The challenge of third and subsequents kidney transplantion in children.

Introduction: Third and subsequent kidney transplants (TASKT) remain a surgical and immunological challenge, allegedly associated to a higher incidence of surgical complications and graft loss. Although the improved survival of pediatric transplant recipients has led to an increasing number of potential candidates for TASKT, reports regarding TASKT in children are practically non-existent.

Objective: The aim of this study was to describe the outcomes of pediatric TASKT in our program.

Patients And Methods: Retrospective study of TASKT in pediatric patients undertaken between January 2000-December 2024. Primary etiology of renal disease, cause of initial graft failure, history of acute rejection, surgical technique, surgical complications, and outcomes are reported.

Results: Among 296 kTs, 21 corresponded to TASKT. In one patient a simultaneous liver transplant was performed. Mean recipients age at TASKT was 17.50 years (SD:5.80) and mean weight 46.5 kg (SD:11.8). The most frequent primary renal disease was congenital nephrotic syndrome in 7 (33.3 %). Sixteen patients (76.1 %) received a third KT, 4 (19.04 %) a fourth, and 1(4.7 %) a fifth graft. The approach was extraperitoneal in 14 (66.6 %) and intraperitoneal in the remaining 7 (33.3 %). Three of those intraperitoneal grafts were hockey stick incisions in the flank secondarily converted to an intraperitoneal approach. We registered postoperative complications in 8 (38.09 %): hemorrhage (3), urinary leak (2), Page's kidney (1) and eventration of the surgical wound (2). There were no graft vascular complications in any case. With a mean follow-up of 11 years (SD: 14.14), graft survival was 90 %, 85 % and 79 % at 1,3 and 5 years, respectively. Patient survival was 100 % at 1, 3, and 5 years, respectively.

Discussion: Our pediatric KT program results support retransplantation in this high-risk pediatric population based on careful individual pretransplantation evaluation and planning, personalized surgical procedure and team expertise.

Conclusions: In our experience TASKT constitutes a medical and surgical challenge but can be associated with good outcomes and an acceptable rate of complications in expert centers. Preoperative multidisciplinary patient risk evaluation, meticulous surgical planning and careful vessel manipulation can prevent vascular complications. The extraperitoneal approach, even in previously occupied iliac fossae, is achievable and reduces the risk of intraperitoneal complications.