Continuing improvement in cadaver donor graft survival in North American children: The 1998 annual report of the North American Pediatric Renal Transplant Cooperative Study (NAPRTCS)

This report of the North American Pediatric Renal Transplant Cooperative Study (NAPRTCS) covers the years 1987-1997, and analyses data on 3133 cadaver donor (CD) transplants performed in 2736 patients. There has been a steady decline in the number of CD transplants in children since 1996. Kidneys recovered from donors under 10 years of age accounted for 35% of all transplants in 1987, whereas by 1996 they comprised less than 20%. Caucasian children received 54% of CD transplants, whereas African-American children received 21%. Children under 6 years of age received 17% of CD transplants. Approximately half (46%) of the patients were induced with a T-cell antibody, and at 7 years post-transplant triple therapy is used in 70% of those with a functioning graft. Cyclosporin A is the primary immunosuppressant, with 92% of the patients being maintained on it at 5 years post-transplant. Among patients receiving a transplant in 1997, 11% were initiated with another calcineurin inhibitor, tacrolimus. At 15 days post-transplant 20% of the patients have had a rejection episode and by day 45, 46% have had an acute rejection. The probability of developing a rejection within the first year was reduced from 71% in 1987-1988 to 47% in 1995-1996. For infants (0-1 years) the first episode of rejection ends in graft failure or patient death in 18% of patients, compared with 8% for older children. In more recent years irreversible graft failure has been reduced significantly. Estimated graft survival probability for primary transplants at 1 year is 81%, at 3 years 72%, and at 5 years 64%. Recipient age < 2 years (relative risk (RR = 1.95), donor age < 10 years (RR = 1.26), absence of induction therapy (RR = 1.29), African-American race (RR = 1.34), and HLA-AB/DR mismatches (RR = 1.25) are relative risk factors for graft failure. One-year graft survival for primary grafts has shown a consistent improvement from 72% in the 1987-1988 cohort to 88% in the 1995-1996 cohort. Patient survival for primary grafts at 1 year is 96.3%, at 3 years 94.1%, and at 5 years 91.4%. For infants however, the three-year patient survival is 77%. Mean height deficit at baseline (n = 2648) is - 2.03 and at 5 years (n = 517) it is - 2.33. Steady improvement continues in short-term graft survival of CD transplants, however, at 7 years post-transplant CD graft survival is 16% less than that of living donor (LD) transplants. Measures to prevent acute rejection and thereby delay the onset of chronic rejection are needed. Additional areas of concern include the high mortality of infants and the continuing growth retardation for the majority of children over 6 years of age at the time of transplantation.