Renal Transplantation In Children Research Articles

To Evaluate the Epidemiology, Etiology, Risk Factors and Treatment Management in Chronic Kidney Disease in Children, Adult and Geriatric Patients in a Tertiary Care Teaching Hospital in Nellore

Chronic renal failure is a life-threatening disease to society. The study was conducted from October 2021 to June 2023 the study was done in the Nephrology inpatient ward, Vijaya Super Speciality Hospital, Pogathota Nellore, Andhra Pradesh. The study design is a cross-sectional for epidemiology and prospective observational study-1 for etiology, II-risk factors, III-treatment management. The sample size are 381 subjects in that children are 51 subjects, adult 171 subjects and geriatric are 159 subjects. The male are 199 volunteers and the female are 182 volunteers with chronic kidney disease (CKD). The result of this study was the epidemiology factor more in adults (45%) when compared to children (13%) and geriatrics (42%). In the sex parameters are less affected to females (48%) and males (52%) are more affected with chronic kidney disease. The etiology causes in children are glomerulonephritis, adults diabetes mellitus (DM) and geriatrics pyelonephritis these are the main causes for chronic renal disease when compared to other etiological causes. Risk factors in children are congenital defects, adult are diabetes mellitus and geriatric are kidney disease these are the risk factors to the renal failure patients. In treatment management, hemodialysis is the most effective treatment to adults when compared to children’s and geriatric eng stage renal failure disease. The conclusion of this study initially may rectify causes and risk factors of the patients may not high prevalent in end-stage renal failure disease it not cause hemodialysis therapy and renal transplantation in children, adults and geriatric patients.

Hospitalizations after Renal Transplantation in Children: Risk Factors, Causes, and Outcomes

Introduction: The aims of this study were to evaluate the frequency and causes of hospitalizations in the posttransplant period of children, investigate the risk factors, and evaluate the relationship between hospitalizations and renal prognosis in the long term. Methods: We retrospectively reviewed the files of pediatric renal transplant patients, followed at least 6 months after kidney transplantation, in our center. Clinical information including age at transplantation, gender, primary disease, donor type, immuno-suppressive medication, hospitalization dates, and indications (infections and non-infectious) during follow-up period and graft outcomes was recorded. Results: A total of 74 children (46 males) were followed up for a median of 54 months. Among them, 69 patients (93.2%) were hospitalized 446 times. The most common cause of hospitalizations was infections (314 times, 70%). Urinary tract infections were the most important cause followed by upper respiratory tract infections. Forty (54%) patients were hospitalized 132 times (29.5%) for non-infectious reasons. The most common non-infectious reason was nonspecific graft dysfunction (19 patients, 30 times), followed by rejection (17 patients, 27 times). Younger age, use of induction therapy, and having congenital anomalies of kidney and urinary tract (CAKUT) were found to be risk factors for increased hospitalization rates (p < 0.05). The number of hospitalizations was found to be negatively affecting the final glomerular filtration rate of transplant recipients (p: 0.04, r: –0.023). Conclusion: Patients with CAKUT, who received induction therapy, and small children were hospitalized more frequently after transplantation. Strategies to prevent hospitalizations will achieve a better graft prognosis.

Long-term effect of eplerenone treatment in children with chronic allograft nephropathy.

