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Engen RM, Bartosh SM. Long-term outcomes of two-dose alemtuzumab induction in pediatric kidney transplantation. Pediatr Transplant 2024; 28:e14753. [PMID: 38623881 DOI: 10.1111/petr.14753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 03/15/2024] [Accepted: 03/26/2024] [Indexed: 04/17/2024]
Abstract
BACKGROUND Alemtuzumab is a lymphocyte depleting agent used for induction in kidney transplant, but long-term information on its use in pediatric recipients remains sparse. METHODS We performed a single-center retrospective cohort study of 57 pediatric kidney transplant recipients receiving alemtuzumab 20 mg/m2/dose ×2 doses for induction immunosuppression. All patients underwent surveillance biopsies, and 91.3% underwent steroid withdrawal by day 4 post-transplant. Outcomes of interest included graft survival, development of donor specific antibodies (DSA), incidence of viremia and PTLD, and duration of lymphopenia. RESULTS Median follow-up time was 7.9 years (IQR 5-13.6 years). Median graft survival was 16.5 years (95% CI 11.6-unknown). DSA developed in 36.5% at a median of 944 days (IQR 252-2113 days). Incidences of BK polyomavirus DNAemia (BKPyV-DNAemia), CMV DNAemia, and EBV DNAemia were 38.6%, 22.8%, and 14%, respectively; one patient developed PTLD at 13.3 years post-transplant. Median duration of lymphopenia was 365 days (IQR 168-713 days); 19.3% of patients remained lymphopenic at 3 years post-transplant. There was no association between duration of lymphopenia and graft survival, rejection, DSA detection, or viremia. CONCLUSIONS A two-dose alemtuzumab induction protocol can have excellent outcomes with a steroid-free maintenance immunosuppression regimen. More comprehensive, multicenter, comparative studies of pediatric kidney transplant are needed to improve long-term outcomes.
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Affiliation(s)
- Rachel M Engen
- Department of Pediatrics, University of Wisconsin Madison, Madison, Wisconsin, USA
| | - Sharon M Bartosh
- Department of Pediatrics, University of Wisconsin Madison, Madison, Wisconsin, USA
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Riar S, Srivastava T, George R. Transition of Care in Children with Chronic Kidney Disease, Dialysis, and Transplantation. Indian J Pediatr 2023; 90:1237-1244. [PMID: 37291387 DOI: 10.1007/s12098-023-04629-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 04/18/2023] [Indexed: 06/10/2023]
Abstract
Improvement in management of pediatric renal disorders has led to patient survival rates of 85-90%, increasing the number of adolescent and young adult (AYA) patients with childhood onset chronic kidney disease (CKD) transitioning to adult care settings. Pediatric CKD patients differ from adults with CKD in view of early onset of disease (sometimes with fetal onset), different disease spectrum, the potential effect of CKD on neurodevelopment, and substantial involvement of parents in medical decision making. In addition to the usual challenges of emerging adulthood (graduation from school to work, independent living, peak in impulsivity and risk-taking behaviors), young adults with pediatric CKD need to learn to manage a serious medical condition independently. In kidney transplant patients, regardless of the age at transplantation, graft failure rates are higher during adolescence and young adulthood than at any other age. All pediatric CKD patients must move from a pediatric to adult-focused settings and this transition is a longitudinal process requiring collaboration and interactions of AYA patients, their families, providers, health care environment and agencies. Consensus guidelines have provided recommendations to pediatric and adult renal teams to enable successful transition. Suboptimal transition is a risk factor for poor adherence to treatment and unfavorable health outcomes. The authors discuss the process of transition as it applies to pediatric CKD patients and review challenges faced by patients/families, pediatric and adult nephrology teams. They provide some suggestions and available tools to optimize the transition of pediatric CKD patients to adult-oriented care.
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Affiliation(s)
- Sandeep Riar
- Division of Pediatric Nephrology, Emory University and Children's Healthcare of Atlanta, 2015 Uppergate Drive, Atlanta, GA, 30322, USA.
