PAEDIATRIC RENAL TRANSPLANTATION IN MALAYSIA
CCM Lei, Koh ET, Murali S, Susan W, Yap YC, Lim YN
Institute of Urology & Nephrology, Hospital Kuala Lumpur
The first kidney transplant in Malaysia was done on 15th December 1975 with a living related kidney from his younger brother. The patient and kidney survived till 26.3.2006 when the patient died with a functioning kidney. The first cadaveric kidney transplantation was done in Malaysia in 1979. The cadaveric transplant programme was re-activated on 22.7.1992 when a brain dead American lady donated both her kidneys, one of them going to an 11 year old paediatric recipient. Since then, the kidney transplant programme has remained stable, with an average of about 30 cases per year and more than one third of them from cadaveric sources.
With improved medical care by 10 paediatric nephrologists in Malaysia, there is an increasing number of paediatric kidney transplants. There are 25 children being worked up with a view to living related transplantation. Despite a good adult kidney transplantation programme, paediatric renal transplantation remains a formidable challenge, worldwide. All paediatric kidney transplantations in Malaysia are done at the Hospital Kuala Lumpur and the present review includes cases from 2000 to 2007. There are a total of 58 recipients, with 23 from live donors. The number of transplants are ( cadaveric in [ ] ): 2 [7] in 2000, 2 [2] in 2001; 3 [1] in 2002; 1 [3] in 2003; 1 [2] in 2004; 5 [2] in 2005; 3 [7] in 2006; 6 [11] in 2007). There were 3 mortality: 2 cadaveric (1 graft rupture and 1 non-functioning kidney) and 1 from a live donor who suffered severe pulmonary hypertension. There were 3 nephrectomies: 2 cadaveric and 1 living related graft which at ruptured 3 weeks postoperative. There were 3 significant surgical morbidity, namely, 2 perinephric haematomas which subsequently resolved and 1 aortoiliac renal artery false aneurysm which was repaired with the help of the vascular team. One recipient required cystoplasty (for posterior urethral valve) before receiving a cadaveric kidney, which was unfortunately lost because of thrombosis 2 weeks post transplant. Many paediatric patients are on CAPD. If there is primary function on table, the Tenchkoff is removed at the time of transplantation. Ureteric reimplantation is via extravesical submusoacl tunnel over a ureteric stent..
Infarction is a well known problem of paediatric transplants mainly because of a mis- match in blood flow of large donor kidney and small vessels. The larger vessels of external or common iliac are used for anastomosis. The internal iliac may be used to vascularise any accessory artery. In 10 cadaveric paediatric transplants in 2006, 4 of them had ischaemia and 2 required a graft nephrectomy. The other 6 kidneys have satisfactory renal function. Most paediatric recipients have a body weight >15 kg; 2 patients with body weight 10 to 15 kg were transplanted in deserving situations. Cadaveric donors less than 2 years old were extremely challenging and there were a total of 4 of them. Two sets were transplanted enbloc and both did not do well: one had bleeding, possibly associated with heparin on the 8th postoperative day and another kidney infarcted on the 10th postoperative day. The other set of small cadaveric kidneys were transplanted in 2 separate recipients and one patient died of unrelated chickenpox and the other kidney is functioning well. One set of cadaveric donors were transplanted into 1 recipient, 1 in each iliac fossa and both kidneys are functioning well.
All patients were closely followed by paediatric nephrologists throughout Malaysia. In addition to above vascular problems, 1 patient had exploration for wound haematoma, 1 lymphocele, 2 ATN requiring dialysis. One patient re-started CIC for hypoactive bladder. One had angioembolisation for bleeding after renal biopsy. Infection contributes to significant morbidity: UTIs in 9, CMV infection in 1, Herpes in 1, lung infection in 2. The patients were closely monitored with immunosuppression and for recurrent primary disease (2 cases of recurrent nephrotic, FSGS noted).
PAEDIATRIC RENAL TRANSPLANTATION
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