Long-term outcome of pediatric renal transplantation: the Norwegian experience in three eras 1970-2006

Pediatric renal transplantation; 10 years experience

Objectives

Although renal transplantation (RT) is the first treatment option for children with end-stage renal failure, the number of transplanted chil- dren remains low compared to adults. Experience of the individual pediatric transplant center is very important in the prognosis of pediatric transplant recipients. In this study, our pediatric RT experience was presented.

Material and Methods

We retrospectively analyzed the data of 27 patients who had RT in our clinic between April 2009 and April 2019.

Results

Fifteen of the patients were males, and mean age of all patients was 12.36 ± 4.18 years (range 4-17 years). The most frequent etiology for end- stage renal disease (ESRD) was vesicourethral reflux. Eighteen (66.7%) of the transplanted kidneys came from cadaveric donors and 9 (33.3%) from live donors. One patient had preemptive RT and one patient had a re-RT. Twenty-two patients were on peritoneal dialysis program and four patients were on hemodialysis program. Mean dialysis time before transplantation was 29 (3-104) months. Bleeding was the most common surgical complication. Delayed graft function developed in four patients, and all of their grafts were from cadaveric donors. Rejection developed in 12 of our patients, graft loss was observed in only four of them. Considering all patients, graft survival rates were 100% in the 1st and 3rd years, and 92% in the 5th year.

Conclusion

Pediatric RT program is difficult to establish, maintain and develop. Complications after transplantation are not uncommon; therefore, early detection and appropriate management are needed. Strategies are still needed to increase post-transplant success.

Long-term outcomes during 37 years of pediatric kidney transplantation: a cohort study comparing ethnic groups

BACKGROUND

This study aimed to evaluate short- and long-term outcomes of kidney transplantation over 37 years in a national referral center and compare outcomes between Israeli Jewish and Arab children.

METHODS

Data on 599 pediatric transplantations performed in 545 children during 1981-2017, including demographic parameters, kidney failure disease profile, and pre-transplant dialysis duration, were retrieved from our computerized database and patient files. Patient and graft survival were estimated using the Kaplan-Meier method.

RESULTS

Twenty-year patient survival was 91.4% for live donor (LD) and 80.2% for deceased donor (DD) kidney recipients. Respective 10-year and 20-year graft survival rates for first kidney-only transplants were 75.2% and 47.0% for LD and 60.7% and 38.4% for DD grafts. Long-term graft survival improved significantly (p < 0.001) over the study period for recipients of both LD and DD allografts and reached 7-year graft survival of 92.0% and 71.3%, respectively. The proportion of DD transplantations was higher in the Arab subpopulation: 73.8% vs. 48.4% (p < 0.001). Graft survival was not associated with age at transplantation and did not differ between the Arab (N = 202) and Jewish children (N = 343). Median (IQR) waiting time on dialysis did not differ significantly between the Arab and Jewish children: 18 (10-30) and 15 (9-30) months, respectively (p Mann-Whitney = 0.312).

CONCLUSIONS

Good and progressively improving long-term results were obtained in pediatric kidney transplantation at our national referral center, apparently due to expertise gained over time and advances in immunosuppression. Equal access to DD kidney transplant and similar graft survival were found between ethnic groups.

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 (≤18 years) 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 59.5 mL/min/1.73 m² 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.

Long-term outcomes of pediatric kidney transplantation: A single-center experience over the past 34 years in Japan

OBJECTIVES

To evaluate long-term outcomes and risk factors for graft loss in pediatric kidney transplantation over a 30-year period.

METHODS

We retrospectively assessed 400 consecutive kidney transplants carried out in 377 children during 1975-2009. Patients were stratified according to the immunosuppressive regimen (era 1: methylprednisolone and azathioprine; era 2: calcineurin inhibitor-based therapy, including methylprednisolone and azathioprine or mizoribine; era 3: basiliximab induction therapy, including calcineurin inhibitors, methylprednisolone and mycophenolate mofetil).

