Background
The prevalence of ESRD (End Stage Renal Disease) is currently increasing as a global health problem in both developed and developing countries [
1‐
3]. Chronic kidney disease (CKD) is a disease associated with irreversible kidney damage that can progress to ESRD (end-stage renal disease) [
4‐
8]. ESRD is a destructive disorder that is associated with extreme mortality and cardiovascular complications, and certain problems such as developmental and psychosocial disorders occur in children, all of which severely affect quality of life [
9,
10]. Chronic kidney disease (CKD) is a public health problem that affects the general population and has significantly grown in recent years. Kidney transplantation is the treatment of choice for children with ESRD [
11,
12]. Transplantation also improves survival, growth, and health-related quality of life compared to dialysis. Due to new immunosuppressant drugs, the incidence of transplant rejection has decreased, and transplant success has improved. Since children receiving a kidney transplant have a longer life expectancy, it is important to maximize the transplant function and survival of the transplant in this population [
13‐
15]. In the literature, the 5-year survival of transplantation is 85% from living donors and 78% from deceased donors. Overall survival is steadily improving over time [
16]. The most common causes of ESRD in children are congenital, cystic, and inherited diseases, while primary and secondary glomerular diseases are the major cause in adolescents [
17]. A kidney transplant is the transfer of a healthy kidney from a compatible donor to the body of another person with a nonfunctional kidney and is the most promising option for patients with ESRD. The first organ transplant was performed in Boston, the USA, on 23/Dec/1954 with a living donor, and the first kidney transplant in the Middle East was performed in Shiraz, Iran, in 1967. The main sources of kidney transplantation are live donors (related to consanguinity or affinity), unrelated for financial benefit or altruistic motivation [
15,
18]. CKD in children presents with clinical characteristics specific to their age, such as the impact on growth. Also, some of the typical characteristics of pediatric CKD, such as the etiology and cardiovascular complications, represent variables that not only influence the patient’s health during childhood but also impact their future adult life. Moreover, CKD has an important psychosocial impact on the patient and the immediate family [
19,
20]. Studies show that kidney transplantation improves survival, life expectancy, and quality of life compared to dialysis treatment for ESRD patients. The present study is a systematic review and meta-analysis on the published studies to determine the Global Survival Rate of Graft and Patient in Kidney Transplantation of children.
Discussion
In this study, we investigated the survival of children and grafts after kidney transplantation. The results of our meta-analysis study show that the survival of 1-year, 3-year, 5-year, 7-year and 10-year transplants are 92, 83, 78.4, 67.1%, and 63.5, respectively. In all, one-, three-, five-, seven-, and 10-year graft survival is higher in Asia than on any other continent. North America has the lowest graft survival, except for 1-year of graft survival, whereas South America reports lower.
Survival rates of 1, 3, 5, 7 and 10 years after transplantation are 99.6, 97.3, 95.2, 74.6, and 87.9%, respectively. Except for the 1-year survival of patients, which is higher in Asia, the rest of the endpoints have a lower survival rate, which contrasts with the positive graft survival that seems favorable in Asia.
This study of children with ESRD showed that transplant survival and patient survival were not significantly different in several geographical areas. In a study by Lidwien A. Tjaden et al. [
24], Transplant survival rates were similar in different racial groups, but in the study, Asian patients were 2.5 times more likely to die than white patients, which differed from the results of our study. This was partly explained by differences in the initial distribution of kidney disease. However, another study suggests that differences in survival in kidney patients may be explained by racial differences [
24] .
Studies suggest that black and Hispanic patients have less access to kidney transplantation than white people, even after adjusting for the individual-level and neighborhood-level measures of socioeconomic status [
24‐
28]. These differences have been observed even in countries with universal access to health care, such as Indigenous children in Canada, Australia, New Zealand [
19,
20,
23], migrant children, adolescents, and young people in the Netherlands and Belgium [
29‐
32].
The causes of differences in kidney transplantation in children are thought to be multifactorial and may be influenced by a complex mix of biological, socioeconomic, and cultural factors. Given the minor differences in geographical areas, one of the hypotheses could be that primary kidney disease is significantly higher in areas with lower survival, which carries a considerable risk of disease recurrence and subsequent transplant loss. This increased incidence of ESRD explains, to some extent, the difference in access to transplantation [
24,
33‐
36]. However, we did not have the category of primary renal disease information available to assess graft access accurately. For this reason, only the difference in graft access does not fully explain all the variations of survival in different geographical areas, and extra non-biological factors are also possibly involved.
In addition, part of the difference may be due to patients’ varied opinions about the transplant. A Dutch study looking to accept live donor kidney transplants among patients with ESRD recently found other non-medical factors that led to reduced living-related donation and thus longer dialysis time among groups identified as a minority. These factors include different beliefs and attitudes toward donating due to insufficient knowledge and communication in their social network and misunderstandings and miscommunication between patients and their families [
37‐
40]. Behavioral considerations may point towards differences in access to kidney transplantation and patients’ sociodemographic and educational status [
37,
41‐
43]. The patients’ racial background may also influence the physician’s views on the patient’s behavior and the likelihood of successful treatment [
44‐
48].
Our study has several strengths, including comparisons between different continents and reporting both graft survival and patient survival at 1-year, 3-year, 5-year, 7-year, and 10-year. However, there are limitations. First, we did not have detailed information on patients from minority groups and races, so it is suggested that data collection on the racial background and socioeconomic status should be strongly encouraged in the records to investigate identified differences further. Also, we did not have comprehensive clinical information and socioeconomic status data for a sufficient number of patients. As a result, we could not separate biological effects other than primary kidney disease (e.g., blood type and genotype) from socioeconomic and racial backgrounds.
Conclusion
In conclusion, The findings suggest differences in graft and patient survival among children with kidney transplants. Perhaps well-known biological aspects related to racial backgrounds, such as primary kidney disease, can only partially explain this difference, and other biological and social aspects of the environment may be involved. Complex interactions between biological and social environments require further study to guide targeted interventions to reduce this disparity across racial subgroups. Although differences in ethnic origin, incompatibility with deceased donor kidneys, and types of kidney disease are unavoidable, interventions to improve preventive and living-donor transplantation are particularly needed in minority groups. In addition, more research is needed to identify and address the contribution of medical and socio-cultural barriers to preferential treatment among specific groups.
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