The outlook for pediatric kidney transplant has dramatically improved during the last two decades and continues to improve in part due to the surgical techniques developed and ongoing research at Washington University School of Medicine.
An early pioneer in pediatric kidney transplant, St. Louis Children's Hospital remains a leader in the field, achieving a graft and patient survival rate well above the national average over the past decade.
In this segment, Dr. Vikas Dharnidharka discusses caring for a child that has had a kidney transplant and when to refer to a specialist.
Selected Podcast
Caring for a Patient with a Kidney Transplant
Featured Speaker:
Vikas R. Dharnidharka, MD
Vikas Dharnidharka, MD, pediatric nephrologist and director of the Division of Nephrology in the Department of Pediatrics at Washington University School of Medicine and St. Louis Children’s Hospital. Transcription:
Caring for a Patient with a Kidney Transplant
Melanie Cole (Host): Over the last 3 decades, research and surgical innovations at Washington University School of Medicine have dramatically improved the outcome of pediatric renal patients. What is caring for a renal transplant patient like for pediatricians? My guest today is Dr. Vikhat Dharnidharka. He is a Pediatric Nephrologist and a director of the division of nephrology in the Department of Pediatrics at Washington University School of Medicine and St. Louis Children’s Hospital. Welcome to the show, Doctor Vikhat. So please tell us some of the diseases leading to end stage renal failure in infants and children – kind of summarize some of those for us.
Dr. Vikhat Dharnidarka (Guest): Hi, Melanie, thank you for having me on the show. So the diseases that affect children and lead to the need for a kidney transplant are actually very different from those in adults. In the adult age group, diabetes and high blood pressure form about 50% percent of the group, but in children, about a third of the patients have problems that were present right at birth, because their kidneys didn’t form well in the womb or because they had some obstruction to the urinary flow, beyond the kidney, and that led to kidney failure. Another third of patients will develop glomerular diseases later on in life towards early childhood or later childhood. Those are usually diseases of the immune system. And then there is the big mix of other diseases and even in this day and age, about 5% of patients will present in full kidney failure, with very little symptoms, and we cannot find the cause in those patients
Melanie: So tell us about some of the characteristics of a pediatric renal transplant recipient that would make them a good patient for the after care.
Dr. Dharnidharka: We try to get almost every patient to a kidney transplant rather than keeping them on dialysis. We have found over the decades that a kidney transplant patient, particularly if successfully done offers a much better quality of life for these children. They are able to carry on with their schooling normally. We can replace many things with dialysis, but not everything that the kidney organ does for the body, so these patients have better health, better longevity and better quality of life, so unless there are extraordinary contraindications, most of our patients actually do go on to a kidney transplant. Obviously, the ones that are going to have a better social situation will do better. Age no longer matters in the past the youngest children were technologically more challenging from a surgical perspective – that no longer applies, and in fact the best longterm results can be obtained in some of the youngest children.
Melanie: So tell us about some of the pre-transplant interventions that you might like to discuss or you would want pediatricians involved in.
Dr. Dharnidharka: Pediatricians can really help with these patients in terms of trying to complete the immunization schedule to the best extent possible prior to the transplant.
Many of the vaccines which are live viruses cannot be administered post-transplant, particularly if these children are in the toddler age group, between say 1 to 3 years of age, there might be many vaccines that they have not yet received, or might be behind on. We try very hard in those situations through the pediatrician’s office to get as many of those vaccines administered as possible. They don’t have to be on the traditional gaps that are recommended – they can be accelerated, and getting specially the live viral vaccines such as MMR and chicken pox administered up front, helps the children with immunity later, and then helps their overall survival and wellbeing.
Melanie: So you mentioned vaccines and that some cannot get them pre-transplant. Let’s speak about post-transplant now, doctor. So what about well visits, what about vaccines that they might need afterwards? How is that all set up and how do you work with the pediatrician to set up? Does it follow the normal schedule, or does it have to be changed now?
Dr. Dharnidharka: Once the child has a kidney transplant, except for the live viral vaccines, all the other vaccines can be administered on the traditional schedule and we rely on the pediatricians’ offices to administer these. Of particular interest is the annual flu shot. We really need our children to get that regularly also the families of the children. We do not recommend
the Flumist for these families, even if it is not the recipient himself or herself. We don’t want that live virus in the vicinity of the child.
Melanie: And what about other sorts of preventive health, and even before that, what about drug side effects after transplant and if the pediatrician needs to give an antibiotic if there is
Strep throat or bronchitis? How do some of these things tie in?
