Pediatric kidney transplantation in Europe, a clinical snapshot pilot

Abstract

Background: Pediatric kidney transplantations are rarely performed, and there is limited knowledge about the diversity in current clinical practices across Europe. This study aims to explore the utility of clinical snapshot studies in identifying these disparities, establishing a foundation for future snapshot studies and standardization efforts.

Methods: A pilot clinical snapshot study was conducted, with invitations extended to all 109 pediatric kidney transplant centres in Europe. Each participating centre provided pre-, peri-, and postoperative data concerning their most recent thirty transplantations. The primary outcomes encompassed the evaluation of disparities in donor-recipient selection, surgical techniques, post-operative drainage procedures, and immunosuppressive therapy protocols. Secondary outcomes involved the analysis of rejection rates, incidence of infections, and graft survival.

Results: The study involved 439 patients from fifteen centres (14%) in twelve countries, with varying transplant volumes (range 1-29 transplantations per year) and follow-up periods. Significant differences were found among centres in terms of donor types, cold and warm ischemia time, pre-emptive transplant rates, and kidney transplant drainage methods. The rate of living donors varied between 3% and 90% and the median duration of cold ischemia ranged was 770 min after deceased donation and 147 min after living donation. Basiliximab was the dominant induction therapy, yet steroid withdrawal varied widely. Infection, rejection, and graft survival rates also varied significantly between centres.

Conclusion: This study revealed substantial variation in clinical practices among European centres performing pediatric kidney transplantations. These findings could serve as a stimulus for international dialogue and collaboration.

Keywords: Europe; clinical practice snapshot; donor type; graft survival; pediatric kidney transplantation; registries.

Figure 1

Overview of participating centers. (A) Geographical distribution of participating centers within Europe. (B) Number of pediatric kidney transplantations performed per year (n = 439). * Located in La Réunion, a French island not shown on this map. IQR, interquartile range; NTx, kidney transplantation.

Figure 2

Comparison of main characteristics by centre. Percentage of recipients depicted by centre (n = 439). All characteristics were statistically significant (p < 0.05) except for underlying disease. Urologic underlying disease is defined as either vesico-ureteral reflux, neurogenic bladder, or posterior urethral valves. Intra-abdominal placement is defined as intraperitoneal placement of the kidney transplant with anastomosis within the abdominal cavity.

Figure 3

Duration of ischemia by centre. (A) Minutes of cold ischemia time per donor type, median with minimum and maximum (n = 384). (B) Minutes of warm ischemia time per donor type, median with minimum and maximum (n = 267). The default maximum cold ischemia time was set at 1,000 min. When n < 3 data were not shown. *Indicates a significant difference between donor types.

Figure 4

Post-operative kidney and bladder drainage (n = 410). JJ, Double J stent; SPC, suprapubic catheter; TUC, transurethral catheter.

Figure 5

Immunosuppressive regimens in recipients that received their first transplantation (n = 384). (A) Immunosuppressive induction therapy by centre. (B) Immunosuppressive maintenance regimen prescribed at discharge by centre. Other: Tacrolimus monotherapy (n = 3), MMF + Prednisone (n = 2). ATG/ALG, Antithymocyte globulin/Antilymphocyte globulin; Aza, Azathioprine; MMF, Mycophenolate mofetil; Tacro, Tacrolimus.

Figure 6

Graft survival over time. Kaplan-Meier curve for graft survival with 95% confidence interval (n = 439). Number of remaining cases were indicated every 2 years.