Literature supports the protective role of mineralocorticoid antagonist (MRA) against the renal injury induced by aldosterone in kidney transplant recipients. However, there is limited data available regarding the safety and efficacy of MRAs in pediatric renal transplant patients. Therefore, we aimed to investigate the effect of long-term eplerenone administration in children with chronic allograft nephropathy (CAN). Twenty-six renal transplant children with biopsy-proven CAN, an estimated glomerular filtration rate (eGFR ) > 40 mL/min per 1.73 m2 and with a significant proteinuria were included. Selected patients were randomly divided into two groups as follows; Group 1 (n = 10) patients received 25 mg/day eplerenone and Group 2 (n = 16) patients did not receive eplerenone for 36 months. Patients were examined in the renal transplant outpatient clinic biweekly for the first month and once a month thereafter. The primary outcome of the patients was compared. Mean eGFR stayed stable in group 1 patients, but significantly decreased in group 2 at 36 months (57.53 ± 7.53 vs. 44.94 ± 8.04 mL/min per 1.73 m2 , p = .001). Similarly, spot protein-creatinine ratio was significantly lower in group 1 compared to group 2 patients at 36 months (1.02 ± 7.53 vs. 3.61 ± 0.53, p < .001). Eplerenone associated hyperkalemia was not observed in group 1 patients (4.6 ± 0.2 vs. 4.56 ± 0.3, p = .713). The long-term eplerenone administration blunted the chronic allograft nephropathy by maintaining a stable eGFR levels and decreasing urine protein-creatinine ratio. Eplerenone associated hyperkalemia was not observed in our study.

History of Pediatric Nephrology in Türkiye.

This article analyzes the foundation, institutiona-lization, and development of pediatric nephrology in Türkiye. Erich Frank is the pioneer and inspiration for Turkish nephrologists. He pioneered the training of a new generation of modern physicians, the first generation of Turkish nephrologists, and the establishment of the discipline of nephrology. Turkish pediatricians closely followed these developments and tried to improve their knowledge, making an effort to study abroad. These physicians established pediatric nephrology departments in their universities, trained young pediatric nephrologists, initiated pediatric hemodialysis-peritoneal dialysis units, and realized renal transplantation in children. Another pioneer of pediatric nephrology is Prof. İhsan Doğramacı, who established the first pediatric nephrology department at the Ankara-Hacettepe Medical Center in the 1960s. He directed many physicians to pediatric nephrology and provided them education and research opportunities abroad. Pediatric nephrology became a subspecialty in pediatrics in 1983 in Türkiye. Over the years, the number of Turkish pediatric nephrologists has increased; in 1990, they established the Pediatric Nephrology Association. This gave momentum to the standardization of education, better patient care, and scientific studies. Renal biopsies were initiated in 1964, the first pediatric hemodialysis application was conducted in 1974, the first renal transplantation from the living donor was in 1975, and the first continuous peritoneal dialysis was in 1989. With regard to international collaborations, since 2000, a council member from Türkiye has continuously been elected to the executive board of the European Society for Pediatric Nephrology; currently, the European Society for Pediatric Nephrology is led by President Rezan Topaloğlu. Several Turkish pediatric nephrologists have worked in international associations. Today, Türkiye has 107 pediatric nephrology centers, 265 well-trained specialists, 28 hemodialysis units, 39 peritoneal dialysis units, and 26 pediatric transplant centers.

Contextual Vulnerability Should Guide Fair Subject Selection in Xenotransplantation Clinical Trials

Contextual Vulnerability Should Guide Fair Subject Selection in Xenotransplantation Clinical Trials

Limited Sampling Strategies to Predict Ganciclovir Exposure after Valganciclovir Administration and to Reduce Monitoring Constraints in Renal Transplant Children.

Valganciclovir, the ganciclovir prodrug, is an antiviral agent used to prevent cytomegalovirus infection in renal transplant children. Therapeutic drug monitoring is still necessary to ensure optimal therapeutic area under the concentration-time curve from 0 to 24 h (AUC0-24) of 40 to 60 μg·h/mL since valganciclovir presents a high pharmacokinetic variability. To calculate ganciclovir AUC0-24 with the trapezoidal method, 7 samples are needed. The objective of this study was to develop and validate a reliable and clinically applicable limited sampling strategy (LSS) for individualizing valganciclovir dose in renal transplant children. Rich pharmacokinetic data from ganciclovir plasmatic dosages measured in renal transplant children who received valganciclovir to prevent cytomegalovirus infection at Robert Debré University Hospital were collected retrospectively. Ganciclovir AUC0-24s were calculated using the trapezoidal method. The LSS was developed using a multilinear regression approach to predict AUC0-24. The patients included were divided into two groups for model development (50 patients) and validation (30 patients). A total of 80 patients were included between February 2005 and November 2018. Multilinear regression models were developed on 50 pharmacokinetic profiles (50 patients) and validated with an independent group of 43 pharmacokinetic profiles (30 patients). Regressions based on samples collected at T1h-T4h-T8h, T2h-T4h-T8h, or T1h-T2h-T8h presented the best AUC0-24 predictive performances with an average difference between reference and predicted AUC0-24 of -0.27, 0.34, and -0.40 μg·h/mL, respectively. In conclusion, valganciclovir dosage adaptation was required in children to achieve the target AUC0-24. Three LSS models using three pharmacokinetic blood samples instead of seven will be useful for individualizing valganciclovir prophylaxis in renal transplant children.

