Although most pediatric renal allograft recipients are rejection free (56%), rejection is still the most common reason for readmission. Acute rejection usually occurs in the first 6 months posttransplant. The incidence is higher in cadaver (vs. living donor) recipients, recipients not given antibody induction (vs. those given antibody induction), and retransplant (vs. primary) recipients.6 The usual symptoms of rejection include malaise, weight gain, fever, abdominal pain, allograft tenderness, decreased urine output, and an elevation of serum creatinine. In small children, however, rejection is more subtle. Compared to adults, small children have less muscle mass. Therefore, serum creatinine, a byproduct of muscle metabolism, is lower. In addition, the change in serum creatinine seen with a decrease in renal function is much smaller in young children (vs. adults). Small recipients of adult kidneys also have significant renal reserve. Therefore, a large portion of the kidney can be lost (to rejection) before classic signs of rejection are obvious. For these reasons, the indications for renal biopsy in pediatric recipients include a 25% rise in serum creatinine over baseline, unexplained fever for five days, and new onset or worsening hypertension.5 In addition to the usual risks associated with renal biopsy (bleeding, hematuria, and a nondiagnostic biopsy), the small but real risk of allograft loss must be discussed. The biopsy can be performed percutaneously or open. Percutaneous biopsy can be done under general or local anesthesia with sedation. Children with intraabdominal grafts may require ultrasound or CT guidance for percutaneous biopsy.

The treatment of rejection depends of the severity of the rejection episode, the time between the transplant and rejection, and prior antirejection treatments. In general, recipients with early (< 1 month) posttransplant, biopsy proven rejection are treated with antibody and prednisone. Thereafter, rejection episodes are initially treated with prednisone; antibody is added if the rejection is prednisone resistant.

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