Kidney transplant has become a common surgical treatment for patients with end-stage chronic kidney disease. Chronic kidney disease in children is a major health problem in the world, with increasing incidence and prevalence. Uzbekistan is a young country, and surgeons were able to first perform kidney transplant surgery only in 2017. Here, we report a case of the first successful kidney transplant to a child in Uzbekistan. The patient, a 13-year-old boy with end-stage chronic kidney disease due to abnormal development of the urinary tract, received a kidney transplant from his father as a living donor. The diagnosis (abnormal development of the urinary tract, insufficiency of the vesicoureteral segment, and ureterohydronephrosis on both sides) was revealed when the boy was 4 years old, which resulted in vesicoureteral segment plastic surgery at diagnosis. Ten years later, the patient developed end-stage chronic kidney disease. At day 9 posttransplant, creatinine levels decreased from 0.53 to 0.043 mmol/L. Ultrasonography and Doppler imaging showed normal graft size and echogenicity and adequate flow in the renal and iliac vessels. The patient was discharged on posttransplant day 10 in good condition. For children with chronic kidney disease, the main cause is congenital abnormalities of the kidney and urinary tract. Kidney transplant in pediatric patients has become a common surgical procedure and is associated with high success rates. Early and accurate diagnosis and timely management of abnormal development of the urinary tract can reduce the rate of end-stage chronic kidney disease in children.
Key words : Chronic kidney disease, Congenital abnormality of the urinary tract, End-stage renal disease, Pediatric surgery, Renal transplant
Chronic kidney disease (CKD) is a major health problem worldwide with increasing incidence and prevalence.1-5 The pediatric incidence of CKD in Europe is reported to be around 55 to 60 per million of age-related population, and the prevalence of stage 3 to 5 CKD is about 11 to 12 per million of age-related population.6-9 The total prevalence of end-stage renal disease (ESRD) is 80 cases per million of child-age population.10 The rate of ESRD increases with age, and ESRD mostly occurs at ages from 15 to 19 years.10 The incidence and prevalence of CKD are greater in male than in female patients because of the higher frequency of congenital abnormalities of the kidney and urinary tract in males.6 Although structural causes (eg, renal hypoplasia or posterior urethral valves) clearly predominate in younger patients, the incidence of glomerulonephritis increases in those > 12 years old.11,12 In fact, the main causes of CKD in children are congenital abnormalities of the kidney and urinary tract, steroid-resistant nephrotic syndrome, chronic glomerulonephritis, and renal ciliopathies; these account for approximately 49.1%, 10.4%, 8.1%, and 5.3% of cases, respectively.6,12,13
Kidney transplant is the therapy of choice in children with ESRD. In the young country of Uzbekistan, as shown elsewhere, CKD in children is a major health problem.14 In October 2017, surgeons in Uzbekistan were first able to perform kidney transplant procedures. Here, we report the first successful pediatric kidney transplant in Uzbekistan.
The patient was seen at the Surgical Transplantation Department of the Republic Research Centre of Emergency Medicine (Tashkent, Uzbekistan). The patient, a 13-year-old boy with end-stage CKD due to abnormal development of the urinary tract, had urinary incontinence symptoms since birth. Treatment at that time included antibiotic therapy for cystitis.
At age 4 years, the patient developed a fever due to urinary incontinence. At that time, a diagnosis was made of “congenital abnormal development of the urinary tract, insufficiency of the vesicoureteral segment, and ureterohydronephrosis on both sides.” In 2009, the patient received vesicoureteral segment plastic surgery. The patient had recurrent pain in the lumbar region on both sides and fever during the postoperative period. A course of antibiotics and anti-inflammatory therapy was administered every 6 months.
In June 2017, the patient presented with arterial hypertension, vomiting, and fever. The patient also had oliguria (50 mL daily diuresis) and swelling of the face and lower extremities. The patient was diagnosed with ESRD and received hemodialysis for 8 months.
All pretransplant investigations were performed in March 2018, and his 36-year-old father was identified as a living kidney donor. HLA investigations showed compatibility by HLA-A (1 match), HLA-B (2 matches), and HLA-DR (1 match). The crossmatch test was 10%. Laboratory results showed that the patient had symptomatic anemia (hemoglobin level of 94 g/L). Other blood chemistry results showed glucose level of 4.5 mmol/L, total protein level of 68.7 g/L, urea level of 58.7 mmol/L, creatinine level of 0.53 mmol/L, total bilirubin level of 11.5 U/L, potassium level of 5.7 mmol/L, aspartate aminotransferase level of 43.8 U/L, and alanine aminotransferase level of 15.2 U/L.
