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Schild R, Carvajal Abreu K, Büscher A, Kanzelmeyer N, Lezius S, Krupka K, Weitz M, Prytula A, Printza N, Berta L, Saygılı SK, Sellier-Leclerc AL, Spartà G, Marks SD, Kemper MJ, König S, Topaloglu R, Müller D, Klaus G, Weber S, Oh J, Herden U, Carraro A, Dello Strologo L, Ariceta G, Hoyer P, Tönshoff B, Pape L. Favorable Outcome After Single-kidney Transplantation From Small Donors in Children: A Match-controlled CERTAIN Registry Study. Transplantation 2024:00007890-990000000-00739. [PMID: 38685197 DOI: 10.1097/tp.0000000000004993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
BACKGROUND Kidney transplantation (KTx) from small donors is associated with inferior graft survival in registry studies, whereas single-center studies show favorable results. METHODS We compared 175 pediatric KTx from small donors ≤20 kg (SDKTx) with 170 age-matched recipients from adult donors (ADKTx) from 20 centers within the Cooperative European Paediatric Renal Transplant Initiative registry. Graft survival and estimated glomerular filtration rate (eGFR) were analyzed by Cox regression and mixed models. Detailed data on surgical and medical management were tested for association with graft survival. RESULTS One-year graft survival was lower after SDKTx compared with ADKTx (90.9% versus 96.5%; odds ratio of graft loss, 2.92; 95% confidence interval [CI], 1.10-7.80; P = 0.032), but 5-y graft survival was comparable (90.9% versus 92.7%; adjusted hazard ratio of graft loss 1.9; 95% CI, 0.85-4.25; P = 0.119). SDKTx recipients had an annual eGFR increase of 8.7 ± 6.2 mL/min/1.73 m² compared with a decrease of 6.9 ± 5.7 mL/min/1.73 m² in ADKTx recipients resulting in a superior 5-y eGFR (80.5 ± 25.5 in SDKTx versus 65.7 ± 23.1 mL/min/1.73 m² in ADKTx; P = 0.008). At 3 y posttransplant, eGFR after single SDKTx was lower than after en bloc SDKTx (86.6 ± 20.4 versus 104.6 ± 35.9; P = 0.043) but superior to ADKTx (68.1 ± 23.9 mL/min/1.73 m²). Single-kidney SDKTx recipients had a lower rate of hypertension at 3 y than ADKTx recipients (40.0% versus 64.7%; P = 0.008). CONCLUSIONS Compared with ADKTx, 5-y graft function is superior in SDKTx and graft survival is similar, even when performed as single KTx. Utilizing small donor organs, preferably as single kidneys in experienced centers, is a viable option to increase the donor pool for pediatric recipients.
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Affiliation(s)
- Raphael Schild
- Department of Pediatric Nephrology, Pediatric Hepatology and Pediatric Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Karla Carvajal Abreu
- Department of Pediatrics, University Children's Hospital, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anja Büscher
- Department of Pediatrics II, University Hospital of Essen, University of Essen-Duisburg, Essen, Germany
| | - Nele Kanzelmeyer
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Susanne Lezius
- Department of Medical Biometry and Epidemiology, University Medical Center, Hamburg-Eppendorf, Germany
| | - Kai Krupka
- Department of Pediatrics I, University Children's Hospital, Heidelberg, Germany
| | - Marcus Weitz
- Department of General Pediatrics and Hematology/Oncology, University Children's Hospital Tübingen, Tübingen, Germany
| | - Agnieszka Prytula
- Paediatric Nephrology and Rheumatology Department, Ghent University Hospital, Ghent, Belgium
| | - Nikoleta Printza
- Pediatric Nephrology Unit, First Department of Pediatrics, Hippokratio General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - László Berta
- First Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Seha Kamil Saygılı
- Division of Pediatric Nephrology, Department of Pediatrics, İstanbul University-Cerrahpaşa, Cerrahpaşa School of Medicine, Istanbul, Turkey
| | - Anne-Laure Sellier-Leclerc
- Centre de Référence des Maladies Rénales Rares, Service de Néphrologie Pédiatrique, Hôpital Femme Mère Enfant, HCL, Bron Cedex, France
| | - Giuseppina Spartà
- Pediatric Nephrology, University Children's Hospital Zürich, Zurich, Switzerland
| | - Stephen D Marks
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Markus J Kemper
- Department of Pediatrics, Asklepios Klinik Nord Heidberg, Hamburg, Germany
| | - Sabine König
- Department of General Pediatrics, University Hospital Muenster, Muenster, Germany
| | - Rezan Topaloglu
- Department of Pediatric Nephrology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Dominik Müller
