Clinical management of the pediatric renal-allograft recipient.

Abstract

Management of the pediatric renal-transplant recipient requires careful pretransplant evaluation including psychosocial assessment and cautious donor/recipient selection. Early transplantation is preferable in infants less than 1 year of age if a suitable live-related donor is available. However, cadaveric-allograft transplantation is best reserved for patients older than 3 years with donors older than 5 years. Pre-emptive transplantation is suitable for approximately one fifth of the population. Medical preparation includes careful HLA-A, -B, and -DR loci matching, interferon treatment for positive hepatitis antigenemia, and acyclovir prophylaxis for a cytomegalovirus (CMV) antibody-negative patient to a seropositive donor. Postoperative management requires close monitoring of the patient's volume status with careful fluid replacement in the form of colloid and crystalloid. Immunosuppression involves multiple drug regimens that include corticosteroids, ciclosporin, azathioprine, antilymphocyte (or -thymocyte) globulin (ALG/ATG), monoclonal antibodies (OKT3), and a ciclosporin alternative: FK-506. Long-term complications dictate management and are divided into medical, surgical, immune, and infectious categories. These are predominated by treatment of acute and chronic rejection, hypertension, and CMV infection.