Surgical Complications and Evolution of Grafts in Children with Renal Transplantation at Cayetano Heredia National Hospital

doi:10.4236/ojneph.2013.33023

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Open Journal of Nephrology, 2013, 3, 124-127

http://dx.doi.org/10.4236/ojneph.2013.33023 Published Online September 2013 (http://www.scirp.org/journal/ojneph)

Surgical Complications and Evolution of Grafts in

Children with Renal Transplantation at Cayetano

Heredia National Hospital

Roberto Sanchez1,2*, Reyner Loza2,3, Cesar Loza2,4, Luis Zegarra1,2

1Surgery and Urology Unit, Department of Surgery, Cayetano Heredia Hospital, Lima, Peru

2Renal Transplant Unit, Cayetano Heredia Hospital, Lima, Peru

3Paediatric Nephrology Unit, Department of Pediatrics, Cayetano Heredia Hospital, Lima, Peru

4Nephrology Service, Department of Medicine, Cayetano Heredia Hospital, Lima, Peru

Email: *[email protected]

Received April 18, 2013; revised May 9, 2013; accepted June 10, 2013

which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Obje ctiv e: This study aims to determine surgical complications and graft outcome in children undergoing renal trans-

plantation at Cayetano Heredia National Hospital (CHNH). Materials and Methods: A case study series focused on

the incidence of surgical complications and graft outcome in pediatric patients with end stage renal disease (ESRD) who

underwent renal transplant (RT) between December 2007 and March 2011. Results: The study described 29 pediatric

transplant patients whose average age was 13.69 ± 3.38 (6.2 - 17.9) years. The etiology of end stage renal disease

(ESRD) was renal hypoplasia in 12 patients (41.38%), primary glomerulopathy in 10 patients (34.48%), obstructive

uropathy in 4 patients (13.79%), vasculitis in 2 patients (6.9%) and hemolytic uremic syndrome (HUS) in 1 (3.45%)

patient. There were 11 surgical complications (34.48%): 2 cases of arterial thrombosis, 3 cases of urinary fistula, 3 of

lymphocele, 1 of venous thrombosis, urinoma and perineal collection. The follow-up time was 15.84 ± 12.19 months.

Graft survival at 12, 24, and 40 months was 89.29%, 77.16% and 77.16%, respectively. Conclusion: Surgical compli-

cations and graft survival in pediatric renal transplantation in our series did not differ from other published series.

Keywords: Children; Terminal Chronic Renal Disease; Renal Transplantation; Surgical Complications

1. Introduction

ESRD, defined as a permanent loss of the kidneys’

ability to filter waste from the circulatory system, is a

global public health problem of growing proportions [1].

Its prevalence in the pediatric population fluctuates be-

tween 5 to 10 children per million per year. Forty years

ago, children with ESRD died. However, current renal

replacement (RRT) therapies used in children have

changed this bleak picture significantly, enabling almost

all children to be treated by dialysis or renal trans-

plantation (RT). RT has been shown to be the therapy of

choice for this population, resulting in better long-term

survival and quality of life [2]. The costs of transplanted

organ maintenance are low compared to other methods of

RRT. Dialysis provides only a fraction of normal renal

clearance, relieves but does not remove uremic symptoms

such as fatigue and anorexia, and does not resolve the

anomalies of growth and development. In contrast, RT

can provide kidney function equivalent to 40 to 80 per

cent of normal renal function [3-8]. Advances in

anesthesia, surgical techniques, and the discovery of

immunosuppressants have allowed a progressive reduc-

tion in the contraindications to this procedure, even

though the biological behavior and potential compli-

cations in transplanted children differ to those in adults

[4,9,10]. Globally, surgical complications affect survi-

val and renal graft loss, so early diagnosis and prompt

treatment are important. Surgical complications in renal

transplantation are defined as complications that occur

during surgery and the postoperative follow-up. They are

classified as vascular, urological, and collections and

have an incidence ranging from 1% to 38% [9-15]. RT

surgery has been performed in Peru since the 1960s.

Augusto Hernandez Mendoza, a urologist, performed the

first RT, and followed by Raul Romero Torres, who es-

tablished the transplant unit at the Naval Medical Center

*Corresponding author.

R. SANCHEZ ET AL. 125

in August 1969. In the same year, the first kidney trans-

plant was carried out under the Peruvian social insurance

system [16]. In July 2007, a renal transplant pilot pro-

gram at Cayetano Heredia National Hospital was funded.