- Pediatric Nephrology, Charité Children's Hospital, Berlin, Germany
| | - Günter Klaus
- Department of Pediatrics II, University Children's Hospital, Philipps-University Marburg, Marburg, Germany
| | - Stefanie Weber
- Department of Pediatrics II, University Children's Hospital, Philipps-University Marburg, Marburg, Germany
| | - Jun Oh
- Department of Pediatric Nephrology, Pediatric Hepatology and Pediatric Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Uta Herden
- Department of Visceral Transplantation, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Andrea Carraro
- Pediatric Nephrology, Dialysis and Transplant Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
| | - Luca Dello Strologo
- Renal Transplant Unit, Bambino Gesù Children's Research Hospital IRCCS, Rome, Italy
| | - Gema Ariceta
- Division of Pediatric Nephrology, Hospital Universitari Vall d' Hebron, Barcelona, Spain
| | - Peter Hoyer
- Department of Pediatrics II, University Hospital of Essen, University of Essen-Duisburg, Essen, Germany
| | - Burkhard Tönshoff
- Department of Pediatrics I, University Children's Hospital, Heidelberg, Germany
| | - Lars Pape
- Department of Pediatrics II, University Hospital of Essen, University of Essen-Duisburg, Essen, Germany
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Avilez ND, De Souza ABP, Domenico BRD, Prates LC, Mazzali M, De Lima ML. Analysis of Factors Related to the Success of Pediatric Kidney Transplantation: A 35 Years Experience. Transplant Proc 2024; 56:44-49. [PMID: 38216360 DOI: 10.1016/j.transproceed.2023.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 10/15/2023] [Accepted: 11/26/2023] [Indexed: 01/14/2024]
Abstract
BACKGROUND Despite the significant improvement results over the past 20 years, pediatric kidney transplantation remains a challenge. Chronic rejection, thrombosis, and recurrence of the primary disease are frequent causes of graft loss that have been little studied. Therefore, our objective is to analyze factors related to a better prognosis, which can be used to improve future strategies to allow higher pediatric transplant success rates. METHODS A retrospective cohort study with patients under 15 years old submitted for kidney transplantation at the Hospital das Clínicas da UNICAMP between January 1, 1987, and January 1, 2022. Age, patient weight, time and type of dialysis, use of anticoagulation, complications, ischemia time, and donor weight were analyzed and related to graft loss. The significance level adopted for the statistical tests was 5%. RESULTS One hundred ninety-two medical records were anaThe mean follow-up time was 11 years, and the mean graft duration was ration 8.5 years. The main causes of graft loss were chronic dysfunction, thrombosis, and acute cellular rejection. Thrombosis presented significantly with the donor's body mass index and second transplantation. There was no correlation between the analyzed variables and chronic dysfunction or acute cellular rejection. DISCUSSION Thrombosis remains the main cause of early graft loss, followed by acute cellular rejection. Measures such as thrombophilia screening and thromboprophylaxis have been proposed to improve results. However, they are still not standardized. CONCLUSION The main causes of graft loss were chronic dysfunction, thrombosis, and acute cellular rejection. Only the thrombosis was related to the donor's body mass index and a second transplantation.
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Affiliation(s)
| | | | | | - Liliane Cury Prates
- Department of Pediatric Nephrology, University of Campinas - UNICAMP - Sao Paulo, Brazil
| | - Marilda Mazzali
- Department of Nephrology, University of Campinas - UNICAMP - Sao Paulo, Brazil
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3
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Akhaladze DG, Minnullin MM, Krivonosov AA, Kachanov DY, Grachev NS. [Autologous kidney transplantation in a high-risk patient with locally advanced retroperitoneal neuroblastoma]. Khirurgiia (Mosk) 2024:63-69. [PMID: 38477245 DOI: 10.17116/hirurgia202403163] [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: 03/14/2024]
Abstract
Surgery of locally advanced neuroblastoma with risk factors is one of the most difficult in pediatric surgery. Incidence of nephrectomy during subtotal or complete tumor resection is higher due to common involvement of renal vessels. We present a patient with locally advanced retroperitoneal neuroblastoma who underwent heterotopic kidney autotransplantation.
