Kidney transplantation remains the optimal treatment for children with end-stage renal disease (ESRD), 25%-40% of which are estimated to be caused by congenital malformations and genetic syndromes. Given the widespread nature of this surgical procedure, ocular complications may arise from the operation itself or from subsequent medical treatments. The aim of this study is to determine whether there are postoperative refractive changes in pediatric patients who have undergone kidney transplantation and to detect the presence of refractive changes that may cause amblyopia in patient follow-ups. The electronic medical records of 1144 patients who underwent kidney transplantation at the Akdeniz University Hospital Organ Transplant Center between January 2019 and January 2024 were reviewed retrospectively. Of these, 84 pediatric patients who had undergone a complete ophthalmologic examination at least 1 year after kidney transplantation and had no missing data were included in the study. For both eyes, all data were recorded, including Best Corrected Visual Acuity (BCVA), refractive error (measured with the KR-8900; Topcon, Tokyo, Japan), spherical equivalent refractions (SER), slit-lamp examination of the anterior segment, and a dilated fundus examination. The average age of patients who underwent kidney transplantation in the study is 13.01 ± 3.43 (6-18). The average follow-up period was 51.81 ± 33.5 (45-129) months. Thirty-five (41.7%) of the patients are female, and 49 (58.3%) are male. Cataracts were observed in 9 (10.7%) patients during follow-up after transplantation. Cataract development was observed on average in 5.6 years. Posterior subcapsular cataracts were observed in seven patients, cortical cataract in one patient, and anterior polar cataract in one patient. The mean preoperative visual acuity value in patients who developed cataracts after kidney transplantation was 0.00 logMAR, while it was measured as 0.19 logMAR in the postoperative period, and this decrease is statistically significant (p = 0.027). In patients who did not develop cataracts during the follow-up period, there was no statistically significant change in visual acuity in both eyes (p = 0.109). When all eyes are evaluated, the change in SER after kidney transplantation is not statistically significant compared with before (p = 0.689 for the right eye, p = 0.596 for the left eye). Although children receive longer-term immunosuppressive treatment, their cataract development rates are lower than those of adults. Despite intensive and prolonged immunosuppression therapy after kidney transplantation, cataract development and refractive changes in the pediatric age group are at an acceptable level. Especially in children who are too young to express themselves clearly, monitoring refractive changes is crucial to prevent permanent vision loss.

Diffusion tensor imaging (DTI) offers a non-invasive window into kidney microstructure by measuring directional water diffusion. In pediatric populations, where early detection of kidney dysfunction is crucial, DTI shows promise for evaluating structural integrity, diagnosing conditions, and monitoring chronic diseases such as autosomal recessive polycystic kidney disease (ARPKD). This review briefly presents the principles of renal DTI, key acquisition techniques, and important nuances in applying this modality to kidney evaluation. We provide an overview of representative post-acquisition processing pipelines for diffusion tensor generation, tractography, and quantitative analysis. We then summarize current applications of DTI in assessing kidney structure, including its use in select diseases, with focused emphasis on pediatric conditions such as ureteropelvic junction obstruction (UPJO), polycystic kidney disease, and pediatric kidney transplantation. Applications for other renal disorders are also reviewed. Finally, we outline current challenges related to standardization and highlight future research directions needed to refine methodology and further establish the clinical utility of renal DTI.

