Pediatric Renal Transplant Research Articles

Revision ureteroneocystostomy in pediatric renal transplant patients for symptomatic vesicoureteral reflux and its effect on recurrent hospitalizations

Nearly 13,000 pediatric renal transplantations have been performed since 1987 with improving overall mortality and morbidity; however, graft infection remains a significant post-transplant concern. Recurrent urinary tract infections in pediatric patients with vesicoureteral reflux into their renal transplant can result in graft dysfunction, increased hospital cost, and impaired social and cognitive development due to time spent hospitalized. To evaluate the effect of revision ureteroneocystostomy on pediatric renal transplant patients with symptomatic vesicoureteral reflux in reducing hospitalizations and recurrent urinary tract infections. We retrospectively reviewed pediatric patients from 2002 through 2021 who underwent renal transplantation and required revision ureteroneocystostomy due to symptomatic vesicoureteral reflux. We analyzed the differences in days hospitalized, days hospitalized due to urinary tract infection, and treated urinary tract infections prior to and after revision ureteroneocystostomy. Ten patients requiring revision ureteroneocystostomy secondary to symptomatic vesicoureteral reflux were identified. There was no difference in the observation time between transplant to revision, and revision to last follow up (2.3 years (IQR 1.3-6.5) vs 1.7 years (IQR 1-6.7), p=0.4446). Overall, there was a significant decrease in the total number of hospitalization days (21.5 days (IQR 3-43) vs 5.5 days (IQR 0-9), p=0.006), total number of hospitalization days related to urinary tract infection (14.5 days (IQR 3-28) vs 0 days (IQR 0-3), p=0.008) and treated urinary tract infections (3.5 (IQR 3-6) vs 1 (IQR 0-2), p=0.019) following revision ureteroneocystostomy. The rate of hospitalization days for urinary tract infection was also significantly decreased following revision ureteroneocystostomy (7.15 per/year (IQR 0.4-11.75) vs 0 per/year (IQR 0-0.8), p=0.008). Symptomatic vesicoureteral reflux in pediatric transplant patients is difficult to manage and some patients will ultimately require surgery. There have been previous studies on the success of revision ureteroneocystostomy in treating reflux but no data on the reduction in hospitalizations associated with recurrent infections following the procedure. Limitations of this study are the small cohort size, retrospective nature, multi-surgeon study, and inherent selection bias due to evaluation of only surgical patients. Revision ureteroneocystostomy can limit the negative consequences of recurrent graft infections with reduction in hospitalization days and improved hospitalization rates due to urinary tract infections. The reduction in hospitalizations can greatly improve the cost of care along with quality of life for transplant patients and should be strongly considered in children with symptomatic vesicoureteral reflux who have failed conservative therapy.

Frequency of Bacteremia and Urinary Tract Infection in Pediatric Renal Transplant Recipients.

Our primary goal was to determine the frequency of bacteremia and urinary tract infections (UTI) in pediatric renal transplant recipients presenting with suspected infection within 2 years of transplant and to identify clinical and laboratory factors associated with bacteremia. We conducted a retrospective cross-sectional study for all pediatric ( < 18 years old) renal transplant recipients seen at 3 large children's hospitals from 2011 to 2018 for suspected infection within 2 years of transplant date, defined as pyrexia ( > 38°C) or a blood culture being ordered. Patients with primary immunodeficiencies, nontransplant immunosuppression, intestinal failure, and patients who had moved out of the local area were excluded. The primary outcome was bacteremia or UTI; secondary outcomes included pneumonia, bacterial or fungal meningitis, respiratory viral infections, and antibiotic resistance. The unit of analysis was the visit. One hundred fifteen children had 267 visits for infection evaluation within 2 years of transplant. Bacteremia (with or without UTI) was diagnosed in 9/213 (4.2%) and UTIs in 63/189 (33.3%). Tachycardia and hypotension were present in 66.7% and 0% of visits with documented bacteremia, respectively. White blood cell (12,700 cells/mm 3 vs. 10,900 cells/mm 3 ; P = 0.43) and absolute neutrophil count (10,700 vs. 8200 cells/mm 3 ; P = 0.24) were no different in bacteremic and nonbacteremic patients. The absolute band count was higher in children with bacteremia (1900 vs. 600 cells/mm 3 ; P = 0.02). Among Gram-negative pathogens, antibiotic resistance was seen to 3rd (14.5%) and 4th (3.6%) generation cephalosporins, 12.7% to semisynthetic penicillins, and 3.6% to carbapenems. Bacteremia or UTIs were diagnosed in one-quarter of all pediatric renal transplant recipients presenting with suspected infection within 2 years of transplant. Evaluations were highly variable, with one-third of visits not having urine cultures obtained. No single demographic, clinical or laboratory variable accurately identified patients with bacteremia, although combinations of findings may identify a high-risk population.