RESULTS

The median age and bodyweight at transplantation were 9.7 years and 20.6 kg, respectively. In total, 364 (91.0%) children received a living related donor transplantation. The acute rejection rate within 1 year post-transplant decreased significantly from 61.0% in era 1 to 14.5% in era 3 (P < 0.001). For transplant eras 1-3, 1-year graft survival was 81%, 93% and 95%; 5-year graft survival was 66%, 86% and 93%; and 10-year graft survival was 47%, 79% and 89%, respectively. The overall 5-, 10- and 20-year patient survival rates were 96%, 93% and 88%, respectively. A Cox multivariate analysis identified cold ischemia time (hazard ratio 1.385, 95% confidence interval 1.251-1.603), acute rejection (hazard ratio 1.682, 95% confidence interval 1.547-3.842), re-transplant (hazard ratio 2.680, 95% confidence interval 1.759-3.982) and donor type (hazard ratio 2.957, 95% confidence interval 1.754-4.691) as independent risk factors for graft loss at 10 years post-transplant.

CONCLUSIONS

The progress of immunosuppressive therapy has led to a low incidence of acute rejection and a high graft survival rate across 30 years of pediatric transplantation.

Good long-term renal graft survival and low incidence of cardiac pathology in adults after short dialysis period and renal transplantation in early childhood - a cohort study

Over the past 30 years, there has been an improvement in both patient and graft survival after pediatric renal transplantation (RTX). Despite this success, these patients still carry an elevated risk for untimely death, partly through premature aging of the vasculature. The aim of this study was thus to investigate the long-term outcome of individuals with RTX in childhood, as well as to explore the cardiovascular health of these adults more than a decade later. We studied 131 individuals who had undergone a RTX between the years 1979 and 2005. Furthermore, left ventricular hypertrophy (LVH), coronary artery calcifications (CAC), and related metabolic factors were investigated in a cross-sectional study including 52 individuals as part of the initial cohort. The mortality rate (n = 131) was 12.2%. The median estimated graft survival was 17.5 years (95% CI 13.6-21.3), being significantly better in children transplanted below the age of 5 years (18.6 vs. 14.3 years, P < 0.01) compared with older ones. CAC were found in 9.8% and LVH in 13% of the patients. Those with cardiac calcifications had longer dialysis vintage and higher values of parathyroid hormone (PTH) during dialysis. Left ventricular mass correlated positively with systolic blood pressure, PTH, and phosphate measured at the time of the study.

Incidence and magnitude of post-transplant cardiovascular disease after pediatric kidney transplantation: Risk factor analysis of 1058 pediatric kidney transplants at the university of Minnesota

BACKGROUND

KT recipients have increased the risk of CVD. The incidence of post-transplant CVEs among pediatric recipients has not been well-characterized.

PATIENTS AND METHODS

Between 1963 and 2015, 884 pediatric (age: 0-17 years old) recipients received 1058 KTs at our institution. The cumulative incidence of CVEs was analyzed. Statistical models were used to estimate risk factors for developing post-transplant CVEs.

RESULTS

Overall median patient survival was 33 years (IQR: 18.7-47). A total of 362 CVEs occurred in 161 (18.3%) patients at a median age of 20.5 years. Arrhythmias (18%) were most common. Cumulative risk of post-transplant CVEs was 9% at 10 years, 17% at 20 years, 25% at 30 years, and 36% at 40 years. Development of post-transplant CVEs was associated with increased mortality (HR 2.25 [95% CI 1.61-3.14]); of those who developed a CVE and died, 22/51 (43.1%) died of CVD. Multivariable risk factors for post-transplant CVEs included a history of pretransplant CVD (aHR 1.92 [1.18-3.13] and graft failure (4.57 [3.13-6.67]).

DISCUSSION

A pretransplant history of CVD and a failed graft are significant risk factors for the development of post-transplant CVE. CVD increases the risk of post-transplant death or graft loss.

Pediatric Renal Transplantation: Evaluation of Long-Term Outcomes and Comparison to Adult Population

BACKGROUND

In Europe, pediatric transplantation accounts for only about 4% of all kidney transplantations performed. The aim of our work is to evaluate the evolution of pediatric renal transplantation in our department over time, but also to compare this special population with the adult one.

METHODS

We evaluated all pediatric renal transplantations performed in our department between January 1981 and December 2016. We performed the analysis of clinical, analytical, and surgical factors to look for predictive factors of graft loss or decrease of survival. In addition, we performed a comparative study of pediatric and adult populations and an evaluation of the evolution of pediatric renal transplantation in our department over time.