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Affiliation(s)
- D G Akhaladze
- Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - M M Minnullin
- Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - A A Krivonosov
- Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - D Yu Kachanov
- Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - N S Grachev
- Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
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Lazaruc TI, Bodescu Amancei Ionescu L, Lupu VV, Muntean (Duicu) C, Bogos RA, Ivanov A, Scurtu G, Starcea IM, Miron IC, Mocanu MA. Thrombosis in Chronic Kidney Disease in Children. Diagnostics (Basel) 2022; 12:diagnostics12122931. [PMID: 36552938 PMCID: PMC9777211 DOI: 10.3390/diagnostics12122931] [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: 09/27/2022] [Revised: 11/04/2022] [Accepted: 11/21/2022] [Indexed: 11/25/2022] Open
Abstract
Venous thromboembolism (VTE) in children is a rare condition. An increased incidence has been observed in the last few years due to several factors, such as increased survival in chronic conditions, especially chronic kidney disease (CKD), use of catheters, and increased sensitivity of diagnostic tools. VTE includes deep vein thrombosis (DVT) and pulmonary embolism (PE). VTE in children is associated with a two to six times higher mortality risk and a 5-10% prevalence of post-thrombotic syndrome. Overall, 5% of VTE episodes in children are associated with chronic kidney disease. The etiology of VTE in chronic kidney disease covers a wide range of pathologies. Various types of thrombotic complications may occur during long-term use of a chronic dialysis catheter. VTE occurs in 3% of children with nephrotic syndrome (NS). The risks for VTE and arterial thromboembolism (ATE) were particularly high in the first 6 months after the onset of NS. Other causes of VTE are graft rejection due to thrombosis of vascular anastomoses after kidney transplantation (3%) and autoimmune diseases (lupus nephritis, antiphospholipid syndrome). In this state-of-the-art overview, we have reviewed the physiologic and pathologic mechanisms underlying pediatric thrombosis and updated current diagnostic and treatment options, emphasizing personal experience as well.
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Affiliation(s)
- Tudor Ilie Lazaruc
- Department of Pediatrics, “Grigore T. Popa” University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
| | - Lavinia Bodescu Amancei Ionescu
- Department of Pediatrics, “Grigore T. Popa” University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
| | - Vasile Valeriu Lupu
- Department of Pediatrics, “Grigore T. Popa” University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
| | - Carmen Muntean (Duicu)
- Department of Pediatrics I, George Emil Palade University of Medicine, Pharmacy, Science and Technology of Targu Mures, 540088 Targu Mures, Romania
| | - Roxana Alexandra Bogos
- Department of Pediatrics, “Grigore T. Popa” University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
- Nephrology Division, St. Mary’s Emergency Children Hospital, 700309 Iasi, Romania
| | - Anca Ivanov
- Department of Pediatrics, “Grigore T. Popa” University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
| | - Georgiana Scurtu
- Department of Pediatrics, “Grigore T. Popa” University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
| | - Iuliana Magdalena Starcea
- Department of Pediatrics, “Grigore T. Popa” University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
- Nephrology Division, St. Mary’s Emergency Children Hospital, 700309 Iasi, Romania
- Correspondence: ; Tel.: +40-726-704-612
| | - Ingrith Crenguta Miron
- Department of Pediatrics, “Grigore T. Popa” University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
| | - Maria Adriana Mocanu
- Department of Pediatrics, “Grigore T. Popa” University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
- Nephrology Division, St. Mary’s Emergency Children Hospital, 700309 Iasi, Romania
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Wen Y, Zhao M, Fu S, Gu Z, Chen W, Zhao Q, Shu W, Tao X, Zhang F. Pharmaceutical services based on therapeutic care pathway for kidney transplantation from donors of infants and young children: a single-center experience. Transl Pediatr 2022; 11:834-847. [PMID: 35800269 PMCID: PMC9253932 DOI: 10.21037/tp-21-515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 02/11/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The pharmaceutical services based on therapeutic care pathway for kidney transplantation from infants and young children (age <3 years, weight <15 kg) to pediatric recipients can detect and resolve medication-related problems. In this paper, we report our experience on pharmaceutical services based on therapeutic care pathway