P13.02: Significant Fall in Living Donation Rates of Pediatric Kidney Transplants in Puerto Rico

Introduction: Living donation (LD) offers superior outcomes compared to deceased donor (DD) transplantation for patients with ESRD. In the US, an increment in LD rate was observed until 2001 and 2004, when LD rates began to decrease in peds and adult renal transplants (KTx), respectively. Knowledge about LD trends among children who have received KTx in PR is limited. We describe LD trends among pediatric KTx performed in PR from 1977-2013. Methods: Retrospective chart review of all children (0-18yrs) receiving KTx in PR from 1977-2013. Median (range) frequencies (percentages) were calculated. Results: From 1977-2013, 146 children, female: 39%, Hispanic: 100%, age: 14yrs (2-18yrs) were transplanted. 60% received LD and 40%DD. 75%LD were parents, 13%LD siblings, and 1%LD unrelated. 16%DD were from the US. Total number of transplants remained stable from 1980-2000 (1977-79: 5 KTx, 1980’s: 40 KTx, 1990’s: 40 KTx, 2000’s: 45 KTx, 2010-13: 16 KTx). LD rate decreased over time (77-79: 100%, 80’s: 85%, 90’s: 75%, 00’s: 31%, 10-13: 12%). 6%pts received 2nd KTx at 21yrs or younger, with 67% and 33% LD on 1st and 2nd KTx, respectively. Of these pts, female: 44%, age at first KTx: 12yrs(5,18yrs), and age at 2nd KTx: 17yrs(13-21yrs). Conclusions: Living donation in pediatric renal transplants has substantially declined in PR over the last 4 decades. Possible explanations include single parenting, medical unsuitability, shifting practice patterns (i.e. establishment of solid organ procurement organizations), and marketing strategies, among others. Additional studies are needed to better understand the causes of such decline and to develop strategies to increase LD among our children with ESRD. Research reported in this publication was supported by the Hispanic Center of Excellence U.S. Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Workforce University of Puerto Rico School of Medicine (Grant Number D34HP24463) and the National Institutes of Health (Award Number U54GM133807-01A1). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

248.10: COVID-19 Infections in Pediatric Renal Transplant Recipients

248.10: COVID-19 Infections in Pediatric Renal Transplant Recipients

243.9: Equality and Equity in Transplant for Children

Introduction: Thomas E. Starzl, conducted the first paediatric liver transplant in 1963, a routine successful clinical procedure today due to his pioneering efforts. India the second most populous country, 41% under 18 yrs of age, has followed on the heels of developed nations with 1522 pediatric transplants from 2013-2020 for all organs but majority done in private sector. To enable equality and equity, Govt of India has proposed establishing department of transplant medicine in major government hospitals, at least one in each state in the latest National Organ Transplant Program Guidelines. Our aim is to develop an SOP for the establishment of paediatric transplant units in line with the Transplantation of Human Organs and Tissues Rules 2014, starting with VMMC & SJH. Materials & Methods: In 2019, India reported 4,49,002 Road traffic accidents(RTA) with resultant 1,51,113 deaths. Delhi accounted for 5610 RTA with 1463 deaths.DD transplants prove to be exceptionally useful in diseases with high risk of recurrence particularly in children. VMMC & SJH is one of the largest govt tertiary care centres in Delhi catering to a large paediatric population and a large proportion of the RTA victims, the greatest source of deceased donor (DD) organs, if tapped. Living Donor Renal transplant is conducted in adult patients on a regular basis by urologists. A paediatric nephrologist being available, the paediatric renal transplant program can be started by a combined team of paediatric surgeons & urologists. Training in paediatric liver transplants can be done either locally in ILBS, Delhi or internationally through TTS-ILTS paired centers program similar to JIPMER, Pondicherry with St.James University hospital Leeds, UK. TTS in collaboration with NOTTO conducted an online survey of intensivists with regard to brain death declaration. The intensivists need to be trained for brain death declaration and donor maintenance to enable DD transplants. Augmentation of pediatric transplant intensive care beds and personnel is required along with round the clock lab facilities. Results: The Govts of Delhi, Tamilnadu, Kerala, Maharashtra, etc have issued have issued GOs for mandatory declaration of brain death in all patients who fulfill the criteria. DGHS has sought monthly submission of brain death data. Intensivist training for brain death declaration and donor maintenance was first started by NOTTO during the CAST 2019 congress and two more have followed. However, progress can only be achieved with implementation of training and establishment of dedicated centers.