To develop a population pharmacokinetic (PopPK) model of cefepime in paediatric and young adult BMT patients, identify clinical predictors of variability in cefepime clearance and simulate dosing strategies to optimize therapeutic target attainment. This PopPK analysis pooled data from two prospective studies, including 97 BMT patients aged 1 month to 30 years with 252 cefepime plasma concentrations. The final model was validated with goodness-of-fit plots, bootstrap analysis and prediction-corrected visual predictive checks. Monte Carlo simulations assessed the probability of target attainment (PTA) for various dosing regimens, targeting 100% of the dosing interval during which free drug concentrations exceed the minimum inhibitory concentration (100% fT>MIC), across a range of estimated glomerular filtration rates (eGFR) and MICs. A two-compartment model with first-order elimination best described the data. The most predictive covariate for cefepime clearance was eGFR estimated using a combined creatinine-cystatin C equation (eGFRcr-cys). Simulations suggested that standard cefepime dosing (50 mg/kg every 8 h over 30 min) often failed to achieve ≥90% PTA, particularly at MICs ≥2-8 mg/L in patients with normal or augmented renal clearance. Extended (3-hour) or continuous infusions substantially improved PTA. This study presents the first cefepime PopPK model tailored to paediatric and young adult BMT recipients, identifying eGFRcr-cys as a key determinant of cefepime clearance. Prolonging the infusion duration or shortening the dosing interval may be required to enhance target attainment with initial dosing regimens. This PopPK model provides a foundation for individualized dosing adjustments through model-informed precision dosing.

The American Academy of Pediatrics Clinical Practice Guidelines (AAPCPG) recommend 24-h ambulatory blood pressure monitoring (ABPM) for diagnosing hypertension (HTN) in pediatric kidney transplant recipients. The ABPM guidelines were updated in 2022 to incorporate the 2017 AAPCPG thresholds for those ≥ 13years and exclude blood pressure loads. The effect of the 2022 update on ABPM phenotype and its association with end-organ damage in this population remains unexplored. We retrospectively evaluated pediatric kidney transplant recipients (age < 22years) who underwent 24-h ABPM for HTN surveillance between 1/2021 and 9/2024. We grouped ABPM phenotypes into two categories: HTN (masked, ambulatory, and 2014-specific severe ambulatory) and no HTN (normal, white-coat, and 2014-specific uncategorized). We assessed systematic differences between the two guidelines using McNemar's test and agreement using Cohen's Kappa coefficient. Our cohort included 105 recipients. Compared to 2014, the 2022 guidelines identified more recipients with HTN (49.5% vs. 36.2%; McNemar's p < 0.001); however, the overall agreement remained substantial (kappa: 0.73, 95% CI: 0.61, 0.86). Among the 10 recipients with elevated ambulatory arterial stiffness index (AASI), the 2022 guidelines identified 80.0% as abnormal compared to only 30.0% under the 2014 guidelines (McNemar's p = 0.025), reflecting no significant agreement (Kappa: 0.19; 95% CI: -0.1, 0.49). Compared to the 2014 criteria, the 2022 guidelines identified a higher proportion of pediatric kidney transplant recipients with HTN and more effectively identified abnormalities in recipients with elevated AASI. Our findings indicate that 2022 guidelines are better aligned with markers of arterial stiffness and cardiovascular risk.

Kidney biopsies are common diagnostic procedures. Risk factors for biopsy complications in children are not well delineated. The objective of our study is to assess complication rates in pediatric native and transplant kidney biopsies and associated clinical and technical risk factors. Our retrospective study at BC Children's Hospital (Vancouver, Canada) included 402 biopsies performed on 232 patients from 2010-2018. Data were obtained through patient chart review. Minor complications were defined as perinephric hematomas ≥ 2cm or labelled as at least "moderate", arteriovenous fistula, or pseudoaneurysm. Major complications were defined as complication requiring blood transfusion, embolization, or surgery. There were 32 biopsy complications (8%) of which one was a major complication. The most common complication was hematoma in native kidneys, and arteriovenous fistula in transplant kidneys. Complications rates were significantly higher in children < 3years of age (22%, p = 0.046), female patients (11%, p = 0.048), patients with eGFR ≤ 30ml/min/1.73m2 (17%, p = 0.025), hemoglobin < 10g/dL (16%, p = 0.002), vasculitis (15%, p = 0.004), and native kidney biopsies (11%, p = 0.027). Most technical factors such as number of biopsies per patient, cortical tangential vs. perpendicular approach, training level, kidney location, and sedation methods were not associated with increased complication rates. Kidney biopsies are a relatively safe procedure, especially in transplant patients. Specific patient populations (children < 3years, patients with low eGFR, anemia, and vasculitis/SLE) may be at higher risk of complications. Standardization of biopsy protocol and complication definition will enhance consistency of outcome reporting and allow evidence-based improvement in biopsy practices.

