Back-Table Reduction of a Deceased Adult Donor Kidney for Transplantation Into a Small Child: A Six-Year Follow Up.

BACKGROUND

Transplantation of adult-sized kidneys into very small pediatric recipients can be limited by pronounced donor-recipient size mismatch. Although intraperitoneal placement is often considered, extraperitoneal implantation may reduce abdominal morbidity, provided that the graft can be accommodated safely.

CASE PRESENTATION: We report transplantation of a left kidney from a 46-year-old deceased adult donor into a 15-month-old boy weighing 8.5 kg with congenital nephrotic syndrome and previous bilateral nephrectomy. The 14-cm graft had three arteries of comparable caliber. Because the right retroperitoneal space was insufficient to accommodate the graft, the upper pole, supplied by an independent polar artery, was resected ex vivo on the back table, reducing the graft volume by approximately one-third. The remnant kidney was implanted extraperitoneally with venous anastomosis to the inferior vena cava and two arterial anastomoses to the aorta.

OUTCOME: Immediate graft function was excellent. Serum creatinine returned to normal within 24 h and surveillance biopsies at 1 month, 1, 3 , and 5 years showed preserved renal architecture. At 6-year follow-up, the child measured 116 cm, weighed 16 kg, had blood pressure of 90/60 mmHg, serum creatinine of 0.66 mg/dL, and a urine protein-creatinine ratio of 0.26 g/g while receiving mycophenolate monotherapy.

CONCLUSION

In carefully selected circumstances, back-table reduction of a deceased adult donor kidney may be a technically feasible strategy to overcome extreme donor-recipient size mismatch in pediatric kidney transplantation without compromising medium-term graft structure or function.