332.3: Preoperative Systemic Immune-Inflammation Index, Platelet-Lymphocyte Ratio and Neutrophil-Lymphocyte Ratio in Predicting the Delayed Graft Function in Pediatric Renal Transplant Recipients: A Single Centre Study

332.3: Preoperative Systemic Immune-Inflammation Index, Platelet-Lymphocyte Ratio and Neutrophil-Lymphocyte Ratio in Predicting the Delayed Graft Function in Pediatric Renal Transplant Recipients: A Single Centre Study

P8.037: Changes in Body Composition After Renal Transplant in Children

Introduction: Due to the relationship between adipose tissue and cardiovascular outcomes, it is important to monitor the changes in body composition after renal transplant. The aim of the study was to describe the changes in body composition in children during the first-year post- renal transplant. Methods: We included a cohort of patients aged 5-18 years transplanted between 2014-2017, all signed informed consent/assent. A dual-energy X ray absorptiometry (DXA) and anthropometric measurement was performed in the first three months after renal transplant and 12 months afterwards. Bone mineral content (BMC, fat mass (FM), non-bone lean mass (LM) and the index lean mass/Fat mass was calculated to evaluate the proportion of lean mass related to fat. Results: 50 patients were included, 51% males, 69% adolescents. At baseline low height was found in 78%; by body mass index 69% were normal, 14% had overweight, 4% obesity and 12% were emaciated. By body composition median FM was 26% for female children, 27% for males; in adolescents it was 34% for females and 22% for males. At 12 months the frequency of subjects with normal weight increased to 80%, diminishing the frequency of overweight to 12% and obesity to 2%, only 6% continue emaciated. The changes in the body fat percentage in males was -0.01% whereas in females increased 0.03%, p>0.05. Conclusions: It is important to evaluate body composition changes in pediatric renal transplant receptors, we found that they continue with low height. No significant changes were found at 12 months in BF- LM in Mexican transplanted -children. Adolescent women tend to acquire more fat. Financed by Fondos Federales 2014/009.

347.1: Unraveling the Stage-Shift of Acute Rejection in Renal Allografts

Introduction: The lack of accuracy in current allograft monitoring methodologies for allograft monitoring underscores a critical unmet need for more accurate immunosurveillance to uncover the flux in alloimmunity. QSant – a non-invasive, urine based multi-analyte diagnostic test – was clinically validated to prognosticate injury, risk of evolution, and resolution of acute rejection. QScore—the composite score across measurements of DNA markers: the amount of cell-free DNA, fraction of methylated cfDNA, protein and metabolic biomarkers in the QSant assay—enables this risk prognostication. This study now explores the clinical utility of QSant across the alloimmunity gradient of 32–100 for the early diagnosis of allograft injury and rejection. Methods: Utilizing a large real-world dataset of contemporaneous kidney allograft biopsy and QSant data from 11 US kidney transplant centers, the QScore offers a dynamic view into the changing state of allograft injury and rejection in response to alterations in the patients’ immunosuppression regimen. First analysis included Q-Score distributions in the biopsy-paired validation (n = 162) and prediction (n = 91) data from the Yang cohort, which were collected between 2010 and 2018 [10]. Second was a new analysis of a real-world data (RWD) cohort, comprising of prospectively collected urine samples (n = 235). Results: The RWD cohort (n = 235) of both adult and pediatric renal transplant patients demonstrated a spectrum across the Q-Score distribution. Specifically, 37.9% of the samples were enriched for immune quiescence (Q-Score < 32); the remaining 62.1% were enriched for the injury/rejection spectrum (Q-Score ≥ 32). The QScore <32 classifies stable allograft recipients; QScore between 32-55 exposes a state of alloimmunity flux; and the score between 55-100 provides advanced alloimmunity. Serial monitoring by QSant across a subset of 32 patients (RWD cohort,) over a period of two consecutive quarters (timepoints 1 and 2), captures the essence of the alloimmunity flux (p-value: 0.086 by non-parametric Wilcoxon test). Patients in the immunoquiescent domain (31% [10/32]) by and large continue to be stable (with Q-Scores that track at <32) 22% [7/32]). However, 9.4% (3/32) of patients show Q-Score drifts above 32 with evidence of early rejection. Patients in the alloimmune injury domain follow three trajectories: i) a planar gradient in QScore across time, showing persistence of alloimmunity; ii) an increasing gradient, delineating patients moving into the mature acute rejection domain; iii) a decreasing gradient, delineating patients moving into the immunoquiescent domain, putatively in response to immunomodulation following assessment of active rejection (Figure 1). Conclusion: The observed alloimmunity flux suggested precision monitoring with QSant has the potential to differentiate higher-grade acute rejection episodes from sub-clinical rejection, thereby improving a transplant recipient’s’ quality of life.

