Renal Transplantation In Childhood Research Articles

Psychosocial outcomes of children and parents after renal transplantation

Introduction : Although some highlighted problems such as parental stress, child behavioural problems and financial instability occur after transplantation, much still remains unknown about the extent, nature, reasons and implications of family difficulties caused by renal transplantation in childhood. Objectives: To examine the psychosocial aspects, levels of parental stress and behavioural problems among children after renal transplantation and to study the predictors of psychosocial issues in the study sample. Design, setting and method: A cross sectional analytical study was conducted at the University Paediatric Unit of the Teaching Hospital, Peradeniya in September-October 2012. All patients who are being followed up at the post renal transplant clinic were recruited to the study. Data was collected using an interviewer-administered questionnaire and analyzed using SPSS 16.0. Results: Thirty-eight recipients of paediatric renal transplants were recruited. 67.5% were males. Feeling of happiness constantly or regularly was reported by 82.5% of children while irritability was a significant problem in 47.5%. Sleep disturbance was a recognized problem in 50% of children. At 2 years of transplantation 85 % of children had not attended school but at 5 years after transplantation school dropout was 10 %. This difference was statistically significant [X 2 =25.8, p 52.5% of parents had expressed their stress on a constant or regular basis. 37.5% of fathers had lost their jobs consequent to renal transplantation and 30% of families had a monthly income less than LKR 10, 000. Conclusions: 82.5% of children reported feelings of happiness on a constant or regular basis after renal transplantation. Non-attendance at school was observed in 85% at 2 years of transplantation but the school dropout was 10% at 5 years after transplantation. 52.5% of parents had expressed their stress on a constant or regular basis. Sri Lanka Journal of Child Health, 2015; 44 (1): 38-44 DOI: http://dx.doi.org/10.4038/sljch.v44i1.7961

Recent developments in kidney transplantation in children.

Renal transplantation in childhood is a well established procedure with excellent short-term outcomes. However, waiting times for transplantation are still relatively long if living donation cannot be performed, and long-term outcomes after transplantation have not significantly improved during the last decade. This review describes alternative modalities to improve donation rates such as en bloc kidney transplantation from young donors, ABO-incompatible transplantation and kidney paired donation. This review also deals with long-term post-transplant morbidities, such as follows: first, medication side-effects (metabolic syndrome, cardiovascular disease) and with the benefits of steroid and calcineurin inhibitor drug minimization; second, the deleterious impact of viral infections and their management and third, chronic antibody-mediated rejection, its therapeutic and prevention possibilities. Donor shortage and long-term morbidities, after transplantation, are still relevant issues in paediatric renal transplantation medicine. Significant research and efforts have been made to advance the field and create novel approaches for improvement of transplantation rates and post-transplant graft or patient survival. These modalities are to be established in the routine setting.

Left ventricular function in children and adults after renal transplantation in childhood

Renal transplantation improves left ventricular (LV) function, but cardiovascular mortality remains elevated. The aim of this cross-sectional study was to determine whether subclinical abnormalities of LV longitudinal function also persist in patients who underwent renal transplant in childhood. Conventional and speckle tracking echocardiography was performed in 68 renal transplant recipients (34 children and 34 adults, median 9.8 years (range 2.0-28.4 years) after first transplantation and 68 age- and sex-matched healthy controls. Mean age at first transplantation was 8.8 ± 4.8 years. Forty-three percent had a pre-emptive transplant. Of the remaining, 70% received haemodialysis and 30% peritoneal dialysis on average for 6.9 months. Thirty-one percent of paediatric and 35% of adult patients had hypertension. LV mass index was increased in adult patients (92 ± 24 vs 75 ± 11 g/m(2), P< 0.01). LV diastolic function and exercise capacity were impaired in both paediatric and adult patients. LV longitudinal peak systolic strain and strain rate were comparable in patients and controls. In multivariate analysis, systolic blood pressure and LV diastolic relaxation were the main covariates of LV peak systolic strain and strain rate (all P < 0.01). Patients who underwent renal transplantation in childhood have abnormal LV diastolic function and impaired exercise capacity, despite preserved LV longitudinal systolic deformation.