To compare isolated liver transplantation (LT) for cystic fibrosis (CF) versus other indications and versus combined liver-lung transplantation (CLLT) for CF in children and identify factors associated with survival. We compared clinical and survival data after first isolated LT for CF versus other indications and versus CLLT for CF in children (<18 years) using United Network for Organ Sharing data (02/2002-12/2024). A total of 157 pediatric CF transplant recipients were included (LT: 145; CLLT: 12). Isolated CF LT recipients had higher total bilirubin (TB) than CLLT (median 1.6 vs. 0.7 mg/dL, p = 0.02). A higher proportion of CF transplant recipients with high TB levels (≥1.5 mg/dL) had ascites, encephalopathy, and required life support compared to those with low TB levels (<1.5 mg/dL). CF LT demonstrated superior patient survival versus CF CLLT (log-rank test, p = 0.02; 5-year: 89.1% vs. 72.2%), but inferior versus non-CF LT (log-rank test, p < 0.001; 5-year: 91.5%). Multivariable Cox regression showed increased risk of patient mortality and liver graft loss in CF CLLT recipients compared to isolated CF LT recipients (hazard ratio [HR] = 2.92, 95% confidence interval [95% CI]: 1.20-7.07, p = 0.02 and HR = 2.56, 95% CI: 1.09-5.98, p = 0.03, respectively) and recipients with higher TB levels (HR = 1.05, 95% CI: 1.01-1.10, p = 0.008 and HR = 1.05, 95% CI: 1.01-1.09, p = 0.008, respectively), when adjusting for recipient age, albumin and international normalized ratio (INR) at time of LT, ICU status, and liver graft type. Multivariable Cox regression of isolated LT recipients showed increased risk of patient mortality (HR = 2.03, 95% CI: 1.41-2.93, p < 0.001) and liver graft loss (HR = 1.54, 95% CI: 1.13-2.11, p = 0.006) for CF compared to non-CF etiologies, when adjusting for recipient age, albumin, INR, and TB at time of LT, ICU status, and liver graft type. Isolated LT for CF was associated with superior survival compared to CLLT for CF, but inferior survival compared to LT for non-CF indications. Higher TB in CF may be a marker of inferior outcomes post-LT.

Recovery via cytomegalovirus (CMV)-specific cell-mediated immunity (CMI) in pediatric hematopoietic stem cell transplantation (HSCT) recipients is associated with a lower incidence of significant CMV DNAemia and disease. This study aimed to determine whether early post-HSCT CMI monitoring could predict CMV infection outcomes and identify factors that influence CMI recovery. Pediatric patients (≤ 19 years) undergoing allogeneic HSCT at Asan Medical Center Children's Hospital between August 2018 and February 2020 were prospectively enrolled. CMV-specific CMI was assessed using the enzyme-linked immunospot assay for phosphoprotein 65 (pp65) or immediate-early protein 1 (IE-1) antigens at pre-transplantation, and 1 and 3 months post-transplantation. Plasma CMV polymerase chain reaction monitoring was conducted regularly, and the incidence of CMV DNAemia and CMV disease was evaluated over a two-year follow-up period. Of the 55 enrolled pediatric recipients, CMV DNAemia occurred in 74.5%, with 21.8% of cases progressing to significant CMV DNAemia. Cumulative CMI recovery rates at 3 months were 61.8% for pp65 and 43.6% for IE-1. Recipients with a cumulative recovery of pp65-specific CMI exhibited a significantly lower incidence of significant CMV DNAemia and CMV disease. In contrast, the cumulative recovery of IE-1-specific CMI was not associated with CMV outcomes. In the multivariate analysis, haploidentical donor status and post-HSCT CMV DNAemia were independently associated with impaired cumulative recovery of both pp65- and IE-1-specific CMI. Monitoring pp65-specific CMI recovery within three months post-HSCT is valuable for predicting significant CMV infection in pediatric recipients. Haploidentical HSCT recipients demonstrated impaired CMI recovery, highlighting the need for careful monitoring and tailored prophylactic strategies.

