Abstract
This chapter provides a complex review of pediatric renal transplantation. The author discusses the multitude of considerations relevant to patients with chronic kidney disease (e.g. cardiovascular, endocrinologic, hematologic, bone and mineralization homeostasis). The perioperative evaluation is presented in detail in addition to the renal transplant specific anesthetic considerations.
The first case in your operating room assignment is a living related donor kidney transplant. The recipient is a 16-year-old Caucasian female with chronic kidney disease (CKD) 5 due to obstructive nephropathy. She initially presented six months ago with progressive fatigue, headaches, nausea, and vomiting.
Initial workup demonstrated a serum creatinine of 7.5, BUN 105, sodium 134, potassium 5.8, bicarbonate 12, calcium 6.2, phosphorus 10.3, hemoglobin 7.2. Vital signs: heart rate 89, BP 148/89, temperature 36.5°C.
Renal ultrasound demonstrated bilateral small kidneys with loss of cortico-medullary differentiation and bilateral severely dilated collective systems. Since the initial diagnosis, she has been treated with sodium bicarbonate tablets, calcitriol, darbepoietin alfa, atenolol, and sevelamer carbonate. The related donor is her mother, a 38-year-old healthy woman with no significant past medical history.
Immediate preoperative vital signs include: blood pressure 138/86, heart rate 62, temperature 36.5°C, SpO2 100% on room air.
What Is Chronic Kidney Disease (CKD)?
Chronic kidney disease (CKD) is defined by the National Kidney Foundation Kidney Disease and Outcome Quality Initiative (KDOQI) Group in any patient older than two years, with kidney damage lasting for at least three months with or without a decreased glomerular filtration rate (GFR), or any patient who has a GFR of less than 60 mL/min per 1.73 m2 lasting for 3 months with or without kidney damage.
What Are the Stages of CKD?
The KDOQI Group classifies CKD into five stages based on GFR (Table 29.1).
Table 29.1 Classification of chronic kidney disease (CKD) by glomerular filtration rate (GFR).
| CKD Stage | Glomerular filtration rate (GFR) mL/min/1.73 m2 |
|---|---|
| Stage 1 | Kidney disease with GFR greater than 90 |
| Stage 2 | 60–89 |
| Stage 3 | 30–59 |
| Stage 4 | 15–29 |
| Stage 5: End-stage renal disease (ESRD) | <15 |
When Are Patients with CKD Eligible for Kidney Transplantation?
Discussion for renal replacement therapy including renal transplantation starts when the patient reaches stage 4 CKD. Initial workup for renal transplantation is also initiated. Preemptive kidney transplantation is done when dialysis has not been started prior to transplant and it is the optimal treatment to avoid the four-fold increase in morbidity and mortality associated with dialysis.
What Organ Systems Are Affected in Patients with End-Stage Renal Disease (ESRD)?
Multiple systems are affected by ESRD including:
cardiovascular
endocrine
hematologic
bone and mineralization homeostasis.
What Laboratory Abnormalities Would You Expect in a Patient with ESRD?
Anemia.
Anemia of CKD develops as a result of both decreased production secondary to low erythropoietin and increased red blood cell turnover due to uremic toxins in patients with shortened lifespans. It presents as moderate to severe normochromic and normocytic anemia without increased reticulocytes.
Electrolyte Abnormalities.
Common electrolyte disturbances include mild hyponatremia due to volume overload and hyperkalemia due to decreased clearance of potassium and acidosis.
Impairment of tubular excretion function results in hyperphosphatemia with hypocalcemia due to secondary hyperparathyroidism and vitamin D deficiency as there is no conversion of 25-hydroxyvitamin D to 1,25 (OH)2D in renal proximal tubules.
Acid Base Disturbance.
The high-anion gap metabolic acidosis is a consequence of failure of adequate excretion of acid anions (mainly ammonium but also phosphate and sulfate).
There is also a significant decrease in reabsorption and synthesis of bicarbonate which would serve as body buffer.
The deleterious consequences for metabolic derangements include renal osteodystrophy, arterial calcification, and increased risk of death.
What Are the Most Common Clinical Manifestations of ESRD?
Neurological: Headaches, dysautonomia, uremic encephalopathy, cognitive alteration, fatigue, muscle weakness, peripheral neuropathy, increased risk of stroke, and in severe cases seizures and coma.
Cardiovascular: Hypertension, fluid overload, left ventricular hypertrophy, arterial calcifications, early atherosclerosis, increased risk of cardiovascular disease.
Endocrine: Vitamin D deficiency, renal osteodystrophy, short stature, growth retardation, dyslipidemia, malnourishment, sick euthyroid syndrome, delayed puberty, anovulation.
Gastrointestinal: nausea, emesis, gastric paresis, insulin resistance.
Hematologic: anemia, increased bleeding risk (uremia induced platelet dysfunction), immunosuppression due to T and B cell dysfunction.
What Is the Incidence of ESRD in Children?
In 2007, the reported incidence of ESRD in the United States was 1.48 per 100,000 children. As per the United States Renal Data System (USRDS) 2016 report, a total of 9,721 children were treated for ESRD by December 31, 2014.
What Are the Most Common Initial Treatment Options in Children with ESRD?
Treatment for ESRD includes renal replacement therapy and renal transplantation. Peritoneal dialysis (PD) was the most common initial ESRD treatment modality in children younger than nine years weighing less than 20 kg. Overall, the most common treatment for children with ESRD is hemodialysis (HD) at 50.4%.
What Are the Most Common Diagnoses Leading to Transplantation for Children with ESRD?
As per the 2014 annual transplant report from the North American Pediatric Renal Trials and Collaborative Studies (NAPRTCS), out of 11,186 pediatric renal transplants:
What Is the Age Distribution for Pediatric Renal Transplants?
Of the 718 listed pediatric renal transplants in 2015:
Less than 1 year of age: 2 transplants (0.28%).
1 and 5 years old: 163 transplants (22.7%).
6–10 years: 145 transplants (20.2%).
11–17 years: 408 transplants (56.8%).
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