European best practice guidelines for renal transplantation. Section IV: Long-term management of the transplant recipient. IV.11 Paediatrics (specific problems).

GUIDELINES: A. Kidney transplantation should be the treatment of choice for end-stage renal disease (ESRD) in children (up to 16 years of age). Because the incidence rate of ESRD is very low, approximately 1-2 children per million general population or 4-6 children per million childhood population, kidney transplantation in children should be performed in specialized paediatric centres with multidisciplinary experts, i.e. transplant surgeons, anaesthetists and paediatric nephrologists, and optimally should be supported by psychologists, paediatric nurses and social workers. B. Due to the urgent need for transplantation, children should have priority in the allocation systems. In addition, pre-emptive transplantation from either live or cadaveric donors should be offered to all paediatric transplant candidates whenever possible. These protocols will reduce the time on dialysis, thus limiting the retardation of growth and development. C. Absolute contra-indications to renal transplantation in children are extremely rare but should be respected: uncontrollable malignancy, ABO incompatibility, the presence of a current positive cross-match or multi-organ failure. There are few relative or transient contra-indications: history of cancer (Wilms tumour), viral infection (HIV, HBV, EBV), very young age (<6 months), severe mental retardation and/or additional disabilities. D. In contrast to adult patients, primary renal diseases responsible for ESRD in children are mostly congenital and hereditary disorders (60%). Children with massive vesico-ureteric reflux or permanent urinary infection should undergo nephroureterectomy to avoid the development of sepsis. In children with ESRD not due to any urinary tract malformation, pre-transplant bilateral nephrectomy of the native kidney should be considered in the case of severe arterial hypertension, heavy proteinuria or risk of renal cancer. E. Psychosocial evaluation of future transplant recipients and their parents is necessary in assessing compliance with management of dialysis and after transplantation. Poor compliance worsens the outcome of paediatric renal transplantation. F. Routine childhood vaccination should be completed whenever possible prior to transplantation, in addition to vaccination against hepatitis B and varicella. G. The pharmacokinetics of immunosuppressive drugs often differ between adult and paediatric recipients. Therefore, drug monitoring is mandatory in order to find the correct drug dosage. H. Today the actuarial probability of graft survival at 1 year should exceed 90% in unselected renal transplant children, and the acute rejection rate should be lower than 30%. I. Special attention should be paid to specific risk factors in paediatric transplantation, such as thrombotic complications, EBV and CMV infections, post-transplant lymphoproliferative disease (PTLD) and recurrence of original renal disease, mainly in patients with focal segmental glomerulosclerosis (FSGS) or atypical haemolytic-uraemic syndrome (HUS).