243.4: Evolution of Polyomavirus BK and JC Viral Load in Pediatric Renal Transplant Recipients

Introduction: Polyomavirus-associated nephropathy (PVAN) occurs in 5% of renal transplant recipients (RTR) and is caused by Polyomavirus BK (BKPyV) and JC (JCPyV), at a very low rate. This disease causes a progressive impairment of renal function and ultimate graft loss. Monitoring of viral load with pre-emptive reduction of immunosuppression is the only proved preventive strategy to reduce the risk of PVAN. The aim of this study was to describe the evolution of BKPyV and JCPyV viral load in de novo pediatric RTR. Method: A prospective observational study was carried out in a pediatric RTR. Paired samples of serum and urine were collected at baseline (on the day of transplantation), then monthly for at least 9 months post transplantation (PostTx). Viral load of BKPyV and JCPyV was determined by a Multiplex Real Time PCR assay (transferred by Fedele CG,2012). Results: Fourteen patients were enrolled, the median age of the group was 13 years old (8-19) and 11 were male. The monitoring period was from 9 to 20 months (media 16). None of the patients developed PVAN during the study, but 11 (78%) of them tested positive, which were divided into three groups: 1.BKPyV positive (n=7) - they showed a pattern of viruria with a maximum between the 2nd and 7th month PostTx (median 8.5.108copies/ml), after this peak viral load diminished significantly over the time getting undetectable in 4 cases. Two patients had higher values at the maximum in coincidence with impairment of renal function. Viremia was detectable in all cases, but with intermittences and it has not shown a well-defined profile, the highest values were around 104copies/ml. 2.JCPyV positive (n=2) - both cases had JCPyV viruria without viremia with similar patterns: viral load was detectable from 2nd month PostTx and continued along the time with tendency to increase. 3.BKPyV and JCPyV dual positive (n=2) - BKPyV viruria and viremia were detected at low rates at the beginning, then appeared JCPyV viruria simultaneously but with higher viral load, and from 10th month PostTx to the end (17th month) only JCPyV viruria was detectable with the same upward trend as group two. Conclusion: We detected active infection of BKPyV in 64% (9/14) of the cases, although there was no occurrence of any case of PVAN. However, in cases with impair renal function it were observed a significant increase of viruria. There are different proposed algorithms for monitoring BKPyV viral load to identify patients at risk of PVAN. We found a characteristic pattern of BKPyV viral shedding in urine. Based on this finding we would recommend to strengthen controls between 2nd to 7th month PostTx to be more sensitive to detect patients with viruria higher than 107copies/ml, thus at more risk to develop viremia and consequently PVAN. Finaly, when PVAN is suspected and BKPyV is undetectable, JCPyV diagnose should be made, since it can cause PVAN as well although with low frequency, and we demonstrated its presence in 29% of the cases. Cesare Giovanni Fedele.

213.3: Long-term Outcome and Complications in Pediatric ABO-incompatible Living Donor Kidney Transplantation With rituximab Induction: A Multi-centre Investigation From the Nordic Paediatric Renal Transplantation Study Group

213.3: Long-term Outcome and Complications in Pediatric ABO-incompatible Living Donor Kidney Transplantation With rituximab Induction: A Multi-centre Investigation From the Nordic Paediatric Renal Transplantation Study Group

P8.110: The Beneficial Impact of D3 Vitamin on the Decline of Rejection, Epithelial-Mesenchymal Transition (EMT), And Interstitial Fibrosis Among Pediatric Renal Transplant Patients

P8.110: The Beneficial Impact of D3 Vitamin on the Decline of Rejection, Epithelial-Mesenchymal Transition (EMT), And Interstitial Fibrosis Among Pediatric Renal Transplant Patients

Incidence and outcome of SARS-CoV-2 infection in a pediatric kidney transplant recipient cohort from a single center in Northern Italy.

