Paeds · nephrology-urology-fluids-and-electrolytes

Kidney transplantation in children

Also known as Paediatric renal transplantation · Kidney transplant in children · Preemptive kidney transplant · Living donor kidney transplant

Fellowship guide to paediatric kidney transplantation: why a transplanted kidney is the treatment of choice over lifelong dialysis for a child with end-stage kidney disease; the living-donor versus deceased-donor and preemptive versus dialysis-first classifications that predict graft survival; the standard tacrolimus, mycophenolate and steroid maintenance regimen with therapeutic drug monitoring; the distinction between T-cell-mediated and antibody-mediated rejection and how each is treated; and the leading threats to long-term graft survival including non-adherence in adolescence and chronic antibody-mediated rejection.

high12 referencesUpdated 15 July 202625 min readVerification in progress

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Red flags

Sudden oliguria and a swollen tender graft in the early post-operative period suggesting renal vessel thrombosis and imminent graft lossA rising creatinine in a transplanted child that may represent acute rejection, calcineurin inhibitor toxicity, obstruction or recurrence of original diseaseEarly and massive proteinuria within hours of transplant suggesting recurrence of focal segmental glomerulosclerosis requiring urgent plasmapheresisFever with a rising EBV viral load in an EBV-mismatched recipient suggesting evolving post-transplant lymphoproliferative disorderRising creatinine with a high BK virus load suggesting BK nephropathy that mimics acute rejectionAn adolescent with erratic tacrolimus levels, missed clinic visits and graft dysfunction suggesting non-adherence as the cause of late rejectionSevere hypovolaemia or hypotension in the early post-operative period precipitating delayed graft function and acute tubular necrosis

Life stages

infanttoddlerpreschoolschool-ageadolescentyoung-adult-transition

Care settings

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Clinical exam formats

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Recognises kidney transplantation as the treatment of choice for end-stage kidney disease in children and outlines donor source and timing classificationIdentifies the standard maintenance immunosuppression regimen and the need for lifelong follow-upRefers children with advanced chronic kidney disease to a transplant centre early and considers preemptive living-donor transplantJustifies the choice of induction and maintenance immunosuppression based on immunological risk and explains calcineurin inhibitor pharmacology and monitoringDistinguishes T-cell-mediated from antibody-mediated rejection and manages each appropriately, including recurrent disease and BK nephropathyLeads adolescent transition, manages non-adherence, and addresses the long-term complications of chronic immunosuppression including PTLD and post-transplant diabetesClassification of kidney transplantation by donor source and timing, preemptive versus dialysis-firstStandard maintenance immunosuppression and the role of therapeutic drug monitoringCauses of graft dysfunction in a transplanted child and the principles of investigationAssesses and investigates a rising creatinine in a paediatric kidney transplant recipientCounsels a family on living-donor versus deceased-donor transplant and the benefits of preemptive transplantationManages an adolescent transplant recipient with suspected non-adherence and graft dysfunctionLevel 1: Recognises kidney transplant as the preferred treatment for end-stage kidney disease in childrenLevel 2: Outlines immunosuppression principles and the common early complications of transplantationLevel 3: Manages graft dysfunction, rejection and long-term complications, and leads transition to adult careIndications for kidney transplantation in children and the leading causes of paediatric end-stage kidney diseaseClassification into living versus deceased donor and preemptive versus dialysis-firstThe standard immunosuppression regimen and the timeline of post-transplant infections including PTLDAssessment and investigation of graft dysfunction in a child after kidney transplantInterpretation of a creatinine rise with tacrolimus trough and donor-specific antibody resultsStructured explanation of induction, maintenance immunosuppression and rejection treatmentRecognition of kidney transplantation as optimal renal replacement therapy for children with end-stage kidney diseasePrinciples of induction and maintenance immunosuppression including tacrolimus therapeutic monitoringDiagnosis and management of acute rejection, infection and post-transplant lymphoproliferative disorderRecognises the indications for and benefits of paediatric kidney transplantationInitiates appropriate workup and referral for transplant including vaccination and tissue typingIdentifies graft dysfunction and the common complications of chronic immunosuppressionCanadian approach to paediatric kidney transplant candidate selection and donor sourceImmunosuppression protocols and the management of rejection and opportunistic infectionLong-term surveillance, growth, transition and graft-loss prevention strategies

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Saved locally on this device.

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Target exams

RACP DWERACP DCEMRCPCH TheoryMRCPCH ClinicalABP General Pediatrics

Red flags

Life stages

infanttoddlerpreschoolschool-ageadolescentyoung-adult-transition

Care settings

outpatientwardpicutelehealth

Clinical exam formats

written-onlyracp-dce-long-caseracp-dce-short-casemrcpch-history-managementmrcpch-communicationrcpsc-structured-oral

Board mappings

Overview & Definition

A child whose kidneys have failed has end-stage kidney disease, and the question becomes how to replace what the kidneys did. There are two ways: dialysis, which filters the blood by machine or through the abdomen, or a kidney transplant, in which a healthy kidney from a donor is surgically placed in the child's lower abdomen. A transplanted kidney is the treatment of choice for almost every child with end-stage kidney disease, because it does what dialysis cannot: it works continuously, frees the child from the machine, restores near-normal growth and development, and improves long-term survival. [1]

The new kidney does not replace the old ones. The child's own failed kidneys usually stay in place, and the donor kidney is placed in the iliac fossa, the lower abdomen, where its blood vessels are joined to the large pelvic vessels and its ureter is connected to the bladder. The operation is the easy part. The hard part, which dominates everything afterwards, is that the child's immune system sees the donor kidney as foreign and will attack and destroy it unless the child takes immunosuppressant medicines every single day for life. This balance, between protecting the graft and avoiding the infections and cancers that immunosuppression permits, is what paediatric transplant medicine is about. [2]

Paediatrics Fellowship Pro

You have read the opening of this topic. The complete unit — every section and its primary-source references — is part of the Paediatrics Fellowship fellowship atlas.