Over the past six decades, liver transplantation (LT) in Japan has evolved from an experimental surgery to a globally recognized model of ethical and technical excellence. Following the world's first LT in 1963, Japan's early progress was impeded by the 1968 "Wada heart transplant" controversy, which suspended brain-dead donation for more than 30 years. This personal viewpoint reviews the historical development of LT in Japan, focusing on the emergence of living donor liver transplantation (LDLT), key technical innovations, legislative changes, and international contributions-particularly in pediatric transplantation. During this period, Japanese surgeons-many of whom were trained in Western centers-pioneered living donor liver transplantation (LDLT), introducing microsurgical techniques for hepatic artery anastomosis and innovative size-reduction procedures that enabled successful grafting even in infants weighing under 5 kg. Pediatric LDLT became the foundation for adult applications, achieving outstanding long-term outcomes. The Organ Transplant Law (1997) and its 2010 revision gradually permitted brain-dead and pediatric donation, but LDLT remains predominant. Japan's achievements, supported by advancements in tacrolimus immunosuppression, ABO-incompatible LT, and laparoscopic donor hepatectomy, have produced national survival rates comparable to leading Western programs. To date, over 4000 pediatric liver transplants have been performed, establishing Japan as a global leader in pediatric LDLT. Through sustained educational missions, National Center for Child Health and Development and its partner institutions have supported program development in over 20 countries, particularly in Southeast Asia and the Middle East. Despite limited experience with pediatric deceased-donor transplantation, Japan's balanced pursuit of donor safety, ethical integrity, and innovation continues to shape the international landscape. This personal viewpoint reflects on Japan's 60-year journey-progress born from limitation-and its ongoing commitment to advancing pediatric transplantation worldwide under the vision of the International Pediatric Transplant Association.

Outcomes in pediatric thoracic transplantation have significantly improved, yet stark inequities persist. Disparities arise from biases in the healthcare system toward racial, ethnic, or religious groups as well as LGBTQ+ patients and families. Furthermore, geographic and socioeconomic factors and other social determinants of health also play an important role in outcomes. While the impact of these disparities on pediatric transplant recipients has been previously reported, a comprehensive approach to address these root causes is lacking. This article reviews the existing literature on the origins and manifestations of healthcare disparities in pediatric thoracic transplantation. Building upon this analysis, we then propose a blueprint for change, outlining actionable strategies to address the identified causes of inequity and, ultimately, improve outcomes for all pediatric thoracic transplant patients.