to evaluate the therapeutic effects and assess the feasibility of perioperative treatment protocols. METHODS We performed a retrospective study of 12 recipients who received their graft from infants and young children, between September 2011 and December 2013 at our institution. As providers of pharmaceutical services, the clinical pharmacists collected and reviewed the clinical data from all patients, including the clinical characteristics, outcome indices, and follow-up dates. A three-step-protocol of pharmaceutical services including clinician's application, pharmacist consultation, and ongoing direct pharmaceutical care and follow-up was used through the entire length of patient's admission, hospitalization, and discharge. This protocol was developed and refined based on the guidelines for transplant perioperative treatment and experiences of the clinical pharmacists to standardize the workflow, and improve the medical treatment and quality of life of patients. RESULTS There was no acute rejection, graft loss, or death in 10 recipients after transplantation, and another 2 received nephrectomy due to dysfunction. Postoperative follow-up of the patients who received the pharmaceutical services from the clinical pharmacist showed an effectiveness in managing medication-related complications, patient-related factors, and an improvement of the outcomes. CONCLUSIONS The three-step protocol of pharmaceutical services for pharmaceutical care and individual dosing regimen sponsored by pharmacists facilitated access to personalized therapies for children undergoing kidney transplantation in our hospital.
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Affiliation(s)
- Yan Wen
- Department of Pharmacy, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Mengpei Zhao
- Department of Pharmacy, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Shangxi Fu
- Department of Organ Transplantation, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Zhichun Gu
- Department of Pharmacy, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wansheng Chen
- Department of Pharmacy, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Qing Zhao
- Department of Pharmacy, Zhabei Central Hospital of Jing'an District, Shanghai, China
| | - Wei Shu
- Department of Pharmacy, Zhabei Central Hospital of Jing'an District, Shanghai, China
| | - Xia Tao
- Department of Pharmacy, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Feng Zhang
- Department of Pharmacy, Changzheng Hospital, Naval Medical University, Shanghai, China
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Beatrice JM, Takahashi MS, Celeste DM, Watanabe A, Koch VHK, Carneiro JDA. Thromboprophylaxis after kidney transplantation in children: Ten-year experience of a single Brazilian center. Pediatr Transplant 2021; 25:e14101. [PMID: 34324760 DOI: 10.1111/petr.14101] [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: 10/22/2020] [Revised: 07/07/2021] [Accepted: 07/08/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Kidney transplantation is the gold standard treatment for children with end-stage chronic kidney disease. Graft thrombosis is an important cause of graft failure, with high morbidity, mortality, and impact on quality of life and to the health system. The role of thromboprophylaxis in this setting is still uncertain. We describe the demographic characteristics and thrombotic risk factors in pediatric renal transplant recipients, determining the rate of renal graft thrombosis, and discuss the role of thromboprophylaxis. METHODS This retrospective study reviewed 96 pediatric renal transplantations between 2008 and 2017 in a single hospital. Patients were assigned to one of two groups: children who did not receive thromboprophylaxis after transplantation and those who did. We reported their characteristics, comparing the incidence of graft thrombosis and hemorrhagic complications between the groups. RESULTS Forty-nine patients (51%) received thromboprophylaxis. Thrombosis occurred in 5 patients who did not receive thromboprophylaxis (5.2%) compared with none in the group that did (p = .025). In all patients, renal graft thrombosis resulted in early graft loss. Thirteen patients had hemorrhagic complications. Seven were unrelated to pharmacological thromboprophylaxis (2 major, 1 moderate, and 4 minor bleeding, which either did not receive thromboprophylaxis or had bleeding prior to thromboprophylaxis), while six occurred during heparinization (2 major, 1 moderate, and 3 minor bleeding). There was no significant difference in the rate of hemorrhagic complications between the groups (p = .105). CONCLUSIONS The rate of renal graft thrombosis was 5.2%. Thrombosis remains an important cause of early graft loss. Thromboprophylaxis was associated with a reduction in graft thrombosis without increased risk of bleeding.