Renal transplantation in children with abnormal lower urinary tract: Single center experience

Renal transplantation in children with abnormal lower urinary tract: Single center experience

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.

Outcome of Renal Transplantation in Children Given Rabbit Anti-Thymocyte Globulin (rATG) as Induction Therapy

BackgroundInduction immunosuppressive therapy is used to prevent rejection and maintain allograft function in transplantation. Rabbit antithymocyte globulin (rATG), a T-cell depleting antibody, is the most commonly used induction agent for kidney transplantation. To date there is still limited data on outcomes of pediatric kidney transplants with rATG as induction therapy. MethodsRetrospective single-center study of first-time kidney transplant recipients ≤18 years old who received rATG induction between 2005 and 2019 at the National Kidney and Transplant Institute. Data were collected up to 1 year post transplant. ResultsEleven patients were included in the study. They received rATG at 1.5 mg/kg/dose (±0.3 mg/kg/dose) once a day for 3 days. Patient survival was 100% at 6 months, and 90.9% at 1 year. Graft survival was 90.9% at 6 months, and 81.8% at 1 year. Four patients (36.4%) had a glomerular filtration rate of <60 at 1 year. One died of sepsis at 7 months. One patient (9.1%) had acute allograft rejection with recurrence of disease, C3 glomerulopathy, on day 13. A total of 3 patients (27.3%) developed leukopenia and 4 patients (36.4%) developed thrombocytopenia. The majority were anemic at baseline (9.7 mg/dL), and a significant increase in the mean hemoglobin was seen at 4 weeks (11.6 mg/dL) to 1 year (13 mg/dL). Incidence of recurrent infections was 9.1% (with culture growth) and 36.4% (no culture growth). Hypertension remained unchanged before and after transplant. ConclusionsInduction with single dose rATG at 1.5 mg/kg/dose (±0.3 mg/kg/dose) for 3 days provided effective and safe outcomes in pediatric kidney transplant patients in this study.

Long-term outcome of early steroid withdrawal in pediatric renal transplantation.

Steroid use in renal transplant is related to multiple adverse effects. Long-term effects of early withdrawal steroids in pediatric renal transplant were assessed. Renal transplant children with low immunological risk treated on basiliximab, tacrolimus, and mycophenolate with steroid withdrawal or steroid control were evaluated between 2003 and 2019. Clinical variables, treatment adherence, acute rejection, graft loss, and death were analyzed through hazard ratios, and Kaplan-Meier and multivariate analyses. The study included 152 patients, 71.1% steroid withdrawal, mean follow-up 8.5years, 64.5% structural abnormalities, and 81.6% deceased donor. At 12years of transplant, event-free survival analysis for graft loss or death showed no significant difference between steroid withdrawal and control steroid treatment (85.9% vs. 80.4%, p=.36) nor in acute rejection at 10years (18.5% vs. 20.5%, p=.78) or in donor-specific antibody appearance (19.6% vs. 21.4%, p=.98). Delta height Z-score was increased in the steroid withdrawal group (p<.01). The main predictor of graft loss or death was non-adherence to treatment (p=.001; OR: 17.5 [3.3-90.9]). Steroid withdrawal therapy was effective and safe for low-risk pediatric renal transplant in long-term evaluation. Non-adherence was the main predictor of graft loss or death.