Pediatric kidney failure carries high cardiovascular risk. Kidney transplantation is the preferred therapy, yet residual endothelial dysfunction contributes to post-transplant morbidity. The current study determines whether pre-transplant hemodialysis versus peritoneal dialysis affects post-transplant levels of soluble intercellular adhesion molecule-1 (sICAM-1), soluble vascular adhesion molecule-1 (sVCAM-1), P-selectin, and nitric oxide (NO) in pediatric kidney transplant recipients. In a cross-sectional study, we assessed 53 children 6-24 months after kidney transplantation. Fourteen had received peritoneal dialysis and 39 hemodialysis pre-transplant. Serum sICAM-1, sVCAM-1, and P-selectin were measured using a Luminex-based assay and NO by chemiluminescence. Baseline demographic characteristics were similar between groups. Peritoneal dialysis was associated with lower sICAM-1 (p= 0.028) and sVCAM-1 (p= 0.006) and higher NO (p< 0.001), whereas P-selectin did not differ (p= 0.308). sICAM-1 correlated positively with P-selectin (r= 0.286, p= 0.038) and dialysis duration (r= 0.303, p= 0.028) and inversely with glomerular filtration rate (r=-0.328, p= 0.016). sVCAM-1 correlated positively with dialysis exposure time (r= 0.340, p= 0.013) and negatively with NO (r=-0.393, p= 0.004). Dialysis type and duration predicted sVCAM-1 (R2=0.199), dialysis exposure time-predicted sICAM-1 (R2=0.203), and modality-predicted NO (R2=0.252). In pediatric kidney transplant recipients, pre-transplant peritoneal dialysis is associated with reduced endothelial activation and enhanced NO bioavailability compared with hemodialysis, suggesting a vascular benefit that could inform dialysis selection prior to transplantation.

Patient-Caregiver Discrepancy Score: Multisite Evaluation of a Novel Pediatric Outcome Measure.

This study examined the associations between mental health diagnoses, medication nonadherence, and healthcare utilization among pediatric solid organ transplant (SOT) recipients using a large, multistate electronic health record dataset. Data were drawn from 2037 pediatric SOT recipients (ages 0-25 years) within the OneFlorida+ Data Trust (2012-2018). Mental health conditions (depression, anxiety, post-traumatic stress disorder [PTSD], and attention-deficit/hyperactivity disorder [ADHD]), clinician-documented nonadherence, and healthcare utilization outcomes, emergency department (ED) and inpatient (IP) visits, were identified using ICD-9/10-CM codes. Logistic regression estimated predictors of nonadherence, while negative binomial regression models with log-offsets for follow-up time produced incidence rate ratios (IRRs) for utilization outcomes. Models adjusted for demographic and clinical covariates including age, sex, race, ethnicity, and organ type. Mental health diagnoses were common: anxiety (21.6%), depression (15.3%), ADHD (13.7%), and PTSD (13.1%). Clinician-documented nonadherence occurred in 13.3% of patients and was associated with older age, non-White race, depression (OR = 2.85, 95% CI 1.75-4.62), and anxiety (OR = 2.29, 95% CI 1.62-3.23). Nonadherence independently predicted increased healthcare utilization, with approximately twice the rate of ED (IRR = 2.02, 95% CI 1.68-2.43) and IP (IRR = 2.00, 95% CI 1.67-2.40) visits. Anxiety and PTSD also remained significant predictors of elevated utilization across models. Mental health conditions and medication nonadherence are common and independently associated with higher acute care utilization among pediatric SOT recipients. Integrating standardized psychosocial assessment and adherence interventions into routine post-transplant care may help mitigate preventable hospitalizations and improve long-term outcomes.