RESULTS

We evaluated 101 renal transplantations performed in patients younger than 18 years. Pediatric transplantations corresponded to 3.4% of all renal transplantations performed in our department. The rate of living donors was 12%. Donors of grafts for the pediatric population were significantly younger than in the adult population. The increase in donor age was associated with lower renal graft survival rates. Acute rejections were more frequent in the pediatric population. Eleven pediatric recipients (10.9%) died in the follow-up period. Renal graft survival in the pediatric population was 94.8%, 77.4%, and 66.5% at 1, 5, and 10 years, respectively. There was no significant difference in graft survival in the pediatric and adult population. The pediatric overall survival rate at 1, 5 and 10 years was 97.9%, 96.8%, and 91.9%, respectively.

CONCLUSION

Pediatric renal transplantation presents results identical to those identified in adults.

Angiotensin II type 1 receptor antibodies in childhood kidney transplantation

Angiotensin II type 1 receptor antibodies (AT1 RAb) have emerged as non-HLA Ab present in patients with acute AMR and risk of graft loss. Furthermore, AT1 RAb have been shown to increase angiotensin II sensitivity which may play a role in the development of CVD and hypertension. Data on AT1 RAb in stable transplant recipients are lacking. The aim of this study was to analyze the levels of AT1 RAb in a cohort of stable patients after kidney transplantation (tx) in childhood. A cross-sectional study of 30 children (median age 14, range 3-19 yr, median time since tx five yr) and 28 adults who were transplanted in childhood (median age 26, range 20-40 yr, median time since tx 18 yr) transplanted between 1993-2006 and 1983-2002, respectively, was performed. Healthy controls were 51 healthy children (5-8 yr) and 199 healthy donors (median age 56.5 yr, range 42-83 yr). Plasma AT1 RAb were analyzed by immunoassay. Median total AT1 RAb IgG concentration was significantly higher in the pediatric-tx group as compared to the adult-tx group (40.0 and 10.95 U/mL, p < 0.0001). For both groups, the tx group showed higher levels: the pediatric-tx group vs. control group (40.0 vs. 13.3 U/mL, p = 0.0006) and the adult-tx group vs. adult control group (10.95 vs. 6.5 U/mL, p < 0.0001). Age was the strongest indicator of high levels of AT1 RAb IgG (p = 0.0003). AT1 RAb total IgG levels are significantly higher in a stable pediatric-tx cohort as compared to adult-tx patients and healthy controls of comparable age groups. The relevance of our findings in relation to age, time since tx, previous or future rejection, and CVD risk merits future studies.

Long-term outcome of pediatric kidney transplantation: A single-center experience from Greece

Pediatric kidney Tx has critically altered the outcome in ESRD pediatric patients. The aims of this study were to determine long-term graft and patient survival in a homogeneous ethnic population. We reviewed the medical charts of pediatric kidney Tx performed between 1990 and 2012 in Greece. Seventy-five kidney Txs were performed from LRD and 62 from DD. The 10- and 20-yr graft survival was higher in LRD Tx compared with DD Tx. Both patient and graft survival at 10 and 20 yr after Tx were similar in LRD Tx from grandparents compared with parents (92.9% vs. 93.4% 20-yr patient survival, 71.4% vs. 78.7% and 57.1% vs. 72.1%, 10- and 20-yr graft survival, respectively). However, there was a decreasing tendency in LRD Tx rates in period 2001-2012 compared with period 1990-2000 (47.1% vs. 62.7%). Risk factors for poor five-yr graft survival were DD Tx, and induction treatment with ALG compared with basiliximab, but their effect attenuated at 10 yr after Tx. In conclusion, Tx from LRD may offer efficient survival outcomes irrespective of donor age, suggesting that even older LRD could be an excellent option for the 1st kidney Tx in children and adolescents.

Pretransplant Stable Systolic Cardiac Functions Play an Important Role in Short-term Systolic Cardiac Functions After Kidney Transplant in Children

OBJECTIVES

In this study, our aim was to evaluate the systolic cardiac parameters and related risk factors in children within 6 months after kidney transplant.

