Renal failure and transplantation following nonrenal solid-organ transplantation

Sequential transplantation and implications for clinical management: OLT followed by HCT and consequent RT in a pediatric patient

We report a case of a pediatric patient who required three separate transplants: OLT at the age 5, HCT at age 13 (8 years post-OLT), and cadaveric RT at age 15 (10 years post-OLT). The child initially presented with fulminant liver failure without known cause, ultimately undergoing OLT from his mother. He then developed SAA, for which he required HCT. Unfortunately, he developed ESRD secondary to prolonged CNI exposure, for which he underwent cadaveric RT. These processes then resulted in 7 years largely free from complications, during which a multi-disciplinary team monitored the patient for complications. Regrettably, at the age of 21 he developed poorly differentiated mucinous adenocarcinoma of the colon which ultimately led to his demise. While there are case reports of patients requiring two sequential transplants, there is a paucity of reports of successfully completing three separate organ transplants in the same patient. Our case demonstrates progression of a pediatric patient through OLT, HCT, and RT with discussion of notable clinical implications. Secondarily, this case highlights the importance of coordination of care amongst various subspecialties to facilitate tandem transplantations and manage the complications of these processes. As pediatric patients have improved survival rates and may require multiple transplants, it remains important to highlight the feasibility as well as the complications of the tandem transplant process.

Kidney Transplantation in Patients With Chronic Kidney Disease After a Previous Lung Transplantation

BACKGROUND

The development of chronic kidney disease is a common complication after a lung transplantation, especially since the introduction of immunosuppressive treatments based on calcineurin inhibitors. Many of these patients reach end-stage renal disease and even need renal replacement therapy. Among the different options of renal replacement therapy, we consider kidney transplantation as a feasible option for these patients.

METHODS

A single center, observational retrospective study including 8 lung transplanted patients who have received a kidney transplant in the period between 2013 and 2017 with at least 1 year of follow-up was used.

RESULTS

Seven patients maintained an adequate function of the graft 1 year after kidney transplantation, and 1 patient died because of a pulmonary condition in spite of a previous kidney transplant. Two patients presented delayed graft function in the first days after surgery.

CONCLUSIONS

The kidney transplantation is a technique of renal replacement therapy that should be considered in patients with previous lung transplantation. Experienced centers in double sequential lung and kidney transplantation should be established to assess and treat these types of patients.

Cystatin C as a marker of early renal insufficiency in children with congenital neuropathic bladder

PURPOSE

Due to decreased muscle mass in children with congenital neuropathic bladder there may be significant inaccuracy when using the creatinine based estimated glomerular filtration rate. Cystatin C is highly sensitive and specific for measuring changes in the glomerular filtration rate in children and in patients with muscle wasting conditions. We hypothesized that a cystatin C calculated glomerular filtration rate would be more sensitive than the standard creatinine based modified Schwartz equation to detect renal insufficiency in children with congenital neuropathic bladder.

MATERIALS AND METHODS

We prospectively identified children with congenital neuropathic bladder at a multidisciplinary spina bifida clinic who underwent serum creatinine and serum cystatin C testing. Clinical history and anthropomorphic variables at the time of laboratory testing were catalogued. The creatinine based glomerular filtration rate was estimated using the modified (bedside) Schwartz formula and the cystatin C based rate was calculated using the Zappitelli cystatin C formula.

RESULTS

Dual estimated glomerular filtration rate calculation was done in 69 children at a total of 74 patient encounters. Absolute creatinine was within age range normal limits in each patient, including 1 with chronic kidney disease stage 3A. The median creatinine based estimated glomerular filtration rate was 123 ml per minute/1.73 m(2) (range 58 to 229). The median cystatin C based estimated rate was 103 ml per minute/1.73 m(2) (range 47 to 144) for an absolute median rate reduction of 15.4%. Using cystatin C estimates chronic kidney disease stage was upgraded from stage 1 to 2 in 13 patients (18.8%).

CONCLUSIONS

In children with neuropathic bladder the cystatin C estimated glomerular filtration rate is a better screening test for early renal insufficiency that is not detected by creatinine based rate calculations. To our knowledge it remains to be determined whether the cystatin C estimated glomerular filtration rate can ultimately improve the clinical outcome in this population.