Many life-threatening complications of hematopoietic stem cell transplantation (HSCT) develop secondary to endothelial injury and dysfunction, including transplant-associated thrombotic microangiopathy (TA-TMA), sinusoidal obstruction syndrome, idiopathic pneumonia syndrome, and engraftment syndrome. These endotheliopathies are often accompanied by cardiovascular compromise. Echocardiographic abnormalities including pericardial effusions and elevated right ventricular pressure have previously been identified as early indicators of TA-TMA. Additional echo-derived parameters and serologic metrics of ventricular function are yet to be evaluated as predictors of post-HSCT endotheliopathies and mortality among children. We sought to assess the utility of early post-HSCT echo and B-type natriuretic peptide (BNP) screening in predicting the development of TA-TMA, additional endotheliopathies, and death. A single-center, prospective cohort study was performed after the implementation of a uniform screening protocol at our pediatric hospital. Patients who received a HSCT from October 2021 to August 2023 were screened with echocardiography and serum BNP levels pre-HSCT, d +7 and d +30 from transplant. Changes from baseline in echocardiographic metrics of right and left ventricular function, pericardial effusions, and BNP levels were evaluated as predictors of post-HSCT TA-TMA, additional endotheliopathies, and death. Fifty-two patients underwent a first HSCT during the study period. The 1-yr cumulative incidence of TA-TMA was 13.8% ± 9.6%, of any endotheliopathy was 39.2% ± 13.7% and of death was 13.5% ± 9.4%. Several echocardiographic predictors were found to be associated with the later development of TA-TMA, including pericardial effusions (HR 7.59, 95% CI: 1.80 to 32.00, P = .006) and measures of increased right and left ventricular function, such as a 10% increase in longitudinal tricuspid annular systolic velocity (tricuspid s', HR 1.61, 95% CI: 1.08 to 2.38, P = .018), and a 10% increase in mitral s' (HR: 1.70, 95% CI: 1.05 to 2.75, P = .031) evaluated at d +30. Similarly, several echocardiographic metrics were associated with the later development of any endotheliopathy, including measures of increased ventricular function such as a 10% increase in tricuspid annular plane systolic excursion (HR 1.43, 95% CI: 1.08 to 1.90, P = .013) and a 10% increase in mitral s' (HR: 1.28, 95% CI: 1.05 to 1.57, P = .016) at d +30, as well as a BNP increase of 50pg/ml from baseline at d +7 (HR: 2.86, 95% CI: 1.15 to 7.08, P = .024). Mortality was significantly increased for patients with at least a 10% increase in left ventricular ejection fraction at d +7 (P = .035) and pericardial effusions (P = .002). Among pediatric HSCT recipients, acute cardiovascular injury associated with HSCT-related endotheliopathy develops at a subclinical level in the early post-transplant period. Subtle increases in right and left ventricular function, increases in BNP level, and pericardial effusions likely reflect an early response to endothelial injury and are associated with the later development of TA-TMA, other endotheliopathies, and death. Screening protocols and prophylactic and therapeutic interventions for pediatric HSCT recipients should consider these novel cardiovascular biomarkers.

P0317 Outcomes of total extraperitoneal technique on pediatric kidney transplantation

To evaluate the clinical features and outcomes of early laparoscopic appendectomy in pediatric patients who developed acute appendicitis following hematopoietic stem cell transplantation (HSCT). This retrospective, single-center study included 10 pediatric patients diagnosed with acute appendicitis after undergoing allogeneic HSCT between 2015 and 2025. Demographics, laboratory values, imaging findings, surgical timing, and outcomes were recorded. Among 737 pediatric HSCT recipients, 10 patients (1.4%) developed acute appendicitis. The median age was 13 years (range: 4-16), and 80% were male. Nine patients had a diagnosis of acute lymphoblastic leukemia and one had aplastic anemia. Appendicitis was diagnosed at a median of 23.5 days post-transplant. Half the patients were severely neutropenic (Absolute neutrophil count = 0) at the time of diagnosis. The most common presenting symptoms were abdominal pain (80%), vomiting (50%), and fever (40%). C-reactive protein was elevated in all cases (median: 61 mg/L). While 40% of the cases were diagnosed by ultrasonography, 60% required computed tomography. All patients underwent early laparoscopic appendectomy within 24 h of diagnosis. Histopathology revealed perforated appendicitis in two patients. There were no perioperative complications. Oral feeding was resumed within 1-6 days (median: 2), and no patients experienced wound infections or surgical delays in further treatment. One patient died due to progression of underlying disease, unrelated to appendicitis. Despite the immunosuppressed state and neutropenia, early laparoscopic appendectomy was safe and effective in pediatric HSCT recipients, supporting its use as a first-line treatment strategy in this population.