BackgroundConcern about SARS‐CoV‐2 infection has increased over the possible effects on immunocompromised patients. Among them, recipients of solid organ transplantation deserve special attention. Data from the adult population suggest they may be at high risk for developing severe COVID‐19, but little data are available for pediatric solid organ transplantation recipients.MethodsFrom March 2020 to April 2021, KT recipients aged <21 years, routinely managed at our center, who underwent RT‐PCR testing with nasopharyngeal swabs to detect SARS‐CoV‐2 infection, were studied. Tests were performed according to clinical and/or epidemiological criteria.ResultsOne hundred one transplanted patients were managed at our center during the observation period. Among this population, 57 patients were tested for SARS‐CoV‐2 infection with a RT‐PCR test and were subsequently enrolled. A total of 111 swabs were performed. Twelve out of the 57 patients tested (21.1%) had a positive RT‐PCR test result. Among the positive patients, eight were symptomatic (66.7%). Median duration of symptoms and RT‐PCR positivity was two days (IQR 1–2.25) and 17 days (IQR 11–27.25), respectively. No patients required specific treatment or IS therapy reduction; no one was admitted to hospital.ConclusionsOur data show that pediatric renal transplant recipients are at low risk of clinically relevant COVID‐19, as is the healthy age‐related population. On the contrary, our results differed substantially from those seen in adult SOT recipient populations that have a high incidence and an even earlier and higher mortality rate.

Long term tolerability and clinical outcomes associated with tocilizumab in the treatment of refractory antibody mediated rejection (AMR) in pediatric renal transplant recipients.

Treatment options for antibody-mediated rejection (AMR) are limited. Recent studies have shown that inhibition of interleukin-6 (IL-6)/interleukin-6 receptor (IL-6R) signaling can reduce inflammation and slow AMR progression. We report our experience using monthly tocilizumab (anti-IL6R) in 25 pediatric renal transplant recipients with AMR, refractory to IVIg/Rituximab. From January 2013 to June 2019, a median (IQR) of 12 (6.019.0) doses of tocilizumab were given per patient. Serial assessments of renal function, biopsy findings, and HLA DSA (by immunodominant HLA DSA [iDSA] and relative intensity score [RIS]) were performed. Median (IQR) time from transplant to AMR was 41.4 (24.367.7) months, and time from AMR to first tocilizumab was 10.6 (8.317.6) months. At median (IQR) follow up of 15.8 (8.435.7) months post-tocilizumab initiation, renal function was stable except for 1 allograft loss. There was no significant decrease in iDSA or RIS. Follow up biopsies showed reduction in peritubular capillaritis (p=.015) and C4d scoring (p=.009). The most frequent adverse events were cytopenias. Tocilizumab in pediatric patients with refractory AMR was well tolerated and appeared to stabilize renal function. The utility of tocilizumab in the treatment of AMR in this population should be further explored.

Pharmacokinetics of free and total mycophenolic acid in paediatric and adult renal transplant recipients: Exploratory analysis of the effects of clinical factors and gene variants.

Clinical and genetic influencing factors on free fraction of mycophenolic acid (MPA) have rarely been discussed. The present study investigated whether the clinical and genetic factors could explain the variability in the pharmacokinetics of free MPA (fMPA) and total MPA (tMPA) in Chinese paediatric and adult renal transplant recipients. Twenty-eight paediatric and 31 adult patients were enrolled, and the concentrations of tMPA and fMPA were determined at 0 h (predose) and 0.5, 1, 1.5, 2, 4, 5, 8, 9, 10 and 12 h after mycophenolate mofetil administration. Genetic polymorphisms of UGTs (rs671448, rs1042597, rs2741049, rs62298861, rs7439366, rs12233719) and ABCC2 (rs717620) were simultaneously determined. The clinical and genetic data were analysed and reported. tMPA and fMPA concentrations adjusted for dose per body weight were consistently higher in adults than in paediatric patients. In the paediatric group, only albumin and time after transplantation correlated significantly with the MPA-free fraction variation, which could explain 32.4% of the variability. Besides, ABCC2 polymorphism, albumin and time after transplantation correlated significantly with the MPA-free fraction variation in adults, which could explain 56.9% of the variability. The influencing factors in the paediatric group are different from those in adults, which may be due to age-related transporter expression.