| | - Tarak Srivastava
- Section of Nephrology, Children's Mercy Hospital and University of Missouri at Kansas City, Kansas City, MO, USA
- Midwest Veterans' Biomedical Research Foundation (MVBRF), Kansas City, MO, USA
- Department of Oral and Craniofacial Sciences, University of Missouri at Kansas City - School of Dentistry, Kansas City, MO, USA
| | - Roshan George
- Division of Pediatric Nephrology, Emory University and Children's Healthcare of Atlanta, 2015 Uppergate Drive, Atlanta, GA, 30322, USA
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Corr M, McKeaveney C, Wurm F, Courtney A, Noble H. Patient education interventions for adolescent and young adult kidney transplant recipients- a scoping review. PLoS One 2023; 18:e0288807. [PMID: 37459325 PMCID: PMC10351733 DOI: 10.1371/journal.pone.0288807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 06/29/2023] [Indexed: 07/20/2023] Open
Abstract
BACKGROUND Adolescence and young adulthood are high risk periods for kidney transplant recipients. The reasons for this are complex; but are predominantly thought to be due to poor adherence to immunosuppressive medications. Patient education can help support young recipients to reduce their risk of behaviour-related transplant loss. The aim of this review was to understand what is known about education interventions targeted at adolescent and young adult kidney transplant recipients. METHODS Systematic scoping review methodology was utilised. Six online databases were searched for suitable articles. Articles were selected for full text review following title and abstract screening. Articles deemed eligible to be included in the review had data extracted, which were qualitatively analysed using thematic analysis. Findings were validated through a consultation exercise with both young recipients and healthcare professionals. RESULTS 29 studies were eligible for inclusion in the review. There was a high level of heterogeneity in the content, mode, design, and measurement of efficacy of interventions in the selected studies. Traditional face-to-face education and transition clinics were the most common educational interventions. Using technology to enhance patient education was also a major theme identified. Few studies reported using educational theory or involving patients in intervention design. DISCUSSION Four key research gaps were identified. 1.) Lack of educational theory in intervention design 2.) Lack of patient/ stakeholder involvement 3.) Identifying best way to measure efficacy 4.) identifying novel future research questions within already well established paediatric and educational frameworks. Addressing these gaps in future research will help inform best-practice in this vulnerable population.
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Affiliation(s)
- Michael Corr
- School of Medicine- Queen’s University Belfast, Belfast, Northern Ireland
| | - Clare McKeaveney
- School of Nusring- Queen’s University Belfast, Belfast, Northern Ireland
| | - Fina Wurm
- School of Nusring- Queen’s University Belfast, Belfast, Northern Ireland
| | - Aisling Courtney
- Regional Nephrology & Transplant Unit-Belfast Health and Social Care Trust, Belfast, Northern Ireland
| | - Helen Noble
- School of Nusring- Queen’s University Belfast, Belfast, Northern Ireland
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Puliyanda D, Barday Z, Barday Z, Freedman A, Todo T, Chen AKC, Davidson B. Children Are Not Small Adults: Similarities and Differences in Renal Transplantation Between Adults and Pediatrics. Semin Nephrol 2023; 43:151442. [PMID: 37949683 DOI: 10.1016/j.semnephrol.2023.151442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
Kidney transplantation is the treatment of choice for all patients with end-stage kidney disease, including pediatric patients. Graft survival in pediatrics was lagging behind adults, but now is comparable with the adult cohort. Although many of the protocols have been adopted from adults, there are issues unique to pediatrics that one should be aware of to take care of this population. These issues include recipient size consideration, increased incidence of viral infections, problems related to growth, common occurrence of underlying urological issues, and psychosocial issues. This article addresses the similarities and differences in renal transplantation, from preparing a patient for transplant, the transplant process, to post-transplant complications.
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Affiliation(s)
- Dechu Puliyanda
- Pediatric Nephrology and Comprehensive Transplant Program, Cedars Sinai Medical Center, Los Angeles, CA.
| | - Zibya Barday
- Department of Nephrology and Hypertension, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Zunaid Barday
- Department of Nephrology and Hypertension, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Andrew Freedman
- Pediatric Nephrology and Comprehensive Transplant Program, Cedars Sinai Medical Center, Los Angeles, CA
| | - Tsuyoshi Todo
- Pediatric Nephrology and Comprehensive Transplant Program, Cedars Sinai Medical Center, Los Angeles, CA
| | - Allen Kuang Chung Chen
- Pediatric Nephrology and Comprehensive Transplant Program, Cedars Sinai Medical Center, Los Angeles, CA
| | - Bianca Davidson
- Department of Nephrology and Hypertension, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
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Dutta A, Panigrahi SP, Mohamed A, Das S. Lost-to-follow-up: A study on corneal transplantation from Eastern India. Indian J Ophthalmol 2023; 71:1877-1881. [PMID: 37203048 PMCID: PMC10391456 DOI: 10.4103/ijo.ijo_3136_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023] Open
Abstract
Purpose This study aims to analyze the pattern of follow-ups and the reasons for follow-up loss in keratoplasty cases in a tertiary eye care center. Methods This is a single-center retrospective cross-sectional study. During the study period, 165 eyes underwent corneal transplantation. The data on the demographic features of the recipients and the indications of keratoplasty, including visual acuity before and after surgery, duration of follow-up, and the condition of the graft at the last follow-up, were collected. The primary outcome was to determine the factors causing lost-to-follow-up (LTFU) among graft recipients. LTFU was defined when a patient failed to adhere to any of the following seven follow-up visits since the surgery: 4 ± 2 weeks, 3 ± 1 months, 6 ± 1 months, 12 ± 2 months, 18 ± 2 months, 24 ± 3 months, and 36 ± 6 months. The secondary outcome was to analyze the best-corrected visual acuity (BCVA) among patients available for the final follow-up. Results The recipient follow-up rates at 6, 12, 18, 24, and 36 months were 68.5%, 57.6%, 47.9%, 42.4%, and 35.2%, respectively. Old age and distance to the center were significant factors for lost-to-follow-up. A failed graft as an indication for transplantation and those undergoing penetrating keratoplasty for optical purposes were significant factors for completing follow-up. Conclusion The inability to follow-up after corneal transplantation is a common challenge. Elderly patients and those living in remote areas must be prioritized for follow-ups.