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Affiliation(s)
- Julia Maimone Beatrice
- Division of Pediatric Hematology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | | | - Daniele Martins Celeste
- Division of Pediatric Hematology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Andreia Watanabe
- Pediatric Nephrology Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Vera Hermina Kalika Koch
- Pediatric Nephrology Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Jorge David Aivazoglou Carneiro
- Division of Pediatric Hematology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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7
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Bapistella S, Zirngibl M, Buder K, Toulany N, Laube GF, Weitz M. Prophylactic antithrombotic management in adult and pediatric kidney transplantation: A systematic review and meta-analysis. Pediatr Transplant 2021; 25:e14021. [PMID: 33826219 DOI: 10.1111/petr.14021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 03/21/2021] [Accepted: 03/26/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND RGT is a major cause for early graft loss after KTx. Although evidence-based recommendations are lacking, aP is often used to prevent RGT. This systematic review aimed to determine the effectiveness and safety of aP in adult and pediatric KTx recipients. METHODS MEDLINE, EMBASE, Cochrane Controlled Trials Register, conference proceedings, and electronic databases for trial registries were searched for eligible studies using search terms relevant to this review (April 21, 2020). The systematic review was carried out following the recommendations of the Cochrane Collaboration and the Prefered Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement. RESULTS Twelve studies comprising 2370 patients (adult = 1415, pediatric = 955) were included, of which three were RCTs. The overall risk for developing RGT was lower in the group with aP compared with the control group (RR 0.24, 95% confidence interval 0.12-0.49). The antithrombotic drugs used were heparin (7/12), acetylsalicylic acid (2/12), a combination of both (2/12), and dipyridamole (1/12) with a high variability in timing, dosing, and mode of application. Adverse effects were reported rarely, with minor bleeding as the main complication. The non-randomized studies had significant risks of bias in the domains of patient selection, confounder, and measurement of outcomes. CONCLUSION Based on pooled analysis, aP seems to reduce the risk of RGT in KTx. However, the reliability of these results is limited, as the quality of the available studies is poor and information on adverse effects associated with aP is scarce. Additional high-quality research is urgently needed to provide sufficient data supporting the use of aP in KTx.
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Affiliation(s)
- Sascha Bapistella
- Department of General Pediatrics and Haematology/Oncology, University Children's Hospital Tuebingen, Tuebingen, Germany
| | - Matthias Zirngibl
- Department of General Pediatrics and Haematology/Oncology, University Children's Hospital Tuebingen, Tuebingen, Germany
| | - Kathrin Buder
- Pediatric Nephrology Department, University Children's Hospital Zurich, Zurich, Switzerland
| | - Nikan Toulany
- Department of General Pediatrics and Haematology/Oncology, University Children's Hospital Tuebingen, Tuebingen, Germany
| | - Guido F Laube
- Department of Pediatrics, Children's Hospital Baden, Baden, Switzerland
| | - Marcus Weitz
- Department of General Pediatrics and Haematology/Oncology, University Children's Hospital Tuebingen, Tuebingen, Germany
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8
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Successful living-donor kidney transplantation after vena cava flow obstruction in a small recipient. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2021. [DOI: 10.1016/j.epsc.2020.101683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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9