Cardiorespiratory fitness in young adults with a history of renal transplantation in childhood

Limited knowledge exists on cardiorespiratory fitness (CR fitness) in adults having a renal transplant (Rtx) during childhood. Our aim was to assess CR fitness (V0(2peak)) with a maximal treadmill test in former Rtx children reaching adulthood (ped-tx, n = 31), compared to patients Rtx as adults (adult-tx, n = 17) and healthy controls (HC, n = 36). Median age was 26.9 (19-41), 28.6 (23.5-34) and 33.5 (20-42) years, respectively. Median time since first Rtx was 18.1 (7-29) and 3.7 (1.2-12.6) years. Body composition was measured by dual-energy X-ray absorptiometry (DXA). V0(2peak) was median 37.9 (12.5-56.3), 40.8 (26.5-57.5), and 44.4 (29.5-65.6) ml kg (-1)min (-1) in the ped-tx, adult-tx, and HC, respectively. Ped-tx had significantly lower V0(2peak) compared to HC (p = 0.01). Adult-tx had higher exercise capacity (test duration) compared to ped-tx (median 10.5 (7.5-16) and 9 (6-14) min, respectively (p = 0.016). In multiple linear regression analysis, test duration, fat-free mass (FFM, kg) and Hgb (g/dl) were significant predictors of V0(2peak) explaining 86% of its variance. There was no significant difference between ped-tx and adult-tx in V0(2peak.) CR fitness depicts long-term health outcome in Rtx patients both in regard to physical functioning and is a plausible indirect marker of CV health.

Pubertal Development is Normal in Adolescents After Renal Transplantation in Childhood

This study was conducted to evaluate the pubertal development in adolescents after renal transplantation (RTx) in childhood. We performed a retrospective review of medical records of 109 RTx recipients (72 males) transplanted at the median age of 4.5 years (range: 0.9-15.8 years). Data on the clinical signs of puberty, growth, bone age, medication, and graft function of 98 patients were analyzed. Furthermore, serum levels of reproductive hormones in 87 patients were assessed to evaluate the progression and outcome of pubertal development. The age at the onset of puberty averaged 12.7 years (range: 9.4-16.2 years) in 55 males and 10.7 years (range: 8.9-12.7 years) in 29 females. The mean age at menarche was 12.5 years (range: 10.5-14.5 years). Twenty-two percent of the boys and none of the girls had a moderately delayed onset of puberty. Children who underwent RTx before the age of 5 years reached puberty earlier than those transplanted at later age (boys 12.3±1.2 vs. 13.4±1.5 years, P<0.01; girls 10.3±0.9 vs. 11.0±1.0 years, P>0.05). The mean length of puberty was 3.9 and 4.7 years for boys and girls, respectively. The bone age was delayed in practically all, and final height was reached at the mean age of 18.1 and 16.0 years in boys and girls, respectively. Pubertal maturation resulted in acceptable final height and reproductive hormone status in great majority of the patients. Pubertal development was normal in all female and most male adolescents after RTx in childhood.

Long-term outcome after renal transplantation in childhood.

and learning objectives:The purpose of this article is to review: Factors influencing long-term outcome data after transplantationPatient survival overall, the effect of recipient age and donor type, causes of death, comparison of mortality after transplantation with that on dialysis, and effect of pre-emptive transplantation and raceTransplant survival overall, and the effect of recipient and donor age, donor type, pre-emptive transplantation, recurrent diseases, human leukocyte antigen (HLA) matching, immunosuppression, concordance, hypertension, bladder dynamics and type of donor nephrectomyFinal height and obesityPsycho-social outcome

Effect of renal transplantation in childhood on longitudinal growth and adult height

Severe growth failure is frequently observed in children suffering from end-stage renal disease (ESRD). We analyzed the effect of renal transplantation (RTx) on longitudinal growth and final height in 37 children (19 girls) with ESRD with a mean follow-up of 8.5 years. The mean age at RTx was 11.3 years. In children transplanted before start of puberty, mean height velocity increased significantly from 4.9 to 8.0 cm/year (P < 0.01), resulting in an increase in standardized height of 0.6 SD within two years post RTx. Although peak height velocity during puberty was significantly increased compared with healthy children, total pubertal height gain was reduced by 20% because of its shortened duration. Mean standardized height significantly increased from the time of RTx until final height by 1.3 SD and 0.7 SD in children transplanted before and after start of puberty, respectively. Mean adult height (boys 170 cm; girls 151 cm) was normal (> -2 SD) in 68% of patients. Change in standardized height from RTx until adult height was associated with initial degree of stunting and glomerular filtration rate (GFR; cumulative r2 0.49). Total pubertal height gain was associated with the age at start of puberty, GFR, and age at RTx (cumulative r2 0.57). RTx in children with ESRD induces moderate catch-up growth during the prepubertal growth period. However, final height is reduced in about one third of patients due to the reduced pubertal height gain and preexisting height deficit at the time of RTx.

