Parents, your angel can save another

CHENNAI: Life savers come in all sizes. But when they are kids, the dichotomy of grief and happiness relief is real. While the family reels from the gut-wrenching pain and heartbreak of having their little one be an organ donor or denied an organ, the recipient’s family is overcome with joy and hope. The proverbial yin and yang of life never felt so real.

In the field of medicine, organ transplant among infants and children remains one of the most challenging parts of being a doctor. While kidney and liver are the commonly transplanted organs, the donation remains considerably low. Heart transplantation is rare due to the availability of valve replacement procedures.

Moreover, an adult’s heart or lungs cannot be transplanted into a child. And intestine transplantation comes with its own set of complications with a very high risk of infection.

Similar to the evaluation for adult transplant, the donor needs to be of the same blood group as the patient or have the O-type blood group. The donor should not have co-morbidities like diabetes and hypertension. Hypertension is acceptable if controlled by one drug.

Less transplants for kids

The willingness of families to donate their child’s organs cannot be denied. However, this is secondary to another medical conundrum: how well the donor organ would suit the recipient, as the risk of infection is very high among kids.

“We cannot take the organs from child donors because the risk of infection is high. It does not work on the same principle of brain deaths as in adults,” says a paediatric surgeon at a city-based government hospital (GH).

Organ transplants are expensive for everyone. It also includes a lifetime of regular follow-ups, medicines, dietary changes, etc., which middle-class families struggle with. “Yes, the cost of treatment is very high. Since transplants have become common only recently in the public sector, organ transplants in kids remain low, particularly at GHs. But still, we have gradually started doing them with partnership with private hospitals,” he added

The surgeon also pointed to another factor that impacts transplants in GHs in the State. “Transplant surgery requires a specific skill set. Given the huge footfall of patients at GHs in any city or district, the number of doctors and skilled staff to perform these surgeries is also limited when compared to private hospitals. So, the lack of workforce is also huge a challenge,” he stated.

Adapting organs a problem

Since getting a child donor is very difficult, most children requiring a liver or kidney transplant receive organs from their family members. It’s common in GHs for families to donate their organs for the kids.

So getting a donor for a child is not very difficult. The biggest challenge is whether the organ would fit into the child’s body,

“For kidneys, we can perform adult-to-children transplants as the life cycle of a kidney transplant is about 10-15 years. Liver transplant in children can last longer because the organ regenerates. However, since the majority of donors are adults, the main challenge is adapting the organ into a child’s body and fitting it in,” explained Dr R Velumurugan, head of paediatrics, Institute of Child Health.

Blood vessels need to be managed accordingly, and the size mismatch is almost always expected. “To avoid this, we try to manage the illness with medications so that they get the right donor as they grow up. This is one reason why transplants in children are low,” he added. “When kids are on immunosuppressants (to ensure that the organ is accepted), they are at high risk of getting infections, which can lead to more health complications.”

Renal transplant

Kidney transplant is one of the most common surgical procedures done in children. There are many cases of end-stage chronic kidney disease (CKD) in children that leave them with no choice but a transplant.

“The causes of CKD in kids are different from the causes in adults. The most common cause is congenital anomalies of the kidney and urinary tract,” elaborated Dr Navinath M, consultant nephrologist, Asian Institute of Nephrology and Urology. “It can include vesicoureteric reflux, or obstruction in the urinary tract or dysplastic kidneys. Sometimes, cystic kidney disease or chronic glomerulonephritis can also require a transplant.”

Concurring with him was Dr M Subashri, consultant of internal medicine and nephrology, Prashanth Hospitals, who added: “Congenital anomalies affect the normal development of kidneys and urinary tract in children. Around 35% of children born with CKD require an organ transplant.”

The second reason is an inflammatory condition that affects the filtering part of the kidneys. This accounts for another 20%.

The general question is: Will an adult-size kidney fit inside a small child? Most hospitals perform transplants in children once they weigh above 10-15 kg. So, it’s possible to consider an adult donor of any size and age for a child, no matter how young the recipient is.

“Living-donor kidney transplantation provides better survival of the donor-organ than an organ from a dead person. Other factors such as donor’s age, HLA matching, and sensitisation are also important,” she pointed out.

However, in donors from the same family as the patient, it becomes important to evaluate the donor for genetic causes of kidney disease before the transplant. “For all deceased donor recipients, kidneys from donors 18-49 years of age usually provide optimal graft survival and function,” stated Dr Subashri.

The outcome of a paediatric renal transplant is also similar to that of an adult renal transplant. Common factors are one-year survival (among more than 90% patients) and immunosuppressive non-compliance among adolescents. The latter can lead to poorer long-term outcomes, but those on regular follow-ups live long enough as adults.

Liver transplants 

Congenital defect is one of the most common reasons for a liver transplant in children, said Dr Naresh Shanmugam, consultant of liver disease and transplantation and paediatric gastroenterology, Dr Rela Hospital.

“There are kids born without a bile duct, which can be found out at birth. A bile duct drains the waste from liver to the intestine Usually, they have jaundice immediately after birth, pale stools and require transplantation at 6-7 months after birth,” he explained.

Another most common cause for liver transplantation in kids is genetic disorders. Children may have an absence of certain enzymes that break down protein, fats or carbohydrates.

“Due to absence of enzymes, the substrates become toxic and affect other organs of the body like kidneys and brains. Such children can have renal failure, brain failure or other organ damage,” explained Dr Naresh.

Even babies can undergo transplantation. The youngest to have undergone transplantation was a 37-day-old baby, and the smallest baby weighed just 2 kg. “The complex part about the liver transplantation is the blood supply, which the organ gets from two sources, and also has drainage. So, bleeding, organ rejection or infection are complications to watch out for,” he pointed out.

“But, the immediate success rate is about 95%. And for the long-term, around 95% of patients live almost a normal life for around 10 years. If the liver survives for 10 years with good care, they can survive longer.”

Outcomes, follow up

Transplantation improves the quality of life in children in terms of survival, growth, neuropsychological development, and also enables them to have a near-normal life like their peers.

But doctors also stress the need for regular follow-ups for a higher success rate and longer life-span. Apart from the medical management, surgical techniques and immunological factors that are unique to paediatric transplants, there are other factors that decide the success rate of a transplant in a child.

“These include the timing of the transplant, recurrence of the primary illness, adherence to treatment especially when they transition into adolescence, and if there are any persisting urological issues. In the broader context, evidence from scientific database proves that the overall patient survival rate 5 years after a transplant is around 95% and that of the graft survival is around 80-85% percent,” Dr Subashri explained.