The utility of native ureter in the management of ureteral complications in children after renal transplantation.

Ureteral complications after renal transplantation in children are a major source of morbidity. Management is complex and variable. With IRB approval, health records were retrospectively reviewed of patients who: were <18years, underwent kidney transplant between 1997 and 2017, had at least 2years of follow-up, and underwent interventions due to post-transplant ureteral complications. Of 136 patients, seventeen (13%) required ureteral intervention due to stricture (n=3), reflux (n=12), or both (n=2). Transplant occurred at median 10.5years (3.1-14.7). Reconstruction occurred at median 10months (7-15) after transplant. Pre-existing bladder pathology was present in 6 (35%) patients. Four of five patients with strictures had at least one endoscopic balloon dilation. Ultimate management included reimplantation, ureteroureterostomy of native to transplant ureter, pyeloureterostomy to native ureter, multiple endoscopic interventions followed by a Boari flap, or multiple failed endoscopic interventions. Fourteen patients with VUR underwent reimplantation (n=5), ureteroureterostomyof native to transplant ureter (n=4), pyeloureterostomyto native ureter (n=4), and one underwent endoscopic injection with Deflux of the transplant ureter. Only one patient had a non-functioning graft due to ureteral complication. All patients were alive at follow-up (median 17years [12-19]). Transplant ureteral reflux and stricture are significant complications following pediatric renal transplantation and may require surgical management. In our population, reflux or stricture requiring ureteral reconstruction occurred in 10% and 4%, respectively. Endoscopic interventions were rarely successful. Native ureters were used for ureteral reconstruction in more than two thirds of patients should be considered in management of ureteral complications.

Hemodynamics in renal transplant in children with various morphological changes in the long-term post-transplant period

Introduction. Ultrasound scanning is one of the main methods of instrumental examination of patients after allogenic transplantation of kidney. The main reasons of dysfunction of the kidney transplant in long post-transplantation term are acute or chronic rejection, as well as acute and chronic nephrotoxicity of calcineurin inhibitors.Objective. Assessment of dopplerographic indicators of the blood flow throughout the transplanted kidney vessels in patients with preserved nitrogen excretion function under various morphological changes.Materials and methods. The study includes an analysis of the medical history of 98 children with end-stage chronic renal failure who underwent 98 allogeneic kidney transplants from a posthumous donor. There were analyzed the results of 185 percutaneous puncture biopsies and ultrasound studies of renal transplants. The analyzed data of morphological studies are divided into 4 groups. 1st group – there are no morphological changes affecting graft function. 2nd group – morphological signs of calcineurin toxicity. 3rd group – borderline damage of the graft. 4th group – acute and chronic graft rejection.Results and discussion. Indices of resistance and pulsation measured at the level of the renal artery and interlobular arteries tended to decrease in the kidneys with immunological influence and remained stable in other morphological groups. This means that, the higher the degree of hyalinosis of the arteries, the lower the indices of resistance and pulsation indices measured at the level of the common renal artery and interlobular arteries.Conclusions. The revealed tendency of a decrease in the values of the resistance index and the pulsation index at the level of the common renal artery of the interlobular arteries can be considered as one of the initial ultrasound signs that allow to speak of a decrease in the elasticity of the vascular wall. Normal indices of renal hemodynamics do not exclude the presence of pathological processes leading to graft dysfunction.

