Table 1.
General differences between adult and pediatric renal transplantation.
| Adults | Children | Implication | |
|---|---|---|---|
| Main causes of end stage renal disease | Diabetes and hypertension | CAKUT and glomerulopathies | Children may require urological surgery or vesical cathetherism after transplantation. Some glomerulopathies such as focal segmental glomerulosclerosis have a high rate of relapse after transplantation |
| Immune system | Thymic atrophy | Thymic output is robust | Antigen presentation, T cell proliferation and immune damage response change with age. This can explain the better results of graft survival in children younger than 5 years |
| Higher expression of CD40L on T cells | Low expression of CD40L on T cells | ||
| Reduced T cell effector function | |||
| Higher percentage of tolerogenic dendritic cells | |||
| Drug Pharmacokinetics and access to new drugs | Pharmacokinetics is well characterized in adult subjects before marketing. | Developmental changes in absorption, distribution, metabolism and excretion Drugs are often prescribed off-label. | Young children in general require higher doses in mg/kg than adults to achieve the same therapeutic drug levels. |
| New drugs can be prescribed soon after approval | Dose and therapeutic drug monitoring are extrapolated from adults | Metabolites, adverse reactions and toxicities may be different with different age groups, even within childhood | |
| Viral infection risk | CMV, EBV and BKV seropositive recipients are more common | Children might be seronegative to many viral agents | Primary infection after transplant can make the outcome worse (i.e., graft or patient loss, post-transplant lymphoproliferative disease) |
| Living donor 10 year graft survival | 65% in recipients 35–49 years | 80% in recipients <5 years | Adolescents need enhanced support for therapeutic adherence |
| 40% in recipients >65 years | 50% in recipients 12–17 years | ||
| Drug formulations of immunosuppressants | Easy to administer, enteric coated and extended release formulations available | Liquid oral or microgranule formulations are not available for all immunosuppressants | Compounding from adult formulations is needed, which can lead to serious errors in dosing |