Peri-operative kidney injury and long-term chronic kidney disease following orthotopic heart transplantation in children

Abstract

Significant advances in cardiac intensive care including extracorporeal life support have enabled children with complex congenital heart disease and end-stage heart failure to be supported while awaiting transplantation. With an increasing number of survivors after heart transplantation in children, the complications from long-term immunosuppression, including renal insufficiency, are becoming more apparent. Severe renal dysfunction after heart transplant is defined by a serum creatinine level >2.5 mg/dL (221 μmol/L), and/or need for dialysis or renal transplant. The degree of renal dysfunction is variable and is progressive over time. About 3-10 % of heart transplant recipients will go on to develop severe renal dysfunction within the first 10 years post-transplantation. Multiple risk factors for chronic kidney disease post-transplant have been identified, which include pre-transplant worsening renal function, recipient demographics and morbidity, peri-transplant haemodynamics and long-term exposure to calcineurin inhibitors. Renal insufficiency increases the risk of post-transplant morbidity and mortality. Hence, screening for renal dysfunction pre-, peri- and post-transplantation is important. Early and timely detection of renal insufficiency may help minimize renal insults, and allow prompt implementation of renoprotective strategies. Close monitoring and pre-emptive management of renal dysfunction is an integral aspect of peri-transplant and subsequent post-transplant long-term care.

Fig. 1

Factors contributing to kidney injury in paediatric heart transplant recipients. ECMO Extracorporeal membrane oxygenation, ESRD end-stage renal disease, ICU intensive care unit, IVIG intravenous immunoglobulin, VAD ventricular assist device

Fig. 2

Recommendations to protect renal function and facilitate renal recovery in paediatric heart transplant recipients. AKI Acute kidney injury, MCS mechanical circulatory support, CNI calcineurin inhibitor, CKD chronic kidney disease, CRI chronic renal insufficiency, RRT renal replacement therapy