MATERIALS AND METHODS

We retrospectively evaluated 24 children who received kidney transplants. Clinical and laboratory parameters before and after transplant were recorded. Results were evaluated statistically, with a P value less than .05 considered significant.

RESULTS

Before transplant, systolic cardiac functions were within normal limits. After transplant, ejection fraction (63.35% ± 5.38% vs 66.95% ± 4.62%; P = .01) was significantly increased and left ventricular mass index (32.63 ± 17.21 g/m2.7 vs 31.29 ± 15.65 g/m2.7; P = .78) was not significantly decreased, whereas fractional shortening (52.16% ± 15.32% vs 59.8% ± 12.94%; P = .54) did not change. Systolic blood pressure, systolic blood pressure index, diastolic blood pressure, and diastolic blood pressure index values were not statistically different before and after transplant (P > .05). The number of antihypertensive agents was significantly decreased (P = .001). Before and after transplant, cardiac geometry was normal in 15 patients (62.5%) and 17 patients (70.8%).

CONCLUSIONS

Our patients, who had stable systolic cardiac function before transplant, showed further improvements in systolic cardiac function even within 6 months after transplant. Therefore, strictly monitored and controlled blood pressure, volume, anemia, and nutrition in children before transplant may play important roles in achieving better cardiac systolic function after kidney transplant.

Long-term effects of paediatric kidney transplantation

Renal transplantation in paediatric patients usually provides excellent short-term and medium-term results. Early diagnosis of chronic kidney disease and active therapy of end-stage renal disease before and after transplantation enables the majority of children to grow and develop normally. The adverse effects of immunosuppressive medication and reduced graft function might, however, hamper long-term outcomes in these patients and can lead to metabolic complications, cardiovascular disease, reduced bone health, and malignancies. The neurocognitive development and quality of life of paediatric transplant recipients largely depend on the primary diagnosis and on graft function. Poor adherence to immunosuppression is an important risk factor for graft loss in adolescents, and controlled transition to adult care is of utmost importance to ensure a continued normal life. In this Review, we discuss the outcomes and long-term effects of renal transplantation in paediatric recipients, including consequences on growth, development, bone, metabolic, and cardiovascular disorders. We discuss the key problems in the care of paediatric renal transplant recipients and the remaining challenges that should be the focus of future research.

Pre-emptive pediatric kidney transplantation or not?

BACKGROUND

Kidney transplantation prior to dialysis (pre-emptive kidney transplantation, PKT) has been controversial because of the paucity of clinical evidence to clarify the risks and benefits of PKT. Several authors have confirmed a significant advantage of PKT in the treatment of patients with end-stage renal disease (ESRD). The aim of this study was to examine the characteristics of patients who received PKT or non-pre-emptive kidney transplant (NPKT).

METHODS

We used a cohort of 323 consecutive kidney-transplanted children (53% boys) from Hospital da Criança Santo Antonio, Porto Alegre, Brazil, who underwent transplantation between January 2000 and December 2010.

RESULTS

The main causes of ESRD were congenital anomalies of the kidney and urinary tract (CAKUT) (39%) and glomerulopathies (27.5%). The 12-, 36-, 60-, and 90-months death-censored graft survival rates were 97%, 92%, 86%, and 76%, respectively, in the PKT group, and 87%, 79%, 72%, and 65% in the NPKT group (P < .05).

CONCLUSIONS

The results of this study suggest that pre-emptive transplantation is beneficial (hazard ratio = 0.37; 95% confidence interval: 0.18-0.82). The main causes of graft loss (n = 67) were recurrence of primary disease (21%), chronic allograft injury (17%), and death with a functioning graft (16%). We recommend PKT as a better choice for transplantation whenever possible to minimize ESRD morbidity and provide better long-term patient and graft survival.

