Pulmonary hypoplasia secondary to potter sequence and associated prolonged ventilation is the reason for tracheostomy. ESKD, multiple fluid overload issues, chronic lung disease, repeated lung infections were repeated challenges for tracheostomy weaning. Over time, granulation tissue with subsequent stenosis, calcification of the tracheal cartilage lead to tracheostomy dependence. The debate at this point is whether to do complex airway repair while on dialysis or proceed with kidney transplant followed by airway repair. Both have equal challenges; please share your views.
It will be advisable to have the airway problem resolved before such procedure but tracheostomy is already a resourse maintaining a correct function of the lung and airway, so, it is left to the anesthesis commitment to the transplant procedure without risks and I think that condition (tracheostomy) alone doesn't contradict transplantation but promotes the physiologic clinical state of the patient .
Complex airway repair/reconstruction could involve multiple procedures and subject the patient to risk for pneumonia and other potential systemic complications (e.g., infecdtion) that could affect a kidney allograft function under immunosuppression. Ideally it would be preferred for competent airway restored prior to kidney transplant procedure. By the way, the second larynx transplant in the U.S. (at UC-Davis in October 2010) was also a kidney-pancreas transplant recipient. See news story at:
http://abcnews.go.com/Health/WellnessNews/voice-box-transplant-recipient-talks-abc-news/story?id=12649144
The first larynx transplant in the U.S. (at Cleveland Clinic in 1998) is still functioning.
The Royal College of Surgeons issued a nice brief review in June 2011 at:
http://www.rcseng.ac.uk/news/docs/rcs_laryngeal_transplant_lo_res%20(2).pdf
This procedure is still considered experimental in nature.
It is Important to take care of respiratory issues before considering renal transplant.
As a nephrologist we all agree but there is a huge reluctance from transplant surgeon as these kind of patients are less ( relative to pediatrics)
If the dialysis is going well, I could conceive reconstructing the airway first as the preferred option. Infectious issues can only get worse with the required surgical/ENT interventions and subsequent wound healing which would all only be compounded further by immunosuppression.
Interesting dilemna and a very healthy discussion above. There is however no absolute answer (which is why the question has been posted here), and the real question is about risk appreciation by the clinicians and patient as well as the expertise for both specialities (ENT and nephrology/ transplant).
I think, that is necessary to consider that in the kidney transplantation the children will be immunosuppressed and so, more exposed to infection. The possibility of infection and risk of pneumonie from the reconstruction of airway is more elevated.
In my opinion is better to give the priority to airway and then to kidney transplantation.
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