MO993: Incidence of Ptld and Its Relationship with Cmv-Serostatus Positivity Among Childhood and Adulthood Population: A Registry Data Study

Abstract BACKGROUND AND AIMS It is unknown how the epidemiology of post-transplant lymphoproliferative disease (PTLD) and its relationship with CMV infection differ between adult and pediatric kidney transplant recipients. In addition, with current advancements in immunosuppressive therapy, the incidence of PTLD has changed dramatically. The aim of our study is to elucidate the relationship between PTLD and CMV infection. Moerover, to assess the incidence of PTLD among Adult and pediatric renal transplant patients in the current era. METHOD All renal transplant patients registered in the Organ Procurement and Transplantation Network between 2005 and 2019 were retrospectively reviewed. Patient were followed up till December 2020. Patients who had multiple organ transplant or those with previous renal transplants were excluded from the study. Data about recipient factors (age, sex ethnicity, diabetes, CMV serostatus, and EBV serostatus), donor factors (living or deceased), transplant factors (PRA, Cold ischemia time, HLA mismatches, induction and immunosuppressive therapy) were reviewed. Incidence rate of PTLD at one year and five years post-transplant were calculated among the Adult and Pediatric population. Univariate and Multivariate cox-hazard regression models were performed to assess the relationship between CMV serostatus and occurrence of PTLD. RESULTS About 10 947 pediatric renal transplant patients were included. About 315 pediatric patients developed PTLD during the follow-up time (2.88%). About 50.55% of PTLD occurred within the first-year post-transplant. 60% occurred within two-year post-transplant, while 80.63% of them occurred within five years post-transplant. CMV recipient infection was not associated with PTLD occurrence in the pediatric population (HR = 0.88, Pvalue = 0.81, 95% confidence interval ranged between 0.66 and 1.18). Proportional hazard assumption was not violated with P = 0.55. Among the adult population, 1990/277 955 developed PTLD (0.77%). About 25.77% of PTLD among the adult population occurred within the first-year post-transplant. About 39.39% of PTLD in the adult occurred within two-year post-transplant. About 66.55% of PTLD in the adult occurred within five-years post-transplant. CMV recipient positive serostatus was associated with a protective effect against occurrence of PTLD (HR = 0.82, Pvalue &amp;lt;0.01, 95% confidence interval ranged between 0.73 and 0.94). The most common type of PTLD among the pediatric and adult population was monomorphic PTLD ( 40% and 34%, respectively). CONCLUSION PTLD is a rare complication of renal transplantation in the current era. The risk of development of PTLD is highest during the first-year post-transplant. CMV recipient positive serostatus has a protective effect against development of PTLD.

MO1026: Performance of Creatinine and Cystatin-Based Estimates of GFR in Paediatric Kidney Transplant Recipients. Comparison of the CKD-EPI Age- Adjusted Creatinine eGFR with Previous Formulas