The clinical course of kidney transplant recipients after 20 years of graft function

There is a growing population of kidney transplant recipients who have survived 20 years with a functioning graft. This study identified the factors associated with prolonged survival and described the clinical course of recipients after two decades of transplant function. All recipients transplanted in Northern Ireland between 1968 and 1993 were included (n = 706) and data were collected prospectively. At 20 years, 25% had a functioning transplant; in multivariate analysis younger recipient age and living donation were associated with 20-year survival. The median recipient survival beyond two decades was 13.3 years; cancer was the commonest cause of death. De novo malignancy developed in 37% of recipients and cardiovascular disease in 27% after 20 years of graft function. The median graft survival after 20 years was 9.3 years; 69% of graft loss was due to death with a functioning transplant. Advances in kidney transplantation have improved the long-term survival of both graft and recipient. After two decades the majority of patients die with a functioning graft. The focus of management in long-term survivors may need to be on the prevention of cancer and cardiovascular disease to allow further improvements in graft and recipient survival.

Long-term outcome of pediatric renal transplantation: a single center study in Japan

Little is known about the risk factors for long-term poor outcome in pediatric renal transplantation. Between 1973 and 2010, 111 renal transplants (92 living donations) were performed in 104 children (56 males, mean age, 12.5 yr) at the Social Insurance Chukyo Hospital, and followed-up for a mean period of 13.6 yr. The patient survival at 1, 5, 10, 15, 20 (living- and deceased-donor transplants), and 30 yr (living-donor transplants only) was 98.1%, 92.8%, 87.8%, 84.9%, 82.6%, and 79.3%. The graft survival at 1, 5, 10, 15, 20, and 30 yr was 92.0%, 77.3%, 58.4%, 50.8%, 38.5%, and 33.3%. The most common cause of graft loss was CAI, AR, death with functioning, recurrent primary disease, ATN, and malignancy. Donor gender, ATN, malignancy/cardiovascular events, and eras affected patient survival. AR and CAI were the risk factors for graft loss. The evolved immunosuppression protocols improved the outcome by reducing AR episodes and ATN but not CAI, suggesting CAI as the major risk factor for graft loss. CAI was correlated with AR episodes, CMV infection, and post-transplant hypertension. Strategies for preventing the risk factors for malignancy/cardiovascular events and CAI, including hypertension/infection, are crucial for better outcomes.

Nutrition management after pediatric solid organ transplantation

Survival rates for pediatric transplant recipients and organ grafts have increased due to improvements in surgical techniques and with immunosuppressant treatment therapies. Interdisciplinary management after pediatric organ transplantation is essential to assist not only with the complex medical issues and complications that can result from immunosuppressant therapy but also with the achievement of normal growth and development. Impaired growth is a complication frequently experienced by pediatric transplant patients. The presence or absence of impaired growth is affected by the length of illness prior to transplant, graft function, the use of corticosteroids, and the development of infectious complications after surgery. A review of posttransplant nutrition assessment, nutrition requirements, and nutrition goals is provided. In addition, a case series of experiences with nutrition management of pediatric solid organ transplant recipients is described.

Long-term experience of steroid-free pediatric renal transplantation: effects on graft function, body mass index, and longitudinal growth

Increased focus on the potential negative side effects of steroid usage in pediatric transplantation has led to steroid minimization or steroid-free transplantation. In this study, we report results after complete steroid avoidance in renal transplantation in the period 1994-2009. We evaluate the effects of complete steroid avoidance on allograft function, BMI, and linear growth. The majority of transplanted children were induced with antithymocyte globulin and immunosuppressed with a calcineurin inhibitor and mycophenolate mofetil. Steroids were given only when rejection occurred or due to comorbidities. Anthropometric data were collected from 65 transplantations in 60 children. Patient survival was 93%; graft survival was 81% after five yr (N = 42) and 63% after 10 yr (N = 16). Acute rejection within the first year of transplantation was 9%. The distribution of the children's BMI before transplantation was normal; the mean BMI-SDS was 0.21 before transplantation, and this value remained stable during the next five yr. Post-transplantation the children demonstrated significant improved growth as the mean height-SDS increased significantly from -1.7 to -1.1. Catch-up growth was most pronounced in the youngest (< six yr). Steroid-free immunosuppression in pediatric renal transplantation is safe and protects against steroid-induced obesity and short stature.

