneys under FK 506 immunosuppression

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