Graft Survival in Preemptive Renal Transplantation in Children

Graft Survival in Preemptive Renal Transplantation in Children

Outcomes of renal transplantation in children with cystinosis

Outcomes of renal transplantation in children with cystinosis

THE SCHOOL HEALTH PROGRAMME INCREASED ACCESS TO PEDIATRIC RENAL TRANSPLANTATION IN STATE OF GUJARAT IN INDIA

Introduction: Renal transplantation is still out of reach for large number of children in low-middle-income countries like India where transplantation causes extraordinary out of pocket expenditure. The School health programme, funded by the government of state of Gujarat and government of India, caters to the expenditure of acute and chronic kidney disease treatment which includes dialysis, renal transplantation surgery and post-transplant care for Gujarat domicile children 0-18 years. The aim of the study was to analyse the impact of this programme on access to transplantation in children at institute of kidney disease and research centre, a tertiary referral teaching institute in state of Gujarat, India. Methods: Electronic record of the school heath programme was retrieved and data on total number of children benefitted were collected. The total annual expenditure, per-capita expenditure and expenditure on kidney transplantation were analysed. Result: Total 49000 children benefitted from the scheme in last 6 years. US $ 4.68 million was the total expenditure with an average annual expenditure of US $ 780797. 146 children got transplanted in last 5 years under the scheme. Total expenditure was US $ 424282 and average per transplant recipient was US $ 2906. Conclusion: The school health programme is one of its kind unique health benefit scheme by any state government in India benefitting large number of children and families across all socioeconomic strata providing access to quality care for kidney diseases including transplantation. This scheme is an example for other states of India as well as other low middle income countries to emulate to increase access to acute and chronic kidney disease care including renal transplantation in children.

Intravesical monitoring of intra-abdominal pressure after renal transplantation in children: A safety and feasibility study.

IAH after RTX can threaten graft viability. This study aimed to assess the feasibility and safety of longitudinal IAP measurements as an IAH screening method in children after RTX. A cohort of eight children with a mean±SD [range] age 9.6±6.2 [2-17] years who underwent RTX and 18 control patients were evaluated between May 2017 and February 2018. We compared longitudinal IAP measurements using a Foley manometer to other clinical monitoring data. In total, 29 IAP measurements were performed in RTX patients and 121 in controls. The mean post-operative IAP was 7.4±4.3 [1-16] mmHg following RTX and 8.1±3.7 [1-19] mmHg in controls. We noted IAH in 9 (31%) of 29 IAP measurements after RTX and in 41 (34%) of 121 IAP measurements in controls. No graft dysfunction occurred in RTX patients despite elevated IAP values. The mean±SD [range] time expenditure for IAP measurement was 2.1±0.4 [0.6-3.2]minutes. No severe complications occurred during the IAP measurements. Analysis of longitudinal IAP measurements demonstrated that IAP measurement is safe and feasible in children recovering from renal transplantation in the PICU.

Cytomegalovirus Experience in Pediatric Kidney Transplantation in 26 Years’ Time

IntroductionIn this study,we investigated the presence of cytomegalovirus (CMV) infection in kidney transplanted children and its effect on kidney dysfunction. Material and MethodsOne hundred thirty-five pediatric renal transplant patients were included in this study. The presence of CMV infection, CMV risk status, and other clinical features of the patients were evaluated retrospectively. ResultsFifty-three percent of all patients and 68.8% of patients with CMV were male. The mean age was 12 years in all patients and CMV groups. According to the CMV risk classification, 40.9% of the patients with CMV infection/disease were in the high-risk group (CMV D+R-). In CMV risk groups, the presence of CMV infection/disease was similar. Cold ischemia time, male sex (patients and donors), deceased donor, higher HLA-mismatches, and cumulative antithymocyte globulin dose were found as risk factors for CMV infection/disease. Acute rejection/graft failure was observed in 27% of all patients. CMV infection has no effect on rejection/graft failure and survival. DiscussionThe frequency and risk factors of CMV in renal transplant children in our study were consistent with the literature. ConclusionsCMV infection was found in one-fifth of our patients and the majority (71.9%) of them developed infection in the first 6 months. In one-third of our patients acute rejection/graft failure was observed. There was no effect of CMV infection on rejection/graft failure and survival in pediatric patients with proper and effective treatment.

Feeding patterns and outcomes of enterally tube fed paediatric kidney transplant recipients.

