Successful rescue of a 3-year-old with end-stage renal disease by adult-sized kidney transplantation
Precise spatial magician - measurement, localization, and precise fluid control. Completing high-difficulty organ transplantation with extreme weight differences – a child of low body weight with congenital urinary tract abnormalities successfully received kidney transplantation of adult-size
2023.3.29
Presented by: Dr. Jei-Wen Chang (張瑞文), Director of Division of General Pediatrics, Department of Pediatrics, and Dr. Hsin-Lin Tsai (蔡昕霖), Director of Division of Pediatric Surgery, Department of Surgery
The Taipei Veterans General Hospital Children's Kidney Transplantation Team upholds the concept of "no child should receive long-term dialysis." Since August 2020, the team has successfully completed 6 cases of difficult kidney transplantation for children and adolescents with end-stage renal disease, helping them escape the lifelong suffering of dialysis. Among the patients cared for by the team, the transplantation rate before the age of 18 is as high as 100%, and the overall transplantation rate for patients is also as high as 57.1%. Considering the significant impact of chronic renal failure on the physical, mental, developmental, and quality of life aspects of pediatric patients, in March of this year, Dr. Jei-Wen Chang (張瑞文) initiated a special clinic for pediatric kidney transplantation, providing comprehensive medical care for pediatric kidney transplant recipients.
Division of General Pediatrics Director Dr. Jei-Wen Chang stated that kidney transplantation is the best treatment for children with end-stage renal disease, not only providing the best prognosis but also significantly catching up with their peers in terms of height, weight, and even intellectual development after successful transplantation. It is crucial to seize the golden time for transplantation. The Organ Donation Registration Center of the Taiwan Organ Registry and Sharing Center has also revised its organ allocation principles in accordance with international practices, gradually increasing the scores for children and adolescents under 18 years old waiting for kidney transplantation, in order to assist pediatric patients in receiving kidney transplantation opportunities as early as possible.
Pediatric Surgery Division Director Dr. Hsin-Lin Tsai (蔡昕霖) explained that end-stage kidney disease in children is often caused by congenital kidney diseases or abnormalities in the development of the urinary system, which is completely different from adults. Due to the small size and complex urinary structures in pediatric patients, as well as the psychological impact of multiple surgeries at a young age, understanding of pediatric kidney transplantation is often incomplete, resulting in missed opportunities for timely registration for transplantation. To avoid such regrets, in addition to actively urging parents to take this fleeting window of opportunity seriously, Dr. Tsai emphasized that the pediatric kidney transplantation team will overcome various challenges based on each child's condition, and develop personalized transplantation treatment plans to ensure successful transplantation.
3-year-old girl surnamed Hsu (許), was diagnosed with a rare recessive genetic kidney disease, which gradually developed symptoms of poor appetite and electrolyte abnormalities. Since the age of 2, she has been receiving regular peritoneal dialysis treatment, with 300-350cc of dialysis solution injected into the peritoneal cavity each time, using the peritoneum inside her body to remove waste products and excess fluids from her blood, while gradually expanding the peritoneal cavity. This is a successful case of rare peritoneal dialysis treatment at such a young age with stable condition in Taiwan. Due to the disease, the girl’s height before transplantation was only 86.3cm and weight was 11.5kg, at least 10cm shorter than children of the same age. After waiting for a year, she received a kidney donation from a 14-year-old girl in January this year, but the size of the kidney was already adult-sized (12x5x6cm), posing the first and biggest challenge for the transplantation surgery, which is how to implant the kidney into the girl’s small peritoneal cavity.
The transplant team performed precise calculations on the girl’s abdominal 3-dimensional volume and discovered that her original kidney had severe cystic changes. In order to create more space for the transplantation of an adult-sized kidney, the right kidney was removed first. To ensure adequate blood supply to the newly implanted adult-sized kidney, the blood vessels were anastomosed at a challenging location between the aorta and inferior vena cava (see Figure 1).
Preoperative abdominal space precise calculation simulation for transplantation surgery.