Dr. Dharnidharka: Many of our patients live very far distances from our transplant center so a lot of their primary care is managed through the local pediatrician’s offices. These things include the management of a variety of simple infections. These children are at greater risk of bigger infections – but they can get the common cold, gastroenteritis, just like anybody else and these things we often depend on the local pediatrician, local laboratory to treat, and even sometimes local hospitals to manage the simpler things. Anytime these children have a fever above 101 degrees Fahrenheit or 38.5 degrees Centigrade, we do like to evaluate these children, particularly for kidney transplant patients. Getting a urinalysis, urine culture and blood culture are some of the minimum things we would like to get through the local pediatrician’s offices. Urinary tract infections are a very common issue for these children.
If there are bigger infections, then those often fall to us to evaluate and manage. A lot of the drugs that we use, the immunosuppressive medications that prevent rejection of the transplanted organ, raise that infection risk, but those drugs have their own side effects. For instance, Mycophenolate is a very commonly used medication used in 2 different forms, causes a lot of gastrointestinal side effects such as vomiting and diarrhea. Steroids, which we were using a lot of in the past and that we are using less of these days, causes things like bloating up of the face, a particular type of hairiness, obesity, high blood pressure, bone weakness. These are things again the pediatrician has to be aware of and keep in mind that certain side effects occur with certain drugs.
Cyclosporine causes gum hypertrophy and bushy eyebrows. So when they are aware of these effects, they can pick up that the children are starting to experience things before we might get to know and then we can adjust the medication if possible.
Melanie: And what about sports and managing their social life and the things that children go through normally? There is a pre-participation sports physical that most schools require, doctor, but when a child has a kidney transplant is this now different? Are they able to still do this, and what does the pediatrician need to know about that?
Dr. Dharnidharka: Our goal is to have all these children live as normal a life as possible. That is the big benefit to receiving a kidney transplant. Along the way, these children ask us a lot of different questions which come into the category of what you just asked about. In terms of sports, the new kidney, unlike what happens in heart or lung transplants, the new kidney is not placed where the old kidneys were.
The original kidneys that we were all born with are higher up to the back of the belly. They’re protected by muscle and the rib cage whereas the transplant kidney is placed by the surgeon in the front of the belly on the lower side, either on the left, typically and more commonly, and occasionally on the right. So these transplanted kidneys aren’t quite as well protected. We do encourage our children to participate in sports. We do recommend against certain very high contact sports which may offer direct injury to the kidney, for instance martial arts would be something we would recommend against, and in certain sports where there is the risk of occasional direct injury, such as soccer or baseball or football, we might recommend that they wear a protective guard over that kidney transplant. Other sports such as swimming, cycling, running, tennis – those we encourage them to participate in with no restrictions whatsoever.
There are children who also want to know about things like sexual activity and they can certainly participate with the appropriate safeguards and general health measures which we generally recommend to all children. They should get the human papilloma vaccine. We do recommend if they are going to be outdoors and exposed to the sun for long periods, that the risk of skin cancer is much higher than the general population because of these medications, so using sunscreen very religiously every 2 hours is particularly important, and if they want to get tattooed, while we don’t completely prohibit them, we do discourage them a little bit because of the higher risk of infection with the needles, and we do recommend that they take precautions to whatever extent possible in those situations.
Melanie: So in summary, doctor, tell other pediatricians what you would like them to know about caring for a patient with a kidney transplant and when to refer to a specialist.
Dr. Dharnidharka: Caring for a kidney transplant is something that will be in the pediatrician’s life going forward. We are doing nationally about 700 to 800 kidney transplants a year in children, and that means there has already been more than 13 to 15,000 done, and probably 5 to 6,000 in the current population that have that. Most of the specialized care happens at a few centers – the surgical care and the immediate postoperative care and the lifelong medical management, but the pediatrician can help us in so many of these different ways that I’ve just described. We have a lot of experience with these kinds of transplants here at St. Louis Children’s Hospital. We’ve been doing these kinds of transplants since the late 1960’s, over 300 now, we have a big team now, with lots of experience and great results, doctors with national reputation and research expertise and we have particularly good results in terms of getting them to a transplant early. The number that wait more than year is less than 5% in most cases, and because we do what is known nowadays as a “rapid steroid taper”, we are able to keep some of the drug side effects and the cosmetic issues to a much lower degree of impact than we had before.
Melanie: And what can a pediatrician expect from your team after referral insofar as communication with the referring physician and your team approach?
Dr. Dharnidharka: Once a child is referred for a kidney transplant these patients may have been in our own dialysis program or may not have needed dialysis before, or may have come from a pediatrician or another nephrologist. We go through an extensive evaluation of the recipient, that includes medical, surgical, psychosocial management. We then send a detailed report to the physician. The patient may have a living donor available, or may get placed on the deceased donor list. Once the patient gets a transplant, every time we see the patient in our clinic, we send a letter to the pediatrician explaining what we did in each of these visits and, where needed, we talk to the pediatrician if there is a medical issue that needs to be managed locally, or if there are specific complications that have come up, such as obesity or diabetes, where the pediatrician can help with.