In the same year, the CHNH was accredited by the

National Organization of Organ and Tissue Transplants

(ONDT) as a transplant-donation center, performing its

first kidney transplant on December 14, 2007, on a

pediatric patient [17]. To date, 51 patients, both adults

and children, have received transplants. The aim of the

present study was to describe the incidence of surgical

complications and evolution of the renal graft in children

who received transplants

2. Material and Method

Reviewed twenty-nine medical records of pediatric

patients (under 18 years) who received transplants (28

from living donors and 1 from a nonliving donor) between

December 2007 and March 2011. Any event that oc-

curred in the intra- and/or postoperative period, classified

as vascular, urological, and/or collection, was defined as

a surgical complication. In all transplants, lateral ana-

stomosis was performed of the artery and renal vein from

the donor to the external iliac vein and artery from the

receptor, respectively. For ureteral reimplantation the Polit-

ano-Leadbetter technique was performed in 2 patients,

and Lich-Gregoir in 27 patients, with posterior ureteral

catheterization in a systematic way. The Jackson-Pratt

drain was left in the first 22 patients and then laminated

to the retro peritoneum. Some patients had a urinary

Foley catheter for 5 days. The immunosuppression pro-

cess used was timoglobulina, daclizumab, and basilixi-

mab induction therapy. The maintenance therapy was

tacrolimus (Tac), mycophenolate mofetil (MMF), and

prednisone (Pd). The surgical complications found were

vascular thrombosis, primary vascular anastomosis fail-

ure, lymphocele, urinoma, urinary fistula, perirenal col-

lection, intestinal blockage by adhesions, and secondary

adherence to a previous umbilical hernia surgery. Renal

graft function was evaluated by measuring creatinine

serum and clearance of creatinine. A Doppler ultrasound

was performed on the graft 24 hours after transplantation

and during follow-up. For the analysis of the graft sur-

vival, loss of the graft was considered as a failure. Ac-

cording to Kaplan-Meier survival curves were performed.

Data processing and statistical analysis were carried out

using Stata version 11.

3. Results

The study population comprised 29 patients, 14 girls and

15 boys. The average age was 13.69 ± 3, 38 (6. 2 - 17. 9)

years. Sixteen of the children came from Lima (55.17%)

and 13 from other cities in Peru (44.83%)

The etiology of the ESRD in the patients was renal

hypoplasia in 12 (41.38%), primary glomerulopathy in

10 (34.48%), obstructive uropathy in 4 (13.8 %), vascu-

litis in 2 (6.9%), and hemolytic uremic syndrome (HUS)

in 1 (3.45%).

At the time of the RT, 19 patients (65.52%) were re-

ceiving peritoneal dialysis, 6 patients were receiving

hemodialysis (10.69%), and 4 patients (13.79%) both

therapies. The average time on dialysis was 3.26 ± 2.20

(0.65 - 7.7) years. The related living donors were moth-

ers in 23 (79.31%) patients, fathers in 3 patients (10.34%),

and grandfather in one (3.45%) patient. There was one

unrelated living donor (adoptive mother) and a cadaver

donor (Table 1).

In tests of histocompatibility (HLA), identity between

the recipient and donor was as follows: 6/6 in 1 case

(3.45%), 5/6 in 4 cases (13.79%), 4/6 in 11 cases

(37.94%), 3/6 cases in 10 (34.48%) cases, 1/6 in 2 cases

(6.90%), and 0/6 in 1 case (3.45%).

The duration of warm ischemia was 1.85 ± 0.94 (0.83 -

5) minutes, and cold ischemia 173.83 ± 205.11 (49 -

1200) minutes, with a median of 140 minutes. The dura-

tion of venous anastomosis was 31.86 ± 10.79 (18 - 60)

minutes and for arterial anastomosis 25.66 ± 10.6 (14 -

48) minutes. Nine donors had a double renal artery

(31.03%).

Average post-operative hospitalization was 21.52 ±

21.06 (7 - 113) days and the average follow-up period

15.84 ± 12.19 (0 - 39.57) months. The average glomeru-

lar filtration rate at the end of the observation period was

76.43 ± 28.86 (23 - 130) ml/min/1.73 m2. In the follow-

up period, the variation of post-transplant weight to basal

weight was 7.28 ± 6.57 (−2.4 - 25.9) kg and the average

size gain 6.65 ± 5.09 (0 - 20) cm (Table 2).

Of the 29 patients, 12 (34.48%) had surgical complica-

tions from the procedure and one had intestinal obstruc-

tion due to bands and adhesion without repercussion on

the renal function of the graft (the patient had a history of

surgery for umbilical hernia). Four patients had vascular

complications, with arterial thrombosis in 2 patients

(6.9%) and venous thrombosis in 1 (3.45%). Both led to

loss of the graft. A fourth patient had a double artery

with failure in the anastomosis in one; a reanastomosis

was performed using the same surgical procedure with-

out complications.

There were 3 urological complications (10.34%), all uri-

nary fistula (in 2 patients they were surgically repaired

and in one there was spontaneous closure with the use of

a urinary catheter). There were 5 collections, with diag-

nosis by ultrasound in all cases. Lymphocele occurred in

3 patients (10.34%) (one was resolved by laparoscopic

surgery and 2 reabsorbed spontaneously). There was one

case of urinoma and another of perirenal collection (Ta-

ble 3). Of the major medical complications, we found

R. SANCHEZ ET AL.

126

Table 1. Dialysis modality and type of donor in pediatric

transplants at the national cayetano heredia hospital.