Cardiovascular risk factors in children after kidney transplantation--from short-term to long-term follow-up

Cardiovascular-related mortality is 100-fold higher in pediatric renal transplant recipients than in the age-matched general population. Seventy-seven post-renal transplant children's charts were reviewed for cardiovascular risk factors at two and six months after transplantation (short term) and at two yr after transplantation and the last follow-up visit (mean 7.14 ± 3.5 yr) (long term). Significant reduction was seen in cardiovascular risk factors prevalence from two months after transplantation to last follow-up respectively: Hypertension from 52.1% to 14%, hypercholesterolemia from 48.7% to 33%, hypertriglyceridemia from 50% to 12.5%, anemia from 29.6% to 18.3%, hyperparathyroidism from 32% to 18.3% and hyperglycemia from 11.7% to 10%, and left ventricular hypertrophy from 25.8% at short term to 15%. There was an increase in the prevalence of obesity from 1.5% to 3.9% and of CKD 3-5 from 4.75% to 24%. The need for antihypertensive treatment decreased from 54% to 42%, and the percentage of patients controlled by one medication rose from 26% to 34%, whereas the percentage controlled by 2, 3, and 4 medications decreased from 21.9%, 5.5%, and 1.4% to 6%, 2%, and 0. Children after renal transplantation appear to have high rates of cardiovascular risk factors, mainly on short-term follow-up.

Pediatric renal transplantation: results and prognostic factors

BACKGROUND/OBJECTIVE

As renal transplantation may increase survival rates and improve quality of life for children with end-stage renal disease, we investigated the long-term outcomes and prognostic factors of pediatric renal transplantation.

METHODS

A retrospective study was conducted to review 25 pediatric renal transplantations, either from live or deceased donors, in our hospital from 1995 to 2008. The cumulative graft survival rate was calculated using the Kaplan-Meier method. Log rank tests were employed to identify categorical prognostic factors for graft survival of the pediatric renal transplantations, and Cox regression analysis for numeric factors.

RESULTS

The mean age of our study subjects was 11.63±3.76 years, and the mean follow-up period was 49.24±33.72 months. The 12-month and 36-month graft survival rates were 92% and 82.14%, respectively. The rejection-free survival rates were 88% and 72.88% in the first and third years, respectively. All of the patients were alive during the follow-up period. Acute rejection (p=0.0175) and male sex (p=0.0384) were found to be significant factors for graft survival.

CONCLUSION

For pediatric patients, we found that renal transplantation is now a safe and effective surgical procedure for children with end-stage renal disease. Acute rejection and male gender were identified as prognostic factors for poor graft survival.

Long-term critical issues in pediatric renal transplant recipients: a single-center experience

Data on long-term outcomes after pediatric renal transplantation (Tx) are still limited. We report on a 20-year single-center experience. Medical charts of all consecutive pediatric Tx performed between 1987 and 2007 were reviewed. Data of patients who had been transferred to adult units were extracted from the French databases of renal replacement therapies. Outcomes were assessed using Kaplan-Meier and Cox models. Two hundred forty Tx were performed in 219 children (24.1% pre-emptive and 17.5% living related donor Tx). Median age at Tx was 11.1 years and median follow-up was 10.4 years. Patient survival was 94%, 92%, and 91% at 5, 10, and 15 years post-Tx, respectively. Overall, transplant survival was 92%, 82%, 72%, and 59% at 1, 5, 10, and 15 years post-Tx, respectively. The expected death-censored graft half-life was 20 years. Sixteen patients developed malignancies during follow-up. Median height at 18 years of age was 166 cm in boys and 152 cm in girls with 68% of patients being in the normal range. The proportion of socially disadvantaged young people was higher than in general population. Excellent long-term outcomes can be achieved in pediatric renal Tx, but specific problems such as malignancies, growth, and social outcome remain challenging.

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

BACKGROUND

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.

METHODS

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.

RESULTS

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).

CONCLUSIONS

Patients who underwent renal transplantation in childhood have abnormal LV diastolic function and impaired exercise capacity, despite preserved LV longitudinal systolic deformation.

[Chronic kidney insufficiency in children]

Chronic kidney insufficiency (CKI) in children: Failure to thrive, feeding disorders and/or excessive thirst must evoke CKI in children. More than 50% of renal diseases in children with CKI are congenital or inherited. Major issues are growth, nutrition and renal osteodystrophy. Psychological and social management are crucial aspects of the therapeutic project. Peritoneal dialysis is the renal replacement therapy of choice, especially in children under 2 years, with an important risk of peritonitis. Kidney transplant, which can be performed in children more than 10 kg, is the best treatment of end-stage renal failure in children. Pediatric transplant specificities are increased risks of thrombosis, post-transplant lymphoproliferative disorders in EBV-negative recipients, and poor compliance to medication during adolescence.