An electrocardiogram showed hypertrophy of the right heart. The echocardiography also showed dilatation of the left ventricle and right atrium and hypertrophy of the left ventricle. A cystogram revealed recurrence of insufficiency of the vesicoureteral segment and ureterohydronephrosis on the right side (Figure 1). Ultrasonography revealed wrinkling kidney and ascites.
For pretransplant preparation, the patient received 3 hemodialysis sessions. Although there was a slightly mismatched proportion between the donated kidney and the recipient’s body mass (body mass index of 15.6 kg/m2), the graft from the 36-year-old male donor was transplanted on the left side of the 13-year-old patient. Other than ESRD secondary to abnormality of the urinary tract, the patient had no other coinfections. Arterial anastomosis between the graft artery and the common iliac artery was terminolateral type. The venous anastomosis between graft vein and external iliac vein also was terminolateral type. Ureterovesical anastomosis was in accordance with the standard Lich-Gregoire procedure with double J stent. Duration of cold ischemia was 28 minutes, and duration of warm ischemia was 30 minutes. Graft function was immediately observed during surgery.
Postoperative therapy included standard triple immunosuppression of tacrolimus (4 mg/day), mycophenolate mofetil, and prednisolone. The patient also received antiviral therapy (ganciclovir), uroseptic agents (sulfamethoxazole and trimethoprim), antibiotics, and liquid infusion therapy. On day 1 posttransplant, diuresis was 7300 mL, which decreased to 3100 mL on day 7 (Table 1). Creatinine level decreased from 0.53 to 0.043 mmol/L over 9 postoperative days. Proteinuria level was 66 g/L on day 5 and 0.264 g/L on day 7 posttransplant. Proteinuria decreased further to 0.033 g/L on day 9 posttransplant.
Doppler ultrasonography showed normal echogenicity and graft size (11.0 × 5.9 сm) and adequate flow in the renal and iliac vessels. On posttransplant day 7, an echogenic formation on the suprapubic region was observed with ultrasonographic imaging. The lymphocele was evacuated by puncturing. The patient was discharged on posttransplant day 10 in good condition. The double J stent was removed on posttransplant day 21.
Chronic kidney disease is a major health problem worldwide with increasing incidence and prevalence. The main causes of CKD in children are congenital abnormalities of the kidney and urinary tract, steroid-resistant nephrotic syndrome, chronic glomerulonephritis, and renal ciliopathies. Kidney transplant procedures in children have become common surgical procedures and are associated with high success rates. Kidney transplant in Uzbekistan started in 2017. Our patient described here, the first kidney transplant in a pediatric patient, did not have timely diagnosis of abnormal development of the urinary tract and received plastic surgery at 5 years old, with postoperative symptoms of continued pain in lumbar regions and postoperative fever. A cystogram finally revealed insufficiency of the vesicoureteral segment on the right side, which was the reason for ESRD. For this patient, kidney transplant was the best treatment option and was successful. Early and accurate diagnosis and timely management of abnormal development of the urinary tract can reduce the rate of ESRD in children.
Volume : 18
Issue : 1
Pages : 44 - 46
DOI : 10.6002/ect.TOND-TDTD2019.O22
From the Republic Research Centre of Emergency Medicine, Tashkent, Uzbekistan
Acknowledgements: The authors have no sources of funding for this study and have no conflicts of interest to declare. The authors thank Professor Mehmet Haberal and his team from Başkent University who provided insight and expertise that greatly assisted the providing of transplantation surgery at the Republic Research Centre of Emergency Medicine in Uzbekistan. In addition, the authors thank Experimental and Clinical Transplantation journal editors for making final additions to our manuscripts.
Corresponding author: Pulat Sultanov, 3-39, M. Ismoiliy Street, Mirzo Ulugbek District, Tashkent, Uzbekistan, 100035
Phone: +998 97 3331602
Figure 1. Cystogram Showing Recurrence of Insufficiency of the Vesicoureteral Segment and Ureterohydronephrosis on Right Side
Table 1. Laboratory Results Posttransplant