Many children with chronic kidney disease (CKD) exhibiting symptoms of poor appetite, gastro-oesophageal reflux and vomiting are reliant on enteral tube feeds (ETF) to achieve adequate nutritional intake. Following a successful renal transplant (RT), some of these symptoms may resolve and ETF then discontinued. There are only a few studies reporting the time taken to transition from ETF to complete oral feeding after transplantation. This study aimed to investigate the time taken to discontinue ETF following RT in children attending a large tertiary nephrology unit. A retrospective review of medical and dietetic records between 1 January 2014 and 31 December 2017. The study included 20 paediatric renal transplant recipients (70% male) aged 1 to 17 years. Seventy percent discontinued ETF at a median of 6 (0-70) weeks post-transplantation. Patients had ETF from a median of 0.45 (0-10.8) years of age, for a median of 3.9 (1.1-10.9) years prior to receiving a transplant. Four (20%) were referred to the Feeding and Eating Disorder team at a median of 20 (2-44) months post-renal transplantation. Mean body mass index (BMI) Z-score of 0.43 at 12 months pre-transplant was found to be significantly associated with shorter duration of ETF post-transplant (r = 0.8, p = 0.001). Seventy percent of children stopped ETF by a median of 6 weeks post-renal transplant. A good nutritional status pre-transplant may reduce the duration of ETF following transplantation. Four children experienced behavioural feeding issues post-transplant and required further specialist support. Future multi-centre research is required to support these findings to provide a more robust indication of time to achieve full oral feeding. Graphical abstract.

Five decades with grandparent donors: The Norwegian strategy and experience.

Living donors (LDs) are preferred over DDs for renal transplantation in children due to superior GS. Oslo University Hospital has never restricted living donation by upper age. The aim of this study was to investigate long-term outcomes using grandparents (GPLD) compared to PLD. Retrospective nationwide review in the period 1970-2017. First renal graft recipients using a GPLD were compared to PLD kidney recipients for long-term renal function and GS. 278 children (≤18years) received a first renal transplant: 27/251 recipients with a GPLD/PLD. GPLD (median 59 (42-74)years) were significantly older than PLD (median 41 (23-65)years, (P<.001). Median DRAD was 52 (38-70) vs 28 (17-48)years, respectively. GS from GPLD and PLD had a 1-, 5-, and 10-year survival of 100%, 100%, and 90% vs 93%, 82%, and 72%, respectively (P=.6). In a multivariate Cox regression analysis adjusted for gender, donor age, recipient age, and year of transplant, this finding was similar (HR 0.98; 95% CI 0.34-2.84, P=.97). Five-year eGFR was 47.3 and 59.5mL/min/1.73m2 in the GPLD and PLD groups (P=.028), respectively. In this nationwide retrospective analysis, GS for pediatric renal recipients using GPLD was comparable to PLD. Renal function assessed as eGFR was lower in the GPLD group. The GPLD group was significantly older than the PLD group, but overall this did not impact transplant outcome. Based on these findings, older age alone should not exclude grandparent donations.

Does renal transplant in children with LUTD improve their bladder function?

Much is still unknown about LUT function after receiving renal graft. Graft function was the main focus of different studies discussing the same issue. However, these studies ignored the effects of the graft on lower tract function and more demand for bladder cycling and growth of the child. Therefore, we aimed at evaluating the LUT function after RT into patients with LUTD. We enrolled a retrospective cohort of 83 live renal transplant children with LUTD. The 44 patients in Group (A) had a defunctionalized bladder, and the 39 patients in Group (B) had underlying LUT pathology. All patients had clinical and urodynamic evaluation of LUT functions at least 1year after RT. We found that the improvement in patients with impaired bladder compliance was 73% in Group (A) and 60% in Group (B), with no statistically significant difference between the study groups. In Group (B), there was statistically significant worsening of MFP (8.4%) and mean PVR (79.9%) after RT. In Group (A), mild but stable significant improvement of all clinical and urodynamic parameters was observed. Serum creatinine was significantly worse in patients with pathological LUTD compared with those with defunctionalized bladder but without significant effect on graft survival. All LUT variables seemed to have no adverse effect on graft survival except for use of CIC and augmented bladder. Incident UTI independent of LUT variables accounted for 20% of graft creatinine change.