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Buder K, Zirngibl M, Bapistella S, Nadalin S, Tönshoff B, Weitz M. Current practice of antithrombotic prophylaxis in pediatric kidney transplantation-Results of an international survey on behalf of the European Society for Paediatric Nephrology. Pediatr Transplant 2020; 24:e13799. [PMID: 33119218 DOI: 10.1111/petr.13799] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 06/05/2020] [Accepted: 06/28/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Renal graft thrombosis (RGT) is one of the main causes for early graft loss in pediatric kidney transplantation (KTx). Despite the lack of evidence-based recommendations, antithrombotic prophylaxis (aP) is used to prevent RGT. METHODS An online survey supported by the European Society for Pediatric Nephrology was developed to investigate the current practice of aP in pediatric KTx recipients <18 years. RESULTS A total of 80 pediatric KTx centers from 37 countries participated in the survey. Antithrombotic prophylaxis was performed in 96% of the pediatric renal transplant centers (all/selected patients: 54%/42%). The main overall used drugs were as follows: low-molecular-weight heparin (89%), unfractionated heparin (UFH) (69%), and acetylsalicylic acid (ASS) (55%). Ten different aP management strategies were identified as follows: 51% used a single drug and 48% combined two drugs sequentially. The corresponding centers started aP predominantly within 24 hours after pediatric KTx; 51% preferred UFH for starting aP. In centers switching to a second drug (51%), this change was performed after 10 ± 6 days; of these 57% preferred ASS for maintenance aP. Reported median aP duration was 51 days (range 1-360). CONCLUSIONS Despite the use of aP in almost all responding pediatric KTx centers, there is no uniform management strategy. Notwithstanding, UFH seems to be the preferred drug for the early post-operative period of pediatric KTx, and ASS for maintenance prophylaxis following pediatric KTx. Prospective studies are needed to further evaluate the benefits and risks of aP, preferably resulting in guidelines for the management in pediatric KTx.
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Affiliation(s)
- Kathrin Buder
- Pediatric Nephrology Department, University Children`s Hospital Zurich, Zurich, Switzerland
| | - Matthias Zirngibl
- Department of General Pediatrics and Hematology/Oncology, University Hospital Tübingen, University Children`s Hospital, Tübingen, Germany
| | - Sascha Bapistella
- Department of General Pediatrics and Hematology/Oncology, University Hospital Tübingen, University Children`s Hospital, Tübingen, Germany
| | - Silvio Nadalin
- Department of General, Visceral and Transplant Surgery, University Hospital Tübingen, Tübingen, Germany
| | - Burkhard Tönshoff
- Department of Pediatrics I, University Children's Hospital Heidelberg, Heidelberg, Germany
| | - Marcus Weitz
- Department of General Pediatrics and Hematology/Oncology, University Hospital Tübingen, University Children`s Hospital, Tübingen, Germany
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10
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Kim JK, Chua ME, Teoh CW, Lee MJ, Kesavan A, Hebert D, Lorenzo AJ, Farhat WA, Koyle MA. Assessment of prophylactic heparin infusion as a safe preventative measure for thrombotic complications in pediatric kidney transplant recipients weighing <20 kg. Pediatr Transplant 2019; 23:e13512. [PMID: 31169341 DOI: 10.1111/petr.13512] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 03/20/2019] [Accepted: 05/12/2019] [Indexed: 11/28/2022]
Abstract
Small-sized kidney recipients (<20 kg) are at high risk of allograft vessel thrombosis. HP has been used to mitigate this risk but may infer an increase in bleeding risks. Therefore, we aim to determine whether HP is a safe means to prevent thrombosis in small kidney transplant patients by comparing those who have received HP and those who have NHP. A retrospective review of patients < 20 kg who underwent kidney transplant in our institution from 2000 to 2015 was performed. At our institution, unfractionated heparin 10 units/kg/hour is used as HP since 2009. Patients at increased risk of thrombosis (previous thrombosis, thrombophilia, nephrotic syndrome) and bleeding (therapeutic doses of heparin, diagnosis of coagulopathy) were excluded. Fifty-six patients were identified (HP n = 46; NHP n = 10). Baseline demographics were similar between HP and NHP. There was no statistical difference in frequency of transfusions, surgical re-exploration, or thrombotic events between HP and NHP. The HP group was more likely to have drop in Hb > 20 g/L (67.4% vs 30.0%, P = 0.038), and those who had drop in Hb > 20 g/L were more likely to also require pRBC transfusions (63.0% vs 20.0%, P = 0.017). Within the HP group, those who had bleeding complications had similar Hb levels as those who did not at baseline and post-transplant. Outcomes in the HP and NHP groups were no different with respect to thrombosis or significant bleeding complications requiring pRBC transfusions or surgical intervention. Future prospective studies are required to investigate the balance of preventing thrombosis and risks of pRBC transfusions for small-sized kidney recipients.