References12Show ledger

[1]Roach JP, Bock ME, Goebel J Pediatric kidney transplantation. Semin Pediatr Surg, 2017.PMID 28964479
[2]Holmberg C, Jalanko H Long-term effects of paediatric kidney transplantation. Nat Rev Nephrol, 2016.PMID 26656457
[3]Winterberg PD, Garro R Long-Term Outcomes of Kidney Transplantation in Children. Pediatr Clin North Am, 2019.PMID 30454748
[4]Kidney Disease: Improving Global Outcomes (KDIGO) Transplant Work Group KDIGO clinical practice guideline for the care of kidney transplant recipients. Am J Transplant, 2009.PMID 19845597
[5]Chadban SJ, Barraclough KA, Campbell SB, et al KHA-CARI guideline: KHA-CARI adaptation of the KDIGO Clinical Practice Guideline for the Care of Kidney Transplant Recipients. Nephrology (Carlton), 2012.PMID 22212251
[6]Kizilbash SJ, Jensen CJ, Kouri AM, et al Steroid avoidance/withdrawal and maintenance immunosuppression in pediatric kidney transplantation. Pediatr Transplant, 2022.PMID 34786800
[7]Balani SS, Jensen CJ, Kouri AM, et al Induction and maintenance immunosuppression in pediatric kidney transplantation-Advances and controversies. Pediatr Transplant, 2021.PMID 34216190
[8]Weber LT Therapeutic drug monitoring in pediatric renal transplantation. Pediatr Nephrol, 2015.PMID 24763544
[9]Ng YW, Singh M, Sarwal MM Antibody-mediated rejection in pediatric kidney transplantation: pathophysiology, diagnosis, and management. Drugs, 2015.PMID 25813498
[10]Ashoor IF, Engen RM, Puliyanda D, et al Antibody-mediated rejection in pediatric kidney transplant recipients: A report from the Pediatric Nephrology Research Consortium. Pediatr Transplant, 2024.PMID 38602171
[11]Scaggs Huang FA, Danziger-Isakov L Infectious disease risks in pediatric renal transplantation. Pediatr Nephrol, 2019.PMID 29626241
[12]Holmberg C Nonadherence after pediatric renal transplantation: detection and treatment. Curr Opin Pediatr, 2019.PMID 30672821

Kidney transplantation in children

Also known as Paediatric renal transplantation · Kidney transplant in children · Preemptive kidney transplant · Living donor kidney transplant

high12 referencesUpdated 15 July 202625 min readVerification in progress

Practise this topic

Overview & Definition

Paediatrics Fellowship Pro

You have read the opening of this topic. The complete unit — every section and its primary-source references — is part of the Paediatrics Fellowship fellowship atlas.

References12Show ledger

[1]Roach JP, Bock ME, Goebel J Pediatric kidney transplantation. Semin Pediatr Surg, 2017.PMID 28964479
[2]Holmberg C, Jalanko H Long-term effects of paediatric kidney transplantation. Nat Rev Nephrol, 2016.PMID 26656457
[3]Winterberg PD, Garro R Long-Term Outcomes of Kidney Transplantation in Children. Pediatr Clin North Am, 2019.PMID 30454748
[4]Kidney Disease: Improving Global Outcomes (KDIGO) Transplant Work Group KDIGO clinical practice guideline for the care of kidney transplant recipients. Am J Transplant, 2009.PMID 19845597
[5]Chadban SJ, Barraclough KA, Campbell SB, et al KHA-CARI guideline: KHA-CARI adaptation of the KDIGO Clinical Practice Guideline for the Care of Kidney Transplant Recipients. Nephrology (Carlton), 2012.PMID 22212251
[6]Kizilbash SJ, Jensen CJ, Kouri AM, et al Steroid avoidance/withdrawal and maintenance immunosuppression in pediatric kidney transplantation. Pediatr Transplant, 2022.PMID 34786800
[7]Balani SS, Jensen CJ, Kouri AM, et al Induction and maintenance immunosuppression in pediatric kidney transplantation-Advances and controversies. Pediatr Transplant, 2021.PMID 34216190
[8]Weber LT Therapeutic drug monitoring in pediatric renal transplantation. Pediatr Nephrol, 2015.PMID 24763544
[9]Ng YW, Singh M, Sarwal MM Antibody-mediated rejection in pediatric kidney transplantation: pathophysiology, diagnosis, and management. Drugs, 2015.PMID 25813498
[10]Ashoor IF, Engen RM, Puliyanda D, et al Antibody-mediated rejection in pediatric kidney transplant recipients: A report from the Pediatric Nephrology Research Consortium. Pediatr Transplant, 2024.PMID 38602171
[11]Scaggs Huang FA, Danziger-Isakov L Infectious disease risks in pediatric renal transplantation. Pediatr Nephrol, 2019.PMID 29626241
[12]Holmberg C Nonadherence after pediatric renal transplantation: detection and treatment. Curr Opin Pediatr, 2019.PMID 30672821