Deterioration of nutritional status in allogeneic hematopoietic stem cell transplantation (allo-HSCT) recipients is associated with increased morbidity. Enteral nutrition (EN) has been associated with more favorable outcomes than total parenteral nutrition (TPN); however, TPN remains the first-line nutritional source in many pediatric transplant centers because of health providers and caregiver limitations and biases. Oral nutritional (ON) source may help overcome these limitations, but evidence supporting efficacy in allo-HSCT recipients is currently lacking. We retrospectively evaluated the impact of three nutritional source modalities (ON, EN, and parenteral nutrition) on nutritional status in 125 children undergoing allo-HSCT in two Italian pediatric centers. Secondary endpoints included associations between nutrition modality and several allo-HSCT outcomes: time to engraftment, length of hospitalization, and incidence of acute graft-versus-host disease (aGvHD). A total of 41 patients received TPN, 47/125 received ON, and 37/125 received EN. Patients supported by EN experienced a significantly lower body mass index (BMI) decrease compared to others (-0.45; range -2.18 to 3.95; IQR -0.67 to -0.15 kg/m2; p < 0.05), while a significantly higher decrease occurred in patients who received TPN compared to all others (-1.1; range -9.86 to 0.58; IQR -1.78 to -0.36; p < 0.05); ON was associated with an intermediate outcome (-0.91; range -4.09 to 12.29; IQR -1.66 to -0.06). BMI decrease is greater in male patients (p < 0.05). The length of hospitalization was strongly correlated with nutritional support (p < 0.001), with EN associated with the lowest median time of admission length. Nutrition support modality did not significantly correlate with severe aGvHD in our analysis, nor was there correlation with time to neutrophil or platelet engraftment.

Central venous lines (CVLs) are indispensable in pediatric hematopoietic stem cell transplantation (HSCT) but carry a high risk of complications. This study aimed to compare the clinical, microbiological, and outcome profiles between pediatric HSCT recipients who developed infectious versus non-infectious CVL complications. In this single-center, retrospective study, from a total of 228 pediatric HSCT recipients (2015-2024), this analysis focused on comparing the 76 patients who developed CVL-related infectious complications with the 74 patients who had non-infectious complications. Demographic, clinical, and transplant-related variables were analyzed. Bivariate analyses (Chi-square/Fisher's exact tests) were used to explore unadjusted associations between these variables and complication type. In this study, infection was the most common complication (50.7% of all events). Patients with infectious complications more frequently had a non-malignant underlying disease (63.2% vs. 40.5%; OR=2.51, P=0.006) and had undergone allogeneic transplantation (89.5% vs. 58.1%; OR=6.33, P<0.001) compared to those with non-infectious complications. A higher proportion of patients with infectious complications had received a reduced-intensity conditioning (RIC) regimen (48.7% vs. 32.4%), although this difference did not reach statistical significance after multiple-comparison adjustment (P=0.031). This within-group comparative study characterizes a subgroup of pediatric HSCT recipients with infectious CVL complications, defined by non-malignant underlying disease, allogeneic transplantation, and RIC. These exploratory findings describe clinically relevant patterns among complicated cases and provide a hypothesis-generating basis for future analytical studies to investigate causal risk factors.

This study assessed de novo human leukocyte antigen (HLA) antibodies associated with blood transfusions in a paediatric kidney transplantation cohort, associated risk factors and outcomes. Patients with kidney disease at Royal Children's Hospital (Melbourne, Australia) who were transfused and/or received a kidney transplant between 2000 and 2018 were included. HLA antibody results from pre- and post-transfusion serum specimens, blood donor typing (where available) and clinical and laboratory data were collected. A control group comprised non-transfused patients from the same cohort. The primary outcome was the incidence proportion of de novo blood donor specific HLA antibodies (bDSA). Secondary outcomes included risk factors, including eplet mismatches with the blood donor, kidney donor and both. Screening identified 123 transfused and 63 non-transfused patients, with 34 and 28, respectively, included. Transfused patients were younger. At mean fluorescence intensity (MFI) cutoff 500, 36.7% of transfused patients developed de novo HLA class 1 bDSA and 23.3% de novo HLA class 2 bDSA. Overall, de novo HLA class 1 and class 2 antibodies were non-significantly higher in the transfused group (64.7%/55.9%) than in the non-transfused group (46.4% for both, p = 0.200 and p = 0.610, respectively). Risk factors identified included younger age (p < 0.05) and rhesus factor D (RhD) negative status (p = 0.021). The number of shared eplet mismatches was associated with corresponding de novo HLA antibodies (p = 0.02). Blood transfusion can be associated with bDSA in paediatric kidney disease, especially with shared blood and kidney donor mismatches. Strategies to avoid sensitisation, such as HLA selection of blood donors, may reduce this risk.

