Kidney transplantation in children: Viva

Branch 1: Rationale for preemptive living-donor transplant

The candidate should state that kidney transplantation is the treatment of choice over lifelong dialysis for a child with end-stage kidney disease because it improves survival, growth, quality of life and neurodevelopment. A strong candidate should explain that two factors independently predict superior graft survival: a living-donor kidney and a preemptive transplant performed before dialysis begins. The living-donor kidney, especially from a parent, survives longest because the kidney is healthy, the surgery is elective and the cold ischaemia time is short. A preemptive transplant avoids the morbidity of dialysis itself. ^[2]

If the examiner asks when to plan the transplant, the candidate should state that a preemptive transplant should be planned once the estimated glomerular filtration rate approaches 10 to 15 mL per minute per 1.73 square metres, because at that point dialysis is imminent. The living donor workup must be complete before dialysis is needed so the child never starts dialysis. This girl, with an eGFR of 13, is exactly at that threshold, so her father's donor workup should be expedited. ^[2]