The effect of timing of the first kidney transplantation on survival in children initiating renal replacement therapy

BACKGROUND

Controversy exists concerning the timing of the first kidney transplantation for children who need to start renal replacement therapy (RRT). Our aim was to estimate the effect of timing of the first transplantation on patient survival in children, for the first time also taking into account the mortality on dialysis before transplantation.

METHODS

We included 2091 patients who started RRT between the age of 3 and 18 years in the period 1988-2007, from 13 European renal registries. A multistate model was used to simulate patient survival assuming (i) pre-emptive transplantation, (ii) transplantation after 1 or 2 years on dialysis and (iii) remaining on dialysis.

RESULTS

Over the 20-year period, the highest 8-year survival probabilities were achieved in children transplanted pre-emptively {living donor (LD): 95.9% [95% confidence interval (CI): 93.1-98.8], deceased donor (DD): 95.3% (95% CI: 90.9-99.9)} rather than after 2 years of dialysis [LD: 94.2% (95% CI: 91.6-96.8), DD: 93.4% (95% CI: 91.0-95.9)], although these differences were not statistically significant.

CONCLUSIONS

Even after taking mortality on dialysis into account, the potentially negative effect of postponing transplantation for 1 or 2 years was relatively small and not statistically significant. Therefore, if pre-emptive transplantation is not possible, starting RRT with a short period of dialysis and receiving a transplant thereafter seems an acceptable alternative from the perspective of patient survival.

Solid-organ transplantation in childhood: transitioning to adult health care

Pediatric solid-organ transplantation is an increasingly successful treatment for solid-organ failure. With dramatic improvements in patient survival rates over the last several decades, there has been a corresponding emergence of complications attributable to pretransplant factors, transplantation itself, and the management of transplantation with effective immunosuppression. The predominant solid-organ transplantation sequelae are medical and psychosocial. These sequelae have a substantial effect on transition to adult care; as such, hurdles to successful transition of care arise from the patients, their families, and pediatric and adult health care providers. Crucial to successful transitioning is the ongoing development of a sense of autonomy and responsibility for one's own care. In this article we address the barriers to transitioning that occur with long-term survival in pediatric solid-organ transplantation. Although a particular transitioning model is not promoted, practical tools and strategies that contribute to successful transitioning of pediatric patients who have received a transplant are suggested.

Outcomes in pediatric solid-organ transplantation

LaR Pediatric solid-organ transplantation is an increasingly successful treatment for organ failure. Five- and 10-yr patient survival rates have dramatically improved over the last couple of decades, and currently, over 80% of pediatric patients survive into adolescence and young adulthood. Waiting list mortality has been a concern for liver, heart, and intestinal transplantation, illustrating the importance of transplant as a life-saving therapy. Unfortunately, the success of pediatric transplantation comes at the cost of long-term or late complications that arise as a result of allograft rejection or injury, immunosuppression-related morbidity, or both. As transplant recipients enter adolescence treatment, non-adherence becomes a significant issue, and the medical and psychosocial impacts transition to adulthood not only with regard to healthcare but also in terms of functional outcomes, economic potential, and overall QoL. This review addresses the clinical and psychosocial challenges encountered by pediatric transplant recipients in the current era. A better understanding of pediatric transplant outcomes and adult morbidity and mortality requires further ongoing assessment.