Paediatric kidney transplantation, while life-saving, presents significant academic challenges for children. Frequent hospitalisations, medical treatments and the psychosocial impact of chronic illness can severely disrupt educational trajectories. This study aimed to explore the post-transplant academic experiences of children from the perspective of their parents. A qualitative phenomenological study. Data were collected through in-depth, semistructured interviews and analysed using inductive thematic analysis. The study was conducted in Lahore, Pakistan, with participants recruited from the registry of the Punjab Human Organ Transplantation Authority (PHOTA). Thirteen parents of children who had undergone a kidney transplant and were enrolled in a formal school. Five major themes emerged from the analysis: (1) academic disruption and coping, detailing declines in performance and motivation alongside efforts to maintain engagement; (2) cognitive fatigue and emotional strain, encompassing reduced focus, memory difficulties and psychological distress; (3) school attendance, participation and support, highlighting frequent absenteeism, limited engagement in activities, and the critical role of institutional flexibility; (4) social identity and peer exclusion, revealing fears of stigma, self-isolation and misunderstanding from peers and (5) navigating the future, reflecting parental anxieties about long-term educational and career prospects alongside adaptive hope. The findings underscore that formal support systems in schools and healthcare settings are currently underdeveloped to meet these children's complex needs. This study illuminates the profound and multifaceted academic challenges faced by children after kidney transplantation. The results emphasise that a transplant is not merely a medical event but a life-altering experience with significant educational consequences. There is a critical need for integrated, targeted interventions that provide robust psychological support, flexible educational policies and comprehensive school reintegration programmes to ensure these children can achieve their full academic and personal potential.

Background.Nonadherence to immunosuppressive medication remains one of the most critical predictors of late acute rejection, hospitalization, and graft loss in pediatric organ transplant recipients. Despite its clinical importance, longitudinal patterns of adherence behavior in this population remain underexplored, particularly using objective pharmacokinetic indicators. This study aimed to examine adherence trajectories over time using the medication level variability index (MLVI), a validated biomarker of tacrolimus variability, and to assess their association with clinical and demographic factors.Methods.We applied growth mixture modeling to longitudinal MLVI data from a large single-center sample of pediatric heart, liver, and kidney transplant recipients (N = 181). MLVI values were calculated from serial tacrolimus trough levels over a multiyear posttransplant period.Results.Two adherence trajectories emerged with complete separation in MLVI (trajectory 1: range, 1.07–2.10; trajectory 2: range, 2.67–3.99). Across all years of follow-up, posttransplant hospitalization because of late acute rejection occurred in 33.4% of adherent versus 35.1% of nonadherent patients, and on a per-year basis 5.3% versus 7.7% of person-years, respectively (descriptively higher in the nonadherent trajectory). Public insurance status and patient functional status differed significantly between the 2 trajectories, suggesting social and structural determinants of adherence behavior.Conclusions.These findings underscore the dynamic and heterogeneous nature of adherence across pediatric transplant populations. MLVI-based trajectory modeling offers a promising avenue for early risk identification and could inform the development of electronic medical record-integrated alerts or personalized adherence interventions. Future research should integrate psychosocial variables and expand to multicenter samples for enhanced generalizability.