Seizures following renal transplantation in childhood.

Few studies have investigated the incidence of seizures following renal transplantation in childhood. The aim of this study was to determine this incidence and to identify risk factors. Retrospective casenote analysis was carried out on 119 transplants performed in 109 children over 10 years. Twenty-one transplants (in 20 children) were complicated by seizures, the majority of which occurred in the first 55 days after transplantation. Seizures were more common in the 5- to 10-year-old age group (P=0.03), but were no more common in those with a prior history of seizure (P=0.69). Their aetiology was predominantly multifactorial; hypertension (n=15), fever/infection (n=4) and acute allograft rejection (n=6) were commonly identified risk factors; 2 were secondary to intracerebral pathology. Most seizures were short lived, required minimal therapy and had a good long-term neurological outcome. In conclusion, seizures are relatively common following paediatric renal transplantation. Parents are now routinely counselled of this risk.

T-Cell Acute Lymphoblastic Leukemia After Renal Transplantation in Childhood

Lymphoproliferative disorders in solid organ recipients are usually of B-cell type and have rarely been described in childhood. This study describes the development of T-cell acute lymphoblastic leukemia (ALL) in a child occurring 6 years after renal transplantation. An 11-year-old boy had received a renal allograft from his father at 5 years of age. He was receiving imuran, prednisone, and cyclosporin A prophylaxis for graft rejection after transplant until T-cell ALL was diagnosed. Although an acute Epstein-Barr virus (EBV) infection was noted at the time of diagnosis, the EBV genome was not detected by Southern blot analysis and polymerase chain reaction (PCR) in the leukemic cells. A large mediastinal mass and malignant pleural effusion were noted at diagnosis. Leukemic cells of his bone marrow and pleural fluid expressed T-cell antigens with unique cytogenetic features, including add(1)(p36.1), del(11)(q14), and monosomy 7. EBV serology was consistent with a recent infection but EBV genome was not detected by Southern blot and PCR analysis in his leukemic cells. Human T-lymphotropic virus-I (HTLV-I) antibody titer was negative. He has been on chemotherapy for 9 months, maintaining his first remission. Malignancies developing after renal transplantations are usually lymphoproliferative disorders and of B-cell origin. In the majority of these patients, EBV plays an etiologic role. Although adult T-cell leukemia developing during immunosuppressive treatment in renal transplant recipients has been reported, T-cell leukemia after transplant in pediatric patients has not been reported to date. This case is unique in terms of the patient's age, the T-cell immunophenotype, the cytogenetic features, and the absence of an EBV genome within the leukemic cells despite an acute EBV infection before diagnosis.

Renal transplantation and osteoporosis.

A cross sectional study assessed the bone mineral density (BMD) of 20 young adult patients who received a renal transplantation in childhood. The BMD of the lumbar spine, mainly trabecular bone, and of the total body, mainly cortical bone, were measured and expressed as an SD score. Fourteen patients (70%) had a BMD SD score of the lumbar spine below -1, of whom six patients were below -2. Fifteen patients (75%) had a BMD SD score of the total body below -1, of whom seven patients were below -2, Both trabecular and cortical bone appeared to be involved in the osteopenic process. The cumulative dose of prednisone was inversely correlated to both lumbar spine and total body BMD SD score. In a multiple regression analysis the cumulative dose of prednisone appeared to be the only factor with a significant effect on BMD SD score. Most young adult patients who had received a renal transplantation in childhood had moderate to severe osteopenia. Corticosteroid treatment played a major part in the development of osteopenia in these patients.

Final Height and Its Predictive Factors after Renal Transplantation in Childhood

A retrospective study is reported assessing final height (FH) and its predictive factors in 52 patients (31 male, 21 female) who underwent renal transplantation (RTx) before the age of 15 y. They received prednisone daily or on alternate days as well as azathioprine. The study period covered 20 y. FH remained below the third height percentile [height standard deviation score for chronologic age (hSDSCA) < -1.88] for most of these patients (77% males, 71% females). Median (range) FH was 165.0 (143.0-176.8) cm in males and 153.0 (135.0-168.4) cm in females. Median difference between FH and target height was 15.0 and 15.4 cm for males and females, respectively. For both sexes, the median hSDSCA was already below -1.88 at the start of the first hemodialysis, after which it decreased significantly until the first RTx. After RTx, there was no significant improvement of hSDSCA. The predictive factors for FH were determined by evaluating various factors simultaneous in a multiple regression analysis. This analysis provided a regression equation for predicting FH. A higher hSDSCA at the time of the first RTx and alternate-day versus daily prednisone therapy both had a significantly positive influence on FH, whereas a longer duration of reduced GFR (< 50 mL/min/1.73 m2) had a significantly negative effect on FH. Other factors such as age or bone age at first RTx, primary renal disease, duration of initial dialysis, repeat RTx, and the cumulative dose of prednisone did not influence FH significantly. In conclusion, 71-77% of patients that received their first renal transplant before the age of 15 ended up with severely short adult stature. Optimization of the hSDSCA at first RTx appears very important. Long-term administration of prednisone on alternate days would then result in optimal FH, particularly if the GFR remains above 50 mL/min/1.73 m2.