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Affiliation(s)
- Jin K Kim
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of Urology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Michael E Chua
- Division of Urology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Chia Wei Teoh
- Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Min Joon Lee
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of Urology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Amre Kesavan
- Division of Urology, The Hospital for Sick Children, Toronto, Ontario, Canada.,School of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Diane Hebert
- Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Armando J Lorenzo
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Walid A Farhat
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Martin A Koyle
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Surgery, University of Toronto, Toronto, Ontario, Canada
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11
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Wang CS, Greenbaum LA, Patzer RE, Garro R, Warshaw B, George RP, Winterberg PD, Patel K, Hogan J. Renal allograft loss due to renal vascular thrombosis in the US pediatric renal transplantation. Pediatr Nephrol 2019; 34:1545-1555. [PMID: 31129729 DOI: 10.1007/s00467-019-04264-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 02/25/2019] [Accepted: 04/18/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Renal vascular thrombosis (RVT) is a major cause of early allograft loss in the first year following pediatric kidney transplantation. We examined recent trends in allograft loss due to RVT and identified associated risk factors. METHODS We identified 14,640 kidney-only transplants performed between 1995 and 2014 with follow-up until June 30, 2016, in 13,758 pediatric patients aged < 19 years from the US Renal Data System. We examined the 1-year incidence of allograft loss due to RVT by year of transplant, and plotted the trend over time. Cox proportional hazards models were used to investigate the relationship between year of transplant as well as recipient, donor, and transplant characteristics with allograft loss due to RVT. RESULTS The incidence of allograft loss due to RVT consistently declined among pediatric kidney transplant performed between 1995 and 2014. Among transplants performed between 1995 and 2004, 128/7542 (1.7%) allografts were lost due to RVT compared to 53/7098 (0.8%) among transplants performed between 2005 and 2014; average 1-year cumulative incidence was 1.5% (95% CI, 1.3-1.9%) and 0.6% (95% CI, 0.5-0.8%), respectively. Increased risk for allograft loss due to RVT was associated with en bloc kidney transplantation (HR, 3.42; 95% CI 1.38-8.43) and cold ischemia time ≥ 12 h (HR, 1.78; 95% CI, 1.15-2.76). Interestingly, these risk factors were more prevalent in the latter decade. CONCLUSIONS The incidence of allograft loss due to RVT significantly and continuously declined among pediatric kidney transplants performed between 1995 and 2014. The causes for this improvement are unclear in the present analysis.
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Affiliation(s)
- Chia-Shi Wang
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA. .,Children's Healthcare of Atlanta, Atlanta, GA, USA.
| | - Larry A Greenbaum
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA.,Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Rachel E Patzer
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA.,Department of Epidemiology, Emory Rollins School of Public Health, Atlanta, GA, USA
| | - Rouba Garro
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA.,Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Barry Warshaw
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA.,Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Roshan P George
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA.,Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Pamela D Winterberg
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA.,Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Kavita Patel
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA.,Aflac Cancer and Blood Disorders, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Julien Hogan
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA.,Pediatric Nephrology Department, Robert Debre Hospital, Assistance Publique-Hopitaux de Paris, Paris, France
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12
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Malakasioti G, Marks SD, Watson T, Williams F, Taylor-Allkins M, Mamode N, Morgan J, Hayes WN. Continuous monitoring of kidney transplant perfusion with near-infrared spectroscopy. Nephrol Dial Transplant 2018; 33:1863-1869. [DOI: 10.1093/ndt/gfy116] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 04/03/2018] [Indexed: 12/19/2022] Open
Affiliation(s)
- Georgia Malakasioti
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Stephen D Marks
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- University College London Great Ormond Street Institute of Child Health, London, UK
| | - Tom Watson
- Department of Paediatric Radiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Fariba Williams
- Department of Paediatric Radiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Mariesa Taylor-Allkins
- Department of Paediatric Radiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Nizam Mamode
- Department of Transplant Surgery, Guys and St Thomas’ NHS Foundation Trust, London, UK
| | - Justin Morgan
- Department of General Surgery, Southmead Hospital, North Bristol NHS Foundation Trust, Bristol, UK
| | - Wesley N Hayes
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- University College London Great Ormond Street Institute of Child Health, London, UK
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13
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Abstract
Due to progressive advances in surgical techniques, immunosuppressive therapies, and supportive care, outcomes from both solid organ transplantation and hematopoietic stem cell transplantation continue to improve. Thrombosis remains a challenging management issue in this context, with implications for both graft survival and long-term quality of life. Unfortunately, there remains a general paucity of pediatric-specific data regarding thrombosis incidence, risk stratification, and the safety or efficacy of preventative strategies with which to guide treatment algorithms. This review summarizes the available evidence and rationale underlying the spectrum of current practices aimed at preventing thrombosis in the transplant recipient, with a particular focus on risk factors, pathophysiology, and described antithrombotic regimens.