Dialysis Modality n %

Peritoneal dialysis 19 65.52

Hemodialysis 6 20.69

Both 4 13.79

TOTAL 29 100

Type of donor

Mother 23 79.31

Father 3 10.34

Grandfather 1 3.45

Non-related donor 1 3.45

Cadaver donor 1 3.45

TOTAL 29 100

Table 2. Perioperative and evolutionary characteristics of

pediatric patients receiving transplants at the national

cayetano heredia hospital.

Variable X ± D.E.

Duration of warm ischemia (minutes) 1.85 ± 0.94

Duration of cold ischemia (minutes) 173.83 ± 205.11

Duration of arterial anastomosis (minutes) 25.66 ± 10.6

Duration of venous anastomosis (minutes) 31.86 ± 10.79

Glomerular filtration rate (ml/min/1.73 m2) (*) 76.43 ± 28.86

Hospitalization time (days) 21.52 ± 21.06

Variation of weight (kg) 7.28 ± 6.57

Variation of size (cm) 6.65 ± 5.09

Average follow-up (months) 15.84 ± 12.19

*Last control in the follow-up.

Table 3. Surgical complications in pediatric patients under-

going transplant at the National Cayetano Heredia Hospi-

tal.

n %

Vascular complications 4 13.80

Arterial thrombosis 2 6.90

Venous thrombosis 1 3.45

Primary anastomosis failure 1 3.45

Urological complications 3 10.34

Urinary fistula 3 10.34

Collections 5 17.24

Lymphocele 3 10.34

Urinoma 1 3.45

Perirenal collection 1 3.45

Other 1 3.45

Intestinal obstruction 1 3.45

that urinary tract infection occurred in 9 patients (34.61%)

and a sharp rejection in 7 (26.92%).

The overall graft survival 12, 24, and 40 months after

renal transplantation was 89.29% (IC95%: 70.36 - 96.41),

77.16% (IC95%: 51.82 - 90.28), and 77.16% (IC95%: 51,

82 - 90.28) respectively (Figure 1). There were 5 graft

losses (17.24%) after discharge from hospital with a

functioning kidney: 3 due to vascular complications and

2 to medical complications (one due to nephrotoxicity to

tacrolimus and the other to lack of adherence to the treat-

ment).

4. Discussion

In our series, the most common etiology of the TCRD

was renal hypoplasia, followed by the primary glomeru-

lopathies, similar to that reported by Palacios et al. in

Chile [4]. In the area covered by the Latin American

Pediatric Nephrology Association (ALANEPE), the lead-

ing causes are obstructive uropathy and chronic glomeru-

lopathy. In contrast, in the North American Pediatric Re-

gistry Transplant Cooperative Study (NAPRTCS), renal

hypoplasia and obstructive uropathy are reported as the

most frequent [14]. In Argentina, the primary cause in

children is hemolytic uremic syndrome [8]. Our in-

cidence of surgical complications was 34.48%, which is

similar to figures in the literature, highlighting that we

have considered minor surgical complications that are

usually not reported by other series such as El Atat et al.

(30%) and Barba et al. in Spain (38%) [11,12]. The inci-

dence of vascular thrombosis was 10.34%, which is com-

parable with other series such as El Atat et al. (18.9%),

Palacios et al. in Chile (9.2%), and Irtan et al. (13.9%) in

France. In our series, 2 cases of vascular thrombosis were

diagnosed during surgery and 1 on the fifth day post-

surgery by a Doppler ultrasound scan [4,11,18]. The uro-

logical complication in our series was urinary fistula.

Figure 1. General survival of the graft in pediatric patients

undergoing transplant at the National Cayetano Heredia

Hospital. Period 2007-2011 (N = 29).

R. SANCHEZ ET AL.

127

This differs from other reports in the literature, which

present problems between 3.1% and 30%, with vesi-

coureteral reflux being the chief complication [18]. Among

the most frequent collections, lymphocele (10.34%) should

be highlighted, which differs from that reported in adults

(49%) [6]. In all cases, diagnosis and follow-up were by

ultrasound. It should be noted that the graft was lost in

17.24% of cases in our study, a similar situation to that

reported by other series, for example Palacios (25%).

The overall survival rate of the graft was also similar to

Palacios’ data from Chile and Medeiros’ data from

Mexico [4,6]. In the NAPRTCS, the survival rate after 1

and 3 years was 96.5% and 91.5%, respectively, and in

ALANEPE 96% and 93% [14]. At study the mortality

rate of our patients is zero, while Medeiros in Mexico

reported a 4.3% mortality rate and the NAPRTCS a rate

of 4.8% after 3 years [6].

5. Conclusion

The rates of complications in pediatric renal transplanta-

tion surgery in our series and the survival of renal grafts

up to 40 months post-surgery do not differ from other

international series.

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