**2.4 Renal transplantation**

The ultimate treatment for pediatric patients with end-stage kidney disease, including that occurring as a consequence of nephrotic syndrome in the first year of life (NSFL), is renal transplantation. In the early years of renal transplantation era, the results were inferior in young children compared with older children or adults, but in the last few years, results have been improved tremendously mainly because its practice has substantially fine-tuned [14]. Chronic graft loss and opportunistic infectious complications can exist in spite of the improvement in immunosuppression demonstrating excellent results and leading to more 1-year graft survival rates. ESRD in children and adolescents is different from the adult population, in terms of the need to thrive well or have normal growth and have cognitive, psychological, social, and behavioral development. Therefore, the experience gained from adults cannot be extrapolated to pediatric population [15].

Preemptive transplantation (PET), which signifies transplantation prior to the initiation of dialysis, has recently been introduced in the pediatric population, as it is observed that children undergoing renal transplantation before the features of severe uremia sets in are helped by the avoidance of many of the associated longterm complications of ESRD and dialysis.

One of the common causes of ESRD is focal segmental glomerulosclerosis (FSGS). In idiopathic nephrotic syndrome, FSGS is a common pathologic diagnosis, especially in steroid-resistant cases. After kidney transplantation FSGS is known to recur and frequently followed by graft loss [16].

In renal transplantation, patient size and age matching are generally not essential. In fact, it was seen that there is very high rate of graft loss if one matches very young donors to very young recipients, as a consequence of thrombosis. Hence, now pediatric programs are considering the transplant of adult kidneys into small children, once the recipient attains a sufficient size, typically 6.5–10.0 kg of body weight. It has been seen that the peritoneal cavity of an infant has enough space to accommodate an adult kidney without fear of the compression of graft. It has been observed that if body weight of a child is more than 30 kg, the surgical procedure for a kidney transplantation will be similar to that in an adult. However, if the body weight is less than 10 kg, a midline longitudinal abdominal incision is required, and blood vessels from the donor are connected to the recipient's aorta and inferior vena cava. But a tailored approach is needed in children with a body weight of 10–30 kg, in terms of incision site/size, anastomoses of vessels, and allograft sites on the basis of the child's anatomy [17].