Abstract BACKGROUND AND AIMS Estimation of glomerular filtration rate (GFR) is essential for renal function evaluation and the surveillance of kidney transplant recipients. We aimed to compare the GFR estimation by different formulas using creatinine and/or cystatin C, in paediatric kidney transplant recipients and to compare the chronic kidney disease-epidemiology collaboration (CKD-EPI) equation with age-adjusted creatinine values for height-independent estimated GFR (eGFR) calculation. We also intend to evaluate the impact of body mass index (BMI) influence on eGFR. METHOD Data on paediatric renal transplant patients (n = 35) with stable graft function for more than 6 months post-transplantation were enrolled. eGFR was calculated using the revised Schwartz (bedside Cr), CKD-EPI (Cr), CKiD (CysC), Zappitelli (CysC), combined Schwartz (Cr/CysC) and combined Zappitelli (Cr/CysC) formulas. The estimation by CKD-EPI formula used age and sex-adjusted creatinine values to adult levels with 40 as assigned age (CKD-EPI40). RESULTS A total of 35 patients were included, 26 (76%) were male, with a median age of 16 (4–18) years and a median BMI of 21.27 (15.20–32.29) with a Z-score median of 3.26 (2–5). The median eGFR obtained by the Schwartz [64.39 (23.96–115.16) mL/min/1.73 m2] and by the CKD-EPI40 equation [64.99 (13.98-141.80) mL/min/1.73 m2] was similar (P = .176). When compared with the Schwartz estimation, Cys-based eGFR were significantly lower (by CKiD-CysC, 49.48 (25.47–84.68) (P &amp;lt; .001), by Zappitelli formula 51.31 (24.74–92.61) (P &amp;lt; .001), by combined Schwartz 51.37 (24.07–85.31), (P &amp;lt; .001), by combined Zappitelli 54.83 (20.64–109.68).The correlations between eGFR by all formulas were strong and statistically significant, especially between the combined Schwartz and the combined Zappitelli (r = 0.97). The same pattern of differences between the eGFR estimations was observed when BMI groups (normal versus overweight) were analysed separately, with all formulas being significantly different for Schwartz except for CKD-EPI. CONCLUSION As expected, formulas with creatinine were similar to each other but significantly different when compared with formulas that included cystatin. As demonstrated in previous studies, the combined formulas appear to be the closest estimates of the GFR calculated by exogenous methods. Thus, estimates that consider only creatinine may overestimate the GFR. The eGFR obtained by the adjusted CDK-EPI formula is similar to that obtained by the Schwartz bedside, unlike the other formulas. In this study, we did not find differences regarding the BMI, probably due to the number of this sample.

Macular Vessel Density Measurement in Pediatric Renal and Liver Transplant

Microcirculatory dysfunction is known to be associated with organ failure and increased mortality in transplant patients. Noninvasive monitorization of retinal structures of the eye could be a predictor for systemic microvasculature in these patients. Therefore, in this study we aimed to evaluate the retinal microvascular changes in pediatric patients who had undergone liver or renal transplant surgery, using optical coherence tomography angiography. The medical records of pediatric patients who had liver or renal transplant in the past 10 years were reviewed. The macular vessel density parameters were obtained by optical coherence tomography angiography (Avanti RTVue XR). The results were compared with the age-matched, sex-matched, and spherical equivalent-matched healthy participants (control group). The IBM SPSS (version 25.0) statistics program was used for data analysis. We included 32 eyes of 16 liver transplant patients, 20 eyes of 10 renal transplant patients, and 64 eyes of 32 healthy participants (control group). Superficial macular whole image, superficial perifoveal, and deep foveal vessel densities were found to be lower in the liver transplant group compared with the healthy control group (P = .02, P = .01, and P = .01, respectively). Superficial foveal, deep macular whole image, deep foveal, and deep perifoveal vessel densities were found to be lower in the renal transplant group compared with the healthy control group (P = .03, P = .04, P = .01, and P = .02, respectively). Macular vessel density measurements are affected in pediatric renal and liver transplant patients. In those patients, retinal optical coherence tomography and optical coherence tomography angiography measurements may provide a noninvasive window to the microcirculation.

Peripapillary Vascular Density Measurement in Pediatric Renal and Liver Transplant.

Noninvasive monitorization of retinal structures of the eye could be a predictor for systemic microvasculature dysfunction in transplant recipients. In this study, our purpose was to determine the optic disc and peripapillary microvascular changes in pediatric patients who had undergone liver or renal transplant surgery. The study was performed at Başkent University. The medical records were reviewed, and patients who had liver or renal transplant in the last 10 years and were between 4 and 18 years old were included in the study. The optic disc and peripapillary vascular density parameters were obtained by optical coherence tomography angiography (Avanti RTVue XR). The results were compared with the results from age-matched, sex-matched, and spherical equivalent-matched healthy subjects. Our study included 32 eyes of 16 liver transplant patients, 20 eyes of 10 renal transplant patients, and 64 eyes of 32 healthy participants (control). Whole image peripapillary, inside disc, peripapillary, superior and inferior hemisphere, and superior, inferior, temporal, and nasal quadrant peripapillary vascular densities were evaluated. No statistically significant differences in any parameter were noted between the healthy control group and the patient groups (P > .05 for all parameters). Peripapillary vascular density measurements were not affected in pediatric renal and liver transplant patients.

The Role of Platelet-Lymphocyte Ratio and Neutrophil-Lymphocyte Ratio in Predicting the Delayed Graft Function in Pediatric Renal Transplant Patients.