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Affiliation(s)
- Anirban Dutta
- Cornea and Anterior Segment Service, L. V. Prasad Eye Institute, Bhubaneswar, Odisha, India
| | | | - Ashik Mohamed
- Ophthalmic Biophysics Department, L. V. Prasad Eye Institute, Hyderabad, Telangana, India
| | - Sujata Das
- Cornea and Anterior Segment Service, L. V. Prasad Eye Institute, Bhubaneswar, Odisha, India
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The Educational Needs of Adolescent and Young Adult Renal Transplant Recipients-A Scoping Review. Healthcare (Basel) 2023; 11:healthcare11040566. [PMID: 36833100 PMCID: PMC9957013 DOI: 10.3390/healthcare11040566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Revised: 02/03/2023] [Accepted: 02/08/2023] [Indexed: 02/17/2023] Open
Abstract
Renal transplantation is the gold-standard treatment for adolescents and young adults with end-stage renal disease. Despite enjoying excellent short-term outcomes, they suffer the worst rates of premature transplant function loss. Health behaviors: such as lack of adherence to immunosuppressive medications, are felt to be the major contributory factor. Understanding the educational needs of young renal transplant recipients allows healthcare practitioners to better support patients in managing their chronic disease. The aim of this scoping review was to understand what is known about their educational needs. A scoping review methodology was followed. Following an online search, study titles, and abstracts were screened for eligibility, followed by full-text assessment and data extraction. Data were qualitatively analyzed using thematic analysis. A total of 29 studies were included in the scoping review. In young people who struggled with self-management, three themes were identified (1) the Needs of the disrupted youth, (2) the Needs of the disorganized youth (3) the Needs of the distressed youth. There was a paucity of research to identify the protective factors that enable young recipients to successfully manage their health. This review outlines current knowledge of the patient education needs of young transplant recipients. It also highlights remaining research gaps that will need to be addressed with future research.
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Rea KE, Cushman GK, Quast LF, George RP, Basu A, Ford R, Book W, Blount RL. Initial attendance and retention in adult healthcare as criteria for transition success among organ transplant recipients. Pediatr Transplant 2022; 26:e14280. [PMID: 35388604 DOI: 10.1111/petr.14280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 03/15/2022] [Accepted: 03/26/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Adolescent and young adult (AYA) solid organ transplant recipients experience worsening medical outcomes during transition to adult healthcare. Current understanding and definitions of transition success emphasize first initiation of appointment attendance in adult healthcare; however, declines in attendance over time after transfer remain possible, particularly as AYAs are further removed from their pediatric provider and assume greater independence in their care. METHODS The current study assessed health-care utilization, medical outcomes, and transition success among 49 AYA heart, kidney, or liver recipients recently transferred to adult healthcare. Differences in outcomes were examined along two transition success criteria: (1) initial engagement in adult healthcare within 6 or 12 months of last pediatric appointment and (2) retention in adult healthcare over 3 years following last pediatric appointment. Growth curve modeling examined change in attendance over time. RESULTS Successful retention in adult healthcare was significantly related to more improved clinical outcomes, including decreased number and duration of hospitalizations and greater medication adherence, as compared to initial engagement. Significant declines in appointment attendance over 3 years were noted, and individual differences in declines were not accounted for by age at transfer or time since transplant. CONCLUSIONS Findings underscore support for AYAs after transfer, as significant declines in attendance were noted after initiating adult care. Clinical care teams should examine transition success longitudinally to address changes in health-care utilization and medical outcomes. Attention to interventions and administrative support aimed at maintaining or increasing attendance and identifying risk factors and intervention for unsuccessful transition is warranted.
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Affiliation(s)
- Kelly E Rea
- Department of Psychology, University of Georgia, Athens, Georgia, USA
| | - Grace K Cushman
- Department of Psychology, University of Georgia, Athens, Georgia, USA.,Alpert Medical School of Brown University, Bradley/Hasbro Children's Research Center, Providence, USA
| | - Lauren F Quast
- Department of Psychology, University of Georgia, Athens, Georgia, USA
| | - Roshan P George
- Department of Pediatrics, Emory University School of Medicine, Athens, Georgia, USA
| | - Arpita Basu
- Emory Transplant Center, Emory University School of Medicine, Athens, Georgia, USA
| | - Ryan Ford
- Emory Transplant Center, Emory University School of Medicine, Athens, Georgia, USA
| | - Wendy Book
- Emory Transplant Center, Emory University School of Medicine, Athens, Georgia, USA
| | - Ronald L Blount
- Department of Psychology, University of Georgia, Athens, Georgia, USA
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Sharma AA, Sharma A. Pediatric to Adult Transition for Adolescents and Young Adults with Kidney Transplant. CURRENT PEDIATRICS REPORTS 2022. [DOI: 10.1007/s40124-022-00266-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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