INTRODUCTION:Renal transplantation is the therapy of choice for children with end-stage renal failure. There are many challenges associated with a paediatric programme in a developing country where organs are limited.METHODS:A retrospective review was undertaken of 149 paediatric renal transplants performed between 1968 and 2006 with specific emphasis on transplants performed in the last 10 years. Survival of patients and grafts was analysed and specific problems related to drugs and infections were reviewed.RESULTS:On review of the total programme, 60% of the transplants have been performed in the last 10 years, with satisfactory overall patient and graft survival for the first 8 years post transplant. At this point, transfer to adult units with non-compliance becomes a significant problem. Rejection is less of a problem than previously but infection is now a bigger issue--specifically tuberculosis (TB), cytomegalovirus (CMV) and Epstein-Barr virus (EBV) infections with related complications. A wide variety of drugs are available for tailoring immunosuppression to minimise side-effects.CONCLUSION:It is possible to have a successful paediatric transplant programme in a developing country. However, to improve long-term outcomes certain issues need to be addressed, including reduction of nephrotoxic drugs and cardiovascular risk factors and providing successful adolescent to adult unit transition.

The first patient was a 29-year-old woman with chronic renal failure with crescentic mesangiocapillary glomerulonephritis. She received a cadaveric transplant in April 1996. She had good initial renal function and was maintained on cyclosporine, azathioprine, and prednisone. She unfortunately lost renal allograft function due to chronic rejection after 2.5 years, and she was recommenced on hemodialysis. Immunosuppression was discontinued. The patient developed a persistent intermittent fever and subsequently developed mild graft tenderness and haematuria necessitating a graft nephrectomy. The histology of the graft showed caseating granulomata, with acid-fast bacilli seen on Ziehl-Neelsen staining. No other sites of past or present tuberculosis were identified. The patient was commenced on anti-tuberculous therapy consisting of rifampicin, isoniazid, ethambutol, and pyrazinamide.

The management of patients with end-stage renal failure (ESRF) poses worldwide technical, moral, financial and social dilemmas. In order to move into the future in an unencumbered way, many concepts of the past will need to be discarded or radically modified. In South Africa we have a unique but short-lived opportunity to do just that before our current practice again becomes accepted dogma. Our current approach, with few exceptions, has led us to assume that pursuit of 'the ideal' automatically resutts in an optimal outcome. Due regard for the overall price we pay and the likelihood of attaining these 'ideals' have received less emphasis. Compromises may not seem ideal; calculated compromise, however, may surprisingly bring us closer to the attainable best. Issues to be considered include the following.