When should gastrostomy tubes be removed following successful renal transplantation?

Enteral feeding using gastrostomies has been a quiet revolution in the management of infants and children with chronic and end stage renal failure over the last 15 yr with improvement in quality of life, nutrition, growth, cognitive development and metabolic control (1, 2, 3). Ensuring consistent delivery of fluids, medications and nutritional requirements may also delay progression to end stage renal failure and improve longterm survival (4). Many paediatric nephrologists recall the frustration and impotence shared with parents trying to feed children with little or no spontaneous appetite who would then reward their efforts by vomiting and could only observe anxiously as they failed to thrive. Most would agree that early instigation of gastrostomy feeding, which may be combined with an anti-reflux procedure if indicated has improved outcome especially for younger children. Parents who initially may be reluctant to have a gastrostomy placed often express their relief after the procedure as the burden of responsibility for feeding their child is deflected to a pump. Children can often feed normally during the day with the feed delivered overnight to meet nutritional requirements. Potentially damaging effects on the parent-child relationship may be averted with improvement in the outcome for transition to oral feeding post-transplantation. Gastrostomies are placed by an open procedure (gastrostomy tube initially which can then be replaced by a button when the track is formed) or endoscopically (percutaneous gastrostomy/PEG) (5). Minor complications are well documented for both approaches particularly exit site infections. However gastrocolic fistulae and migration of the retention disc can present as significant late complications of PEG placement and gastrocutaneous fistulae may need surgical closure following gastrostomy button removal (6, 7). There were initial concerns of an increased risk of fungal peritonitis in children on peritoneal dialysis with gastrostomies but this has not been identified as a risk factor in more recent registry data (8). However complications should be minimized by surgical expertise and careful surveillance with adherence to management guidelines including antibiotic cover for PEG placements and planned endoscopic PEG changes every 18–24 months. Children already established on peritoneal dialysis must have an open surgical gastrostomy placement as PEG placement is associated with an unacceptably high risk of peritonitis (5). Wong and colleagues paper is a timely reminder that children continue to need their gastrostomies after renal transplantation (9). It is certainly unrealistic to suddenly expect adherence to the demands of a markedly increased fluid intake and taking critically important medications. As they emphasize this is particularly so in the younger children who may have been enterally fed since birth and have limited experience of normal feeding as well as those with significant co-morbidity. It is very important to recognize the special needs of this latter group, which can comprise up to 35–40% of an end stage renal failure programme. Psychological disturbance may adversely affect transition to oral feeding and should be considered a significant comorbid factor. Poor graft function may also delay gastrostomy removal. Wong’s findings have confirmed that there is no definitive time for gastrostomies to be removed post-transplant and we would support this approach. In our practice at the end of 2004, 135 children were being followed up in the posttransplant clinic. Sixty-nine of these children had gastrostomies of which 54 (79%) have been removed. Three children use their gastrostomies for medications and fluids only i.e. 82% of the children previously needing gastrostomy feeds eat normally post-transplant. This is similar to the figure of 86% reported in our previous Pediatr Transplantation 2005: 9: 553–554 Copyright 2005 Blackwell Munksgaard