Hypoglycemia in pediatric renal allograft recipients

Seizures after transplantation

PURPOSE

To summarize information on the history, incidence, clinical manifestation, best treatment, as well as prognosis of seizures in transplant recipients.

METHODS

In October 2017, we searched the literature on PubMed in English with the search terms: "transplantation" AND "seizure", "transplantation" AND "epilepsy", "transplantation"AND "status epilepticus", "immunosuppressant" AND "seizure", "immunosuppressant" AND "epilepsy". Publications not based on new data and original research were not included in this article.

RESULTS

Seizures including generalized seizures, focal seizures and status epilepticus are a common central nervous system complication after transplantation. The incidence of seizures varied between different kinds of transplantations. The reported incidence of seizures was 7%-27% in association with solid organ transplantations and 1.6%-15.4% with hematopoietic stem cell transplantation. Most of seizures appeared in the early post-transplantation period. Patients often had a favorable prognosis, however, in some conditions, recurrent or intractable seizures may occur.

CONCLUSIONS

The underlying pathogenesis of new-onset seizures or epilepsy in recipients of transplantation needs to be further elucidated. In addition, more information is required from prospective studies and research focusing on therapeutic strategies.

Incidence of adverse events requiring intervention after initiation of oral beta-blocker in pediatric cardiac intensive care patients

Only limited clinical data are available to establish the risk factors for adverse events and their frequency among children who have received oral beta-blockers in a critical care unit setting. The authors aimed to analyze the frequency of adverse events experienced by children treated with oral beta-blockers in a cardiovascular intensive care unit (CVICU) and sought out independent risk factors for these adverse events in a tertiary care hospital. The primary end point in this retrospective descriptive study was the incidence of adverse events associated with enteral beta-blocker administration, and the secondary end point was the incidence of readmission to the CVICU after transfer of patients to an acute care floor. At least one clinical adverse event occurred for 38% of the patients. Specifically, the profile of the clinical adverse events included bradycardia in 27 patients (11%), hypoglycemia in 46 patients (19%), and the initiation or escalation of inotropes in 36 patients (15%) after oral beta-blocker administration. Additionally, 41 patients (17%) were readmitted to the CVICU after transfer during the same hospital admission. The patients receiving propranolol were predisposed to have at least one adverse event (p = 0.045). No other patient-specific characteristics significantly predisposed patients to adverse events. The patients admitted after a cardiac procedure had fewer readmissions to the intensive care unit (ICU) during the same hospital admission (p = 0.002). The results demonstrated that adverse events are relatively common among patients receiving oral beta-blockers in a CVICU population. Because these children have less physiologic reserve, more must be done to ensure that the correct beta-blocker is prescribed to avoid clinically significant adverse events that may hamper the recovery of these patients and lead to increased ICU time.

Seizure treatment in transplant patients

OPINION STATEMENT

Solid organ transplantation is frequently complicated by a spectrum of seizure types, including single partial-onset or generalized tonic-clonic seizures, acute repetitive seizures or status epilepticus, and sometimes the evolution of symptomatic epilepsy. There is currently no specific evidence involving the transplant patient population to guide the selection, administration, or duration of antiepileptic drug (AED) therapy, so familiarity with clinical AED pharmacology and application of sound judgment are necessary for successful patient outcomes. An initial detailed search for symptomatic seizure etiologies, including metabolic, infectious, cerebrovascular, and calcineurin inhibitor treatment-related neurotoxic complications such as posterior reversible encephalopathy syndrome (PRES), is imperative, as underlying central nervous system disorders may impose additional serious risks to cerebral or general health if not promptly detected and appropriately treated. The mainstay for post-transplant seizure management is AED therapy directed toward the suspected seizure type. Unfavorable drug interactions could place the transplanted organ at risk, so choosing an AED with limited interaction potential is also crucial. When the transplanted organ is dysfunctional or vulnerable to rejection, AEDs without substantial hepatic metabolism are favored in post-liver transplant patients, whereas after renal transplantation, AEDs with predominantly renal elimination may require dosage adjustment to prevent adverse effects. Levetiracetam, gabapentin, pregabalin, and lacosamide are drugs of choice for treatment of partial-onset seizures in post-transplant patients given their efficacy spectrum, generally excellent tolerability, and lack of drug interaction potential. Levetiracetam is the drug of choice for primary generalized seizures in post-transplant patients. When intravenous drugs are necessary for acute seizure management, benzodiazepines and fosphenytoin are the traditional and best evidence-based options, although intravenous levetiracetam, valproate, and lacosamide are emerging options. Availability of several newer AEDs has greatly expanded the therapeutic armamentarium for safe and efficacious treatment of post-transplant seizures, but future prospective clinical trials and pharmacokinetic studies within this specific patient population are needed.

Renal transplantation in infants, a therapeutic option?

Renal transplantation is widely accepted as the treatment of choice for endstage renal failure in childhood. Since dialysis is regularly applied to infants with renal failure, the question logically arises, can infants also receive renal transplants and what are the outcomes? A review of the literature and the clinical experience at the University of Minnesota supports the performance of renal transplantation in infancy. Present patient and graft survival rates for infants are indistinguishable from those of older children. While living adult donors are preferred, adult cadaveric kidneys have also been successfully transplanted. Following successful transplantation, the infants have generally enjoyed "catch-up" growth and accelerated psychomotor development. While there may be problems related to fluid and electrolyte balance in these smallest patients, the majority of the problems encountered mirror those seen in any child undergoing transplantation. Renal transplantation is regularly successful in infancy and should be considered an integral component of the therapy for any child with chronic renal failure.

Renal transplantation in infants

The timing of renal transplantation in infants is controversial. Between 1965 and 1989, 79 transplants in 75 infants less than 2 years old were performed: 23 who were 12 months or younger, 52 who were older than 12 months; 63 donors were living related, 1 was living unrelated, and 15 were cadaver donors; 75 were primary transplants and 4 were retransplants. Infants were considered for transplantation when they were on, or about to begin, dialysis. All had intra-abdominal transplants with arterial anastomosis to the distal aorta. Sixty-four per cent are alive with functioning grafts. The most frequent etiologies of renal failure were hypoplasia (32%) and obstructive uropathy (20%); oxalosis was the etiology in 11%. Since 1983 patient survival has been 95% and 91% at 1 and 5 years; graft survival has been 86% and 73% at 1 and 5 years. For cyclosporine immunosuppressed patients, patient survival is 100% at 1 and 5 years; graft survival is 96% and 82% at 1 and 5 years. There was no difference in outcome between infants who were 12 months or younger versus those who were aged 12 to 24 months; similarly there was no difference between infants and older children. Sixteen (21%) patients died: 5 after operation from coagulopathy (1) and infection (4); and 11 late from postsplenectomy sepsis (4), recurrent oxalosis (3), infection (2), and other causes (2). Routine splenectomy is no longer done. There has not been a death from infection in patients transplanted since 1983. Rejection was the most common cause of graft loss (in 15 patients); other causes included death (with function) (7), recurrent oxalosis (3), and technical complications (3). Overall 52% of patients have not had a rejection episode; mean creatinine level in patients with functioning grafts is 0.8 +/- 0.2 mg/dL. Common postoperative problems include fever, atelectasis, and ileus. At the time of their transplants, the infants were small for age; but with a successful transplant, their growth, head circumference, and development have improved. Transplantation in infants requires an intensive multidisciplinary approach but yields excellent short- and long-term survival rates that are no different from those seen in older children or adults. Living donors should be used whenever possible. Patients with a successful transplantation experience improved growth and development, with excellent rehabilitation.