Delayed graft function is a common adverse outcome after renal transplant. Attempts for early prediction and prevention of delayed graft function are often challenging and misleading. Herein, we investigated for the first time the correlation between delayed graft function and preoperative noninvasive hematologic parameters to predict the possible adverse outcomes for renal transplant in pediatric patients. In this study, preoperative hematologic parameters of 51 pediatric renal transplant recipients followed between 2015 and 2021 were analyzed retrospectively. The selected 16 renal transplant patients with delayed graft function and 35 patients without delayed graft function had no concomitant comorbidities. The cutoff values for platelet-to-lymphocyte ratio of <5 and neutrophilto- lymphocyte ratio of <175 were considered low. We retrospectively evaluated a total of 51 (male/female, 33/18) pediatric kidney transplant recipients with a median age of 12 (interquartile range, 8-18) years. Median level of circulating lymphocytes was significantly higher in patients with delayed graft function compared with patients without delayed graft function (2 vs 1, P = .040). The preoperative low values for platelet-to-lymphocyte ratio and neutrophil-to-lymphocyte ratio were more prevalent in recipients who developed delayed graft function versus those who did not develop delayed graft function (68.8% vs 31.4% [P = .014] and 68.8% vs 34.3% [P = .023], respectively). Pretransplant low platelet-to-lymphocyte ratio and neutrophil-to-lymphocyte were associated with increased number of delayed graft dysfunction. These novels and noninvasive inflammatory biomarkers may contribute to an early prediction of delayed graft function in pediatric kidney transplant recipients.

Pediatric Kidney Transplantation in the Middle East: Challenges and Solutions.

Pediatric kidney transplant is the best option for treating children with end-stage renal disease. Poor economics and paucity of renal replacement therapy and transplant facilities are the most important challenges of pediatric kidney transplantation in the Middle East. The aim of the study was to collect data on the rates of pediatric kidney transplant during a recent year from the Middle East countries. All well-known kidney transplant centers from the Middle East were contacted to answer specified questions related to adult and pediatric kidney transplant volume from both living and deceased donors that was performed in each country during a recent year (preferably 2021, or, if not available, 2020 or 2019). In the single recent year, 8772 kidney transplants were performed for adult and pediatric patients in Middle East countries, making a total kidney transplant rate per million populations per year of 10.9 (ranging from 1.2 in Yemen and Pakistan to 39.7 in Turkey). Of these, 1399 transplants were from deceased donors (rate of deceased donor kidney transplants of 15.9%, ranging from 0% in 10 countries to 64.2% in Iran). Of 8772 total kidney transplants, 746 were pediatric recipients (<18 years old), with 166 pediatric kidney transplants from deceased donors (percent of deceased donor pediatric kidney transplant of 22.2%, ranging from 0% in 11 countries to 100% in Tunisia). Average pediatric kidney transplant rate per million populations per year was 0.93 (ranging from <0.1 in Pakistan to 3.2 in Syria). Average pediatric kidney transplant share was about 8.5% of total kidney transplants (ranging from 3.2 in Iraq to 20% in Algeria). The deceased kidney transplant program is currently available in only 8 of the 18 Middle Eastern countries included in this study. However, a deceased program is active in some Middle East countries (ie, Iran, Turkey, Kingdom of Saudi Arabia, Kuwait, and United Arab Emirates). Of note, Turkey had the highest kidney transplant rate per million populations per year (39.7), Syria had the highest pediatric kidney transplant rate per million populations per year (3.2), and Iran had the highest deceased donor kidney transplant percent of the total kidney transplants (64.2%). In the Middle East, Iran alone performed 63.5% (888/1399) of all deceased donor kidney transplants and 63.9% (106/166) of all deceased donor pediatric kidney transplants. Algeria had the highest pediatric kidney transplant share of the total transplants (20%). Low health spending, poorly developed infrastructures, delayed referral of children with chronic kidney disease, comorbidities, lack of technical expertise, inadequate pediatric dialysis programs, extended dialysis time, organ shortage, commercial transplantation, and posttransplant infections are the main pre- and posttransplant challenges. The community-government partnership model from the Sindh Institute of Urology and Transplantation in Karachi Pakistan showed that pediatric renal replacement therapy and transplant can be successfully established in a developing country. Although pediatric kidney transplant is active in many parts of the Middle East, it is still inactive in others, mostly relying on living donors. The lack of deceased donor programs in most Middle Eastern countries is a main issue to be addressed to adequately responding to the increasing demand for organs.