1.Total peritoneal cavity length was 20cm
2.The cystic kidney length was 7cm
C.&D. Simulation for transplanting a kidney sized 12x6x5cm
After Dr. Cheng-Yen Chen (陳正彥), the transplant surgeon, successfully harvested the kidney from the altruistic donor, the team at Taipei Veterans General Hospital led by Dr. Hsin-Lin Tsai, Chief of Pediatric Surgery, proceeded with the planned simultaneous right nephrectomy and kidney transplantation surgery for the girl. Due to the small size of the recipient, anesthesiology Dr. Shen-Chih Wang (王審之) spent two hours during the anesthesia process to place the central venous catheter and the preemptive hemodialysis catheter. The team made a midline incision of about 20cm, entered the abdominal cavity, mobilized the liver, duodenum, and right colon to the left side, and then removed the right kidney. The donated kidney was then anastomosed to the girl’s aorta and inferior vena cava for vascular connection, and the ureter was reconstructed using the girl's own right ureter. (Figure 2)
1.Midline abdominal incision, with complete mobilization of the right colon and duodenum. Then removed the right kidney. Mobilized inferior vena cava (1), abdominal aorta (2), right common iliac artery (3), and prepared for vascular reconstruction anastomosis.
2.After releasing the vascular clamps, the blood flow to the newly transplanted kidney is smooth.
3.The cystic and nonfunctional kidney, measuring up to 8cm
After 7 hours of surgery, overcoming challenges including anesthesia, the kidney transplant was successfully completed. The transplanted kidney immediately functioned properly, and by the second day after surgery, the kidney function had returned to normal. With careful postoperative blood pressure and fluid management, the recovery was excellent, and no further dialysis treatment was needed.
Another 9-year-old girl surnamed Chen (陳) who had a congenital single kidney and urogenital abnormalities, had undergone multiple reconstructive surgeries since childhood. Starting from the age of 6, she received peritoneal dialysis treatment due to electrolyte imbalances. Her mother believed that kidney transplantation was the most physiologically appropriate treatment, and once missed, it would be difficult to make up for it. Through referral from Changhua Christian Children's Hospital, she went through the process of registration for kidney transplantation and regular follow-ups in every 6 months at Taipei Veterans General Hospital. Benefiting from the revised scoring system for pediatric kidney allocation, she received a kidney donation from the Tzu Chi Foundation at the end of December 2022. Despite the challenges of complex adhesions from previous reconstructive surgeries and the weight difference between the adult donor (67kg) and the pediatric recipient (20kg), the surgical team overcame the difficulties in vascular anastomosis and maintaining stable blood pressure. By the second day after surgery, the kidney function was quickly restored to normal. Another teenage patient with kidney failure caused by congenital posterior urethral valves had been waiting for a kidney transplant for about 1 year and 2 months. Through precise evaluation and planning by the medical team, he also successfully underwent kidney transplantation in February 2023.
According to data from the Organ Donation and Transplantation Registration Center, currently there are only 22 children and adolescents in Taiwan who have registered for kidney transplantation. However, the number of new cases of children under 20 years old receiving dialysis treatment each year is approximately 20-40 people. In comparison, the number of children and adolescents receiving dialysis treatment far exceeds the number of those willing to undergo kidney transplantation. Before the Children's Day holiday, we sincerely share the successful experience of pediatric kidney transplantation at Taipei Veterans General Hospital, and urge parents of children receiving dialysis treatment to understand the importance of pediatric kidney transplantation, seize the golden opportunity for transplantation, and actively consider deceased donor or living donor kidney transplantation. Our pediatric kidney transplantation team expresses heartfelt gratitude to the assistance from the Organ Donation and Transplantation Registration Center and the selfless donation of organs from donors.
Dr. Jei-Wen Chang and Dr. Hsin-Lin Tsai explained the importance of kidney transplantation for children with end-stage renal disease.
The pediatric kidney transplant team work with the parents to provide comprehensive and holistic medical care for children with end-stage renal disease.