Melanie: Thank you so much for being with us today, doctor for that great information. A physician can refer a patient by calling the physician access line at 1-800-678-HELP, that’s 678-4357. You’re listening to Radio Rounds with St. Louis Children’s Hospital. For more information on resources available at St. Louis Children’s Hospital, you can go to stlouischildrens.org, that’s stlouischildrens.org. This is Melanie Cole, thanks so much for listening
Caring for a Patient with a Kidney Transplant
Melanie Cole (Host): Over the last 3 decades, research and surgical innovations at Washington University School of Medicine have dramatically improved the outcome of pediatric renal patients. What is caring for a renal transplant patient like for pediatricians? My guest today is Dr. Vikhat Dharnidharka. He is a Pediatric Nephrologist and a director of the division of nephrology in the Department of Pediatrics at Washington University School of Medicine and St. Louis Children’s Hospital. Welcome to the show, Doctor Vikhat. So please tell us some of the diseases leading to end stage renal failure in infants and children – kind of summarize some of those for us.
Dr. Vikhat Dharnidarka (Guest): Hi, Melanie, thank you for having me on the show. So the diseases that affect children and lead to the need for a kidney transplant are actually very different from those in adults. In the adult age group, diabetes and high blood pressure form about 50% percent of the group, but in children, about a third of the patients have problems that were present right at birth, because their kidneys didn’t form well in the womb or because they had some obstruction to the urinary flow, beyond the kidney, and that led to kidney failure. Another third of patients will develop glomerular diseases later on in life towards early childhood or later childhood. Those are usually diseases of the immune system. And then there is the big mix of other diseases and even in this day and age, about 5% of patients will present in full kidney failure, with very little symptoms, and we cannot find the cause in those patients
Melanie: So tell us about some of the characteristics of a pediatric renal transplant recipient that would make them a good patient for the after care.
Dr. Dharnidharka: We try to get almost every patient to a kidney transplant rather than keeping them on dialysis. We have found over the decades that a kidney transplant patient, particularly if successfully done offers a much better quality of life for these children. They are able to carry on with their schooling normally. We can replace many things with dialysis, but not everything that the kidney organ does for the body, so these patients have better health, better longevity and better quality of life, so unless there are extraordinary contraindications, most of our patients actually do go on to a kidney transplant. Obviously, the ones that are going to have a better social situation will do better. Age no longer matters in the past the youngest children were technologically more challenging from a surgical perspective – that no longer applies, and in fact the best longterm results can be obtained in some of the youngest children.
Melanie: So tell us about some of the pre-transplant interventions that you might like to discuss or you would want pediatricians involved in.
Dr. Dharnidharka: Pediatricians can really help with these patients in terms of trying to complete the immunization schedule to the best extent possible prior to the transplant.
Many of the vaccines which are live viruses cannot be administered post-transplant, particularly if these children are in the toddler age group, between say 1 to 3 years of age, there might be many vaccines that they have not yet received, or might be behind on. We try very hard in those situations through the pediatrician’s office to get as many of those vaccines administered as possible. They don’t have to be on the traditional gaps that are recommended – they can be accelerated, and getting specially the live viral vaccines such as MMR and chicken pox administered up front, helps the children with immunity later, and then helps their overall survival and wellbeing.
Melanie: So you mentioned vaccines and that some cannot get them pre-transplant. Let’s speak about post-transplant now, doctor. So what about well visits, what about vaccines that they might need afterwards? How is that all set up and how do you work with the pediatrician to set up? Does it follow the normal schedule, or does it have to be changed now?
Dr. Dharnidharka: Once the child has a kidney transplant, except for the live viral vaccines, all the other vaccines can be administered on the traditional schedule and we rely on the pediatricians’ offices to administer these. Of particular interest is the annual flu shot. We really need our children to get that regularly also the families of the children. We do not recommend
the Flumist for these families, even if it is not the recipient himself or herself. We don’t want that live virus in the vicinity of the child.
Melanie: And what about other sorts of preventive health, and even before that, what about drug side effects after transplant and if the pediatrician needs to give an antibiotic if there is
Strep throat or bronchitis? How do some of these things tie in?
Dr. Dharnidharka: Many of our patients live very far distances from our transplant center so a lot of their primary care is managed through the local pediatrician’s offices. These things include the management of a variety of simple infections. These children are at greater risk of bigger infections – but they can get the common cold, gastroenteritis, just like anybody else and these things we often depend on the local pediatrician, local laboratory to treat, and even sometimes local hospitals to manage the simpler things. Anytime these children have a fever above 101 degrees Fahrenheit or 38.5 degrees Centigrade, we do like to evaluate these children, particularly for kidney transplant patients. Getting a urinalysis, urine culture and blood culture are some of the minimum things we would like to get through the local pediatrician’s offices. Urinary tract infections are a very common issue for these children.