Growth and serial changes of bone calcium content after renal transplantation in childhood

We evaluated metacarpal index (MCI) and bone mineral content (BMC) of right 2nd metacarpal bone X-ray films using the microdensitometer technique in 12 pediatric and 32 adult renal transplant (Tx) recipients. Grafts were well functioning for more than 1 year in all adults (serum creatinine < or = 2.0 mg/dl) and in 9 of the children (serum creatinine < or = 1.2 mg/dl). Immunosuppression consisted of cyclosporin (CyA), methylprednisolone (MPL), mizoribine and anti-lymphocyte globulin for all children. 18 of the adults were given CyA and 14 were given conventional immunosuppression. BMC was found to be increased in both children with good renal function and in adults. MCI was improved in 2 children with good renal function and in 2 adults using CyA. Immunosuppression of CyA and low dose MPL had an improving effect on renal osteodystrophy. Alternate-day MPL dosage was between 1, 6 and 7.3 mg/m2/day (mean 3, 6 mg/m2/day) in the 9 children with good renal function. Bone age of the children was seen to be developed in accordance with calendar age. Growth velocity of the 9 children with good renal function was better than the mean level of normal children. However, growth velocity at 3 years after Tx declined slightly, compared with that within 2 years. Similarly, somatomedin C was above the normal range within 2 years after Tx. Thus, bone metabolism after Tx may have been influenced by serial changes of somatomedin C.

Persistence of Diminished Bone Mineral Content Following Renal Transplantation in Childhood

Bone mineral content (BMC) was measured in the nondominant arm of 18 children (aged 3 7/12 to 17 1/2 years) for a total 783 months after renal transplantation. Using photon absorptiometry, 89 measurements were made; 17 of the 18 patients had a functioning graft and one patient died. Significant demineralization, a BMC greater than -2 SD below appropriate control volumes, was found in 11 of 18 patients (62%) and 55 of 89 measurements (61%). Bone loss was progressive; among the 16 patients followed for more than 6 months, ten showed a decline of more than 0.5 SD in BMC, five had no change, and only one showed improvement. No relationship was found between BMC and the use of furosemide, type of transplant (15 living, seven cadaver), prior renal disease (six with glomerulonephritis, 11 tubulointerstitial), need for a second graft (five patients), chronic anticonvulsant therapy, or serum calcium and phosphate values. BMC was slightly correlated (P less than .05) with alkaline phosphatase values. BMC was more strongly correlated with serum creatinine (y = -0.48x + 1.25, r = -.042, P less than .001) and prednisone dose (mg/kg/d) (y = -0.65x + 0.481, r = -.543, P less than .001) in an inverse relationship. Patients whose serum creatinine value was less than 1 mg/dL had a BMC of -0.71 +/- 0.34 SD; those with serum creatinine value greater than 2 mg/dL had BMC of -3.32 +/- 0.31 SD, different at P less than .001. Patients receiving daily prednisone therapy had a significantly lower BMC than those receiving alternate-day therapy (-3.11 +/- 1.23 SD v -1.72 +/- 1.29 SD, P less than .005).(ABSTRACT TRUNCATED AT 250 WORDS)

Results of renal transplantation in childhood: R. Rauhs, O. Wagner, G. Kretschmer, et al. Z Kinderchir 36:107–109, 1982

Results of renal transplantation in childhood: R. Rauhs, O. Wagner, G. Kretschmer, et al. Z Kinderchir 36:107–109, 1982

Hemodialysis and renal transplantation in childhood: Description of a program

Over a 2-yr period eight kidneys have been transplanted in seven patients at the University Children's Hospital of Berne. Six of these patients are alive 4-24 mo after transplantation. The results seem encouraging and the procedure justified, especially in view of the chance of full rehabilitation, which is obviously less complete with chronic hemodialysis.

Home dialysis and renal transplantation in childhood.

Home dialysis and renal transplantation in childhood.