Renal transplantation: Cincinnati Fetal Center

Infants with renal failure are often called for gastrostomy tube and peritoneal dialysis catheter placement within the first few days of life.

Babies that make urine are not likely to need peritoneal dialysis immediately but are likely to need it in the future.

Peritoneal dialysis catheters should ideally be left alone for a couple of weeks after placement if possible.

Gastrostomy tube placement is focused along the lesser curvature or close to it to preserve stomach tissue for potential future bladder augmentation by Doctor Reddy.

Gastrostomy tube placement is performed laparoscopic-assisted to visualize exact stomach location, then the camera is turned into the pelvis to position the PD catheter.

The nephrology team is generally good at predicting which babies will need a peritoneal dialysis catheter.

Hemodialysis catheters need to be fairly large caliber and are preferentially placed in the right internal jugular site because it provides a straight shot into the atrium.

Inguinal and umbilical hernias can develop when babies are on peritoneal dialysis.

Hernias in dialysis patients are generally left alone if they are not affecting dialysis mechanics or causing symptoms.

The ideal weight for infant renal transplantation is around 10 kg if the patient is not on peritoneal dialysis.

Infants on peritoneal dialysis have a more accommodating abdominal cavity and laxity in the abdominal wall, allowing transplantation at weights closer to 8 kg.

All infant renal transplant recipients at this center have been transplanted with adult donor kidneys.

An extraperitoneal approach is used for infant renal transplantation with an incision extending to the upper edge close to the costal margin.

Wound complications are the biggest complication from a general surgical perspective in infant renal transplantation, surprisingly more common than vascular complications.

Some infant transplant patients can only be closed at the skin level initially and develop leaks or dehiscence requiring biologic mesh (such as derma matrix) for closure.

In a 13-year follow-up study of gastrostomy tubes in babies, all G-tubes migrated superiorly onto the chest wall.

Placing gastrostomy tubes too close to peritoneal dialysis catheters creates infection risk early on because drainage can get underneath the PD catheter dressing when there is insufficient space between sites.

The standard gastrostomy tube insertion site is 2 finger breadths below the costal margin.

For patients with posterior urethral valves, gastrostomy tube location is placed high on the stomach toward the lesser curvature to preserve the ability to use a gastric segment for gastric augmentation later in life.

Some infants with posterior urethral valves will need urinary diversion with a vesicostomy placed about 1-2 finger breadths below the umbilicus, requiring mitigation of infection risks by spacing catheter sites appropriately.

Peritoneal dialysis catheters can be placed in a way that allows immediate use with lower volumes, though waiting for healing is preferable.

Amnioinfusions are performed when patients present for first imaging to assess the baby's capacity to swallow and see if the stomach fills.

Early onset large bladders that extend upward and push the diaphragm and stomach back may cause anatomical distortion that results in stomachs ending up higher long-term.