If there are bigger infections, then those often fall to us to evaluate and manage. A lot of the drugs that we use, the immunosuppressive medications that prevent rejection of the transplanted organ, raise that infection risk, but those drugs have their own side effects. For instance, Mycophenolate is a very commonly used medication used in 2 different forms, causes a lot of gastrointestinal side effects such as vomiting and diarrhea. Steroids, which we were using a lot of in the past and that we are using less of these days, causes things like bloating up of the face, a particular type of hairiness, obesity, high blood pressure, bone weakness. These are things again the pediatrician has to be aware of and keep in mind that certain side effects occur with certain drugs.
Cyclosporine causes gum hypertrophy and bushy eyebrows. So when they are aware of these effects, they can pick up that the children are starting to experience things before we might get to know and then we can adjust the medication if possible.
Melanie: And what about sports and managing their social life and the things that children go through normally? There is a pre-participation sports physical that most schools require, doctor, but when a child has a kidney transplant is this now different? Are they able to still do this, and what does the pediatrician need to know about that?
Dr. Dharnidharka: Our goal is to have all these children live as normal a life as possible. That is the big benefit to receiving a kidney transplant. Along the way, these children ask us a lot of different questions which come into the category of what you just asked about. In terms of sports, the new kidney, unlike what happens in heart or lung transplants, the new kidney is not placed where the old kidneys were.
The original kidneys that we were all born with are higher up to the back of the belly. They’re protected by muscle and the rib cage whereas the transplant kidney is placed by the surgeon in the front of the belly on the lower side, either on the left, typically and more commonly, and occasionally on the right. So these transplanted kidneys aren’t quite as well protected. We do encourage our children to participate in sports. We do recommend against certain very high contact sports which may offer direct injury to the kidney, for instance martial arts would be something we would recommend against, and in certain sports where there is the risk of occasional direct injury, such as soccer or baseball or football, we might recommend that they wear a protective guard over that kidney transplant. Other sports such as swimming, cycling, running, tennis – those we encourage them to participate in with no restrictions whatsoever.
There are children who also want to know about things like sexual activity and they can certainly participate with the appropriate safeguards and general health measures which we generally recommend to all children. They should get the human papilloma vaccine. We do recommend if they are going to be outdoors and exposed to the sun for long periods, that the risk of skin cancer is much higher than the general population because of these medications, so using sunscreen very religiously every 2 hours is particularly important, and if they want to get tattooed, while we don’t completely prohibit them, we do discourage them a little bit because of the higher risk of infection with the needles, and we do recommend that they take precautions to whatever extent possible in those situations.
Melanie: So in summary, doctor, tell other pediatricians what you would like them to know about caring for a patient with a kidney transplant and when to refer to a specialist.
Dr. Dharnidharka: Caring for a kidney transplant is something that will be in the pediatrician’s life going forward. We are doing nationally about 700 to 800 kidney transplants a year in children, and that means there has already been more than 13 to 15,000 done, and probably 5 to 6,000 in the current population that have that. Most of the specialized care happens at a few centers – the surgical care and the immediate postoperative care and the lifelong medical management, but the pediatrician can help us in so many of these different ways that I’ve just described. We have a lot of experience with these kinds of transplants here at St. Louis Children’s Hospital. We’ve been doing these kinds of transplants since the late 1960’s, over 300 now, we have a big team now, with lots of experience and great results, doctors with national reputation and research expertise and we have particularly good results in terms of getting them to a transplant early. The number that wait more than year is less than 5% in most cases, and because we do what is known nowadays as a “rapid steroid taper”, we are able to keep some of the drug side effects and the cosmetic issues to a much lower degree of impact than we had before.
Melanie: And what can a pediatrician expect from your team after referral insofar as communication with the referring physician and your team approach?
Dr. Dharnidharka: Once a child is referred for a kidney transplant these patients may have been in our own dialysis program or may not have needed dialysis before, or may have come from a pediatrician or another nephrologist. We go through an extensive evaluation of the recipient, that includes medical, surgical, psychosocial management. We then send a detailed report to the physician. The patient may have a living donor available, or may get placed on the deceased donor list. Once the patient gets a transplant, every time we see the patient in our clinic, we send a letter to the pediatrician explaining what we did in each of these visits and, where needed, we talk to the pediatrician if there is a medical issue that needs to be managed locally, or if there are specific complications that have come up, such as obesity or diabetes, where the pediatrician can help with.
Melanie: Thank you so much for being with us today, doctor for that great information. A physician can refer a patient by calling the physician access line at 1-800-678-HELP, that’s 678-4357. You’re listening to Radio Rounds with St. Louis Children’s Hospital. For more information on resources available at St. Louis Children’s Hospital, you can go to stlouischildrens.org, that’s stlouischildrens.org. This is Melanie Cole, thanks so much for listening