U doctors advocate early transplant over dialysis in children

Having performed the first pediatric kidney transplant in 1963 — and more than 1,000 since then — the University of Minnesota has become one of the world's most aggressive advocates for the idea that children with failing kidneys should get surgery instead of dialysis.

But now surgeons at the U can back that up with powerful data from their half-century of experience.

Comparing surgeries over three eras since 1963, the doctors found that outcomes improved dramatically over time, and that children — even toddlers — now have better outcomes than adults following kidney transplants.

"The outcomes in the youngest children, 2 years and under, are amazing," said Dr. Srinath Chinnakotla, who leads the university's pediatric transplant program. "One-hundred percent survival [in the year following surgery] — you can't beat that."

Five-year survival improved over time as well. Recent pediatric transplant recipients were as likely to die from a motor vehicle accident as they were from a transplant-related infection, according to the study, which was published in the Journal of the American College of Surgeons.

Complications in the past often had to do with steroids that children needed to take after their transplants but struggled to tolerate.

Chinnakotla said a new steroid-free drug regimen has improved outcomes, along with improved surgical techniques. Most cases involve living kidney donations by parents, and Chinnakotla said it is remarkable how the intestines can simply be moved aside, even in babies, to make room.

"I push the intestine to the left and put the kidney on the right and it fits," he said.

Outcomes were better when kidneys came from living donors, the report concluded, and when transplants were performed "pre-emptively" before children received dialysis — a procedure that takes over the blood-filtering work of the kidneys.

Some doctors recommend dialysis first out of caution, but Chinnakotla said the study makes a strong case for surgery first — though it also has risks and consequences, including surgeries that living donors undergo.

And teenagers who don't stick with their medications after transplants continue to represent a challenge. The U is planning a study in which microchips are affixed to pill bottles, with remote alerts sent out if the bottles aren't opened as scheduled.

Jeremy Olson • 612-673-7744