Mentorship for Pediatric Kidney Transplant in Low- and Middle-Income Countries

Kidney transplant is the gold standard treatment for kidney failure. However, access to this life-saving procedure remains a challenge, particularly in low- and middle-income countries (LMICs). Although there is increased transplant for adults in LMICs, there is still variability in access to pediatric kidney transplants due to poor resources, in addition to lack of skilled personnel and training (1–3). To address this issue, many initiatives have been set up over the past decade, including the ISN-TTS Sister Transplant Centers program (a partnership between the International Society of Nephrology [ISN] and The Transplantation Society [TTS]) (4), the International Pediatric Nephrology Association Sister Renal Centers Program (5), and an outreach program of the International Pediatric Transplant Association (6). A recently published article in Pediatric Nephrology by Roberts et al. sheds light on the transformative impact of Transplant Links, one such initiative that seeks to address disparities and foster sustainable solutions for pediatric kidney transplant in LMICs (7).

Established in 2006, the Transplant Links Community (TLC) is a UK-registered charity wherein National Health Service specialists volunteer their time and mentorship to centers in LMICs, helping them create a viable kidney transplant program (8). Since its inception, the TLC has helped many centers in Africa, Asia, and the Caribbean to launch adult kidney transplant programs. It has also assisted in the establishment of pediatric programs in three Caribbean centers [the names of which were intentionally not disclosed by the authors]. The TLC mentors institutions through a unique, multi-tiered approach based on individual centers’ requirements and existing skills. It might assist institutions with developing de novo transplant programs, expanding pre-existing services, providing supplementary training to multidisciplinary teams, or facilitating site visits to other transplant centers in the UK.

Potential centers are identified after reviewing their existing nephrology, surgical, and nursing personnel and their available medical and laboratory facilities. The TLC also helps local teams commit to ethical frameworks (e.g., Declaration of Istanbul and Ethical and Policy Considerations in Organ Donation after Circulatory Determination of Death) and gathers political and funding support for the program. Once established, the team of doctors at the TLC undertakes in-person visits complemented by internet-based teaching and mentoring sessions.

A prior published study of TLC's 10-year outcomes shows excellent patient and allograft survival, and a significant number of supported centers have progressed toward self-sufficiency in adult kidney transplant (9). Unfortunately, the documented results for transplant in children have been dismal. Roberts and colleagues emphasize the difficulties the TLC faces when establishing pediatric kidney transplant programs (7). The primary obstacles encountered are:

• ▸insufficient expertise in pediatric specialty care and allied health fields

• ▸inconsistent access to immunosuppressive medications and therapeutic drug-level monitoring

• ▸the financial burden associated with post-transplant complications and care

• ▸non-adherence to medications

The relatively small number of potential pediatric transplant recipients also results in inadequate and inconsistent political support than what is required to sufficiently develop these programs (7). These challenges are unfortunately common and, to our knowledge, are shared by all LMICs in establishing sustainable pediatric kidney transplant programs.

Pediatric chronic kidney disease is associated with extensive morbidity and mortality, especially in LMICs. Although the TLC's model has been effective in setting up adult kidney transplant services in LMICs, significant hurdles exist in the pediatric domain. More efforts are urgently required to address the training gaps and to overcome additional barriers in developing pediatric transplant programs. Concerted effort is required from key stakeholders (Figure 1), including local transplant professionals, policymakers, and politicians, to overcome the existing challenges.

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Key stakeholders involved in pediatric kidney transplant in LMICs

Citation: Kidney News 16, 3

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