Kidney transplantation in childhood: mental health and quality of life of children and caregivers

Our objective was to assess the mental health and health-related quality of life (HRQOL) in children and their parents after renal transplantation (TX) compared to healthy controls and children with acute lymphoblastic leukemia (ALL) and to identify possible health status variables associated with impaired mental health and HRQOL. Thirty-eight TX children with a median age of 13 (range 3-19) years were investigated. Mental health was assessed by the Pediatric Quality of Life Inventory (PedsQL) 4.0 Generic Core Scales and the Strength and Difficulties Questionnaire (SDQ-20). Each mother's own mental health and QOL were assessed by the General Health Questionnaire (GHQ-30) and the Quality of Life Scale (QOLS). Forty children with ALL [median age 11 (8.5-15.4) years] and 42 healthy children [median age 11 (8.9- 15) years] served as controls. Treadmill exercise results from 22 of the 38 patients were included in the analysis. TX children showed significantly higher levels of mental health problems and lower HRQOL at 2 to 16 years after transplantation compared to both control groups. Body mass index and maximal oxygen uptake (n = 22/38) were significant predictors of child mental health (SDQ) and child QOL (PedsQL), respectively. Based on these results, we suggest that rehabilitation after TX should include a focus on physical activity and QOL to reduce interconnected physical and psychological morbidity in kidney TX children.

Cardiorespiratory fitness is a marker of cardiovascular health in renal transplanted children

Children with renal transplants (TX) are at increased risk of cardiovascular (CV) disease. Study objectives were to assess the level of cardiorespiratory fitness (CR fitness) and daily physical activity (PA) in renal TX children and adolescents in relation to traditional cardiovascular risk factors. Laboratory testing included assessment of CR fitness by treadmill exercise testing (VO(2peak)), 24-h ambulatory blood-pressure (ABPM) measurement, oral glucose tolerance test (OGTT), anthropometrics and measurement of lipid levels. PA was self-reported by questionnaire. Twenty-two TX patients with a median (range) age 14.5 (9-18) years were tested. Median V0(2peak) was 66% (36-97) of the expected values compared with controls. Nineteen (86%) children reported <60 min of daily moderate to vigorous physical activity (MVPA). Sixteen (73%) were hypertensive and 8 (34%) were overweight or obese. Four children fulfilled the criteria for a metabolic syndrome. Children with at least 2 of the 3 metabolic risk factors (hypertension, overweight, and glucose intolerance, n=7) achieved significantly lower VO(2peak) compared with those with one or none of these factors (median V0(2peak) 45% and 73% of the expected values respectively, p=0.003). Renal TX children and adolescents have severely impaired CR fitness and PA. Reduced CR fitness was associated with the clustering of CV risk factors. Routine counseling for increased PA is strongly recommended.

[Rationale for the use of extracorporeal photochemotherapy in children]

The management of immune diseases in children remains challenging, although significant advances have been made. In addition to pharmacological approaches, extracorporeal photochemotherapy (ECP) is distinctive in its ability to provide immunomodulation without immune suppression or toxicity. However, in practice, this therapy is not widely used because of logistical issues and the lack of robust clinical pediatric studies. Here, we discuss the potential clinical applications of ECP in children and emphasize the need for a rigorous and specifically pediatric clinical evaluation of ECP.

2202 kidney transplant recipients with 10 years of graft function: what happens next?

The ultimate goal of clinical transplantation is for the recipients to achieve long-term survival, with continuing graft function, that is equivalent to that of the age-matched general population. We studied subsequent outcome in kidney transplant recipients with 10 years of graft function. In all, 2202 kidney transplant recipients survived with graft function >10 years. For 10-year survivors, the actuarial 25-year patient survival rate for primary transplant living donor (LD) recipients was 57%; graft survival, 43%. For primary transplant deceased donor (DD) recipients, the actuarial 25-year patient survival rate was 39%; graft survival, 27%. The two major causes of late graft loss were death (with graft function) and chronic allograft nephropathy (tubular atrophy and interstitial fibrosis). The two major causes of death with function were cardiovascular disease (CVD) and malignancy. For nondiabetic recipients, the mean age at death with function from CVD was 54 +/- 13 years; for diabetic recipients, 53 +/- 7 years. By 20 years posttransplant, morbidity was common: >40% recipients had skin cancer (mean age for nondiabetic recipients, 53 +/- 13 years; for diabetics, 49 +/- 8 years), >10% had non-skin cancer (mean age for nondiabetic recipients, 53 +/- 16 years; for diabetics, 46 +/- 9 years), and >30% had CVD (mean age for nondiabetic recipients, 53 +/- 15 years; for diabetics, 47 +/- 9 years). We conclude that long-term transplant recipients have a high rate of morbidity and early mortality. As short-term results have improved, more focus is needed on long-term outcome.