Pediatric renal transplantation in a South African teaching hospital: a 20-year perspective.
BACKGROUND
Renal transplantation is established as the standard of care for end-stage renal failure (ESRF) in the developed world. In emerging nations, the appropriateness of such costly interventions has been questioned. We undertook an analysis of all renal transplants undertaken under the care of the pediatric nephrology service at the Johannesburg Hospital, South Africa, in order to establish the outcomes of a transplantation service in a resource-constrained environment in a developing country.


METHODS
This was a retrospective review of renal transplantation undertaken at a single teaching hospital in Johannesburg, part of the University of the Witwatersrand. Two hundred and eighty-two transplants were performed between 1984 and 2003. Demographic characteristics of the transplanted population, diagnosis, morbidity, graft survival, and mortality were recorded.


RESULTS
Overall 1-, 5-, and 10-yr graft survival was 82, 44, and 23%. Overall 1-, 5-, and 10-yr patient survival was 97, 84, and 68%. The median graft survival for all transplantation episodes was 4.38 yr; 70% of patients survive 10 yr and 54% survive 20 yr or more. Although early graft survival was good, there was a more rapid rate of graft loss than when compared to results from developed centers with much poorer results at 5 and 10 yr. Causes of ESRF show marked variation between the races, and black patients have significantly worse outcomes than others. Compared with white patients, black recipients received fewer living donor kidneys (26 vs. 10%, p = 0.0019), a greater proportion of totally mismatched organs (56 vs. 36%, p = 0.015), less pre-emptive transplantation (7 vs. 35%, p = 0.0001) and experienced a higher rate of primary non-function (13 vs. 3%, p = 0.004). Surgical complications of transplantation occurred in 9% of recipients, but rarely led to graft loss.


CONCLUSIONS
Pediatric renal transplantation in Johannesburg can be accomplished with low complication rates, but medium and long-term graft survival is poor when compared with contemporary results achieved in developed countries. The difficulties of undertaking such complex, multidisciplinary interventions in a developing nation are daunting, but we believe that renal transplantation should still be the treatment of choice for all children with ESRF. The poorer outcomes in black recipients can be addressed by increasing education in our communities and expanding the pool of appropriate donors. Better institutional support would allow for improved long-term patient care.
Pitcher
G J
GJ
Division of Pediatric Surgery, Johannesburg Hospital and the University of the Witwatersrand, Johannesburg, South Africa. pitchmax@icon.co.za
Beale
P G
PG
Bowley
D M
DM
Hahn
D
D
Thomson
P D
PD
D000206:Actuarial Analysis; D000293:Adolescent; D044466:Asian People / Q000706:statistics & numerical data; D044383:Black People / Q000706:statistics & numerical data; D002102:Cadaver; D002648:Child; D002675:Child, Preschool; D005260:Female; D005500:Follow-Up Studies; D006084:Graft Rejection / Q000453:epidemiology / Q000208:ethnology / Q000209:etiology; D006085:Graft Survival; D006784:Hospitals, Teaching; D006801:Humans; D007223:Infant; D007676:Kidney Failure, Chronic / Q000453:epidemiology / Q000208:ethnology / Q000209:etiology / Q000601:surgery*; D016030:Kidney Transplantation / Q000009:adverse effects / Q000208:ethnology / Q000401:mortality / Q000706:statistics & numerical data; D019520:Living Donors / Q000706:statistics & numerical data; D008297:Male; D012189:Retrospective Studies; D013019:South Africa / Q000453:epidemiology; D016019:Survival Analysis; D013997:Time Factors; D016896:Treatment Outcome; D044465:White People / Q000706:statistics & numerical data