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Affiliation(s)
- J D Robertson
- Haematology Service, Division of Medicine, Lady Cilento Children's Hospital, Brisbane, Qld, Australia
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14
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15
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Nixon JN, Biyyam DR, Stanescu L, Phillips GS, Finn LS, Parisi MT. Imaging of Pediatric Renal Transplants and Their Complications: A Pictorial Review. Radiographics 2013; 33:1227-51. [DOI: 10.1148/rg.335125150] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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16
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Abstract
Significant progress has been observed in pediatric renal transplantation over the last 20 years, leading to an increase in graft and patient survival. Mortality is low and is mainly due to infections, neoplasias and complications related to the initial disease. Graft survival is 67% at 10 years. Factors which influence graft survival are: donor type (results are better with a live donor), donor age, recipient age (with 2 periods at risk:<2 years old and teenagers), HLA incompatibilities, and recurrence of the initial disease. Chronic allograft nephropathy (CAN) is the major cause of late graft loss. Poor compliance, especially in teenagers, may lead to late rejections and graft loss. Calcineurin inhibitors nephrotoxicity is in part responsible for the development of CAN, thus treatments and the role of mTOR inhibitors will probably evolve. These different factors are discussed in this article.
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17
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Luna E, Cerezo I, Collado G, Martínez C, Villa J, Macias R, Garcia C, Cubero J. Vascular Thrombosis After Kidney Transplantation: Predisposing Factors and Risk Index. Transplant Proc 2010; 42:2928-30. [DOI: 10.1016/j.transproceed.2010.07.085] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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18
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Sampaio MS, Poommipanit N, Kuo HT, Reddy PN, Cho YW, Shah T, Bunnapradist S. Induction therapy in pediatric kidney transplant recipients discharged with a triple drug immunosuppressive regimen. Pediatr Transplant 2010; 14:770-8. [PMID: 20477974 DOI: 10.1111/j.1399-3046.2010.01335.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
We evaluated the effectiveness of induction therapy on transplant outcomes during 2004-2007 in the United States. We retrospectively reviewed OPTN/UNOS registry and selected kidney pediatric (<21-yr) recipients that received no induction (NoIND), IL-2RA, or rabbit anti-THY and were discharged with a triple drug immunosuppressive maintenance regimen, including steroids. Of 2932 recipients, 20%, 36%, and 43% were in NoIND, THY, and IL-2RA groups, respectively. The majority received tacrolimus (88%) and MMF (89%) at discharge. There was no association of induction with the risk of acute rejection even after adjusting for known cofounders. Compared to NoIND, IL2-RA, but not THY, had a modest decrease (3%) in absolute rate of graft loss and was associated with a risk reduction ratio of 0.51 (95% CI, 0.31-0.84) in one-yr graft loss. At three yr, no induction agent was associated with decreased graft loss. In conclusion, induction agents were used in 80% of pediatric kidney recipients discharged with a triple drug immunosuppressive maintenance regimen between 2004-2007 in the United States. Neither THY nor IL-2RA was associated with reduced rejection episodes. The use of induction therapy was not associated with improvement in three-yr graft survival.
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Affiliation(s)
- Marcelo S Sampaio
- David Geffen School of Medicine at UCLA, Kidney and Pancreas Transplant Program, Los Angeles, CA, USA
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19
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Abstract
It has been shown that kidney transplantation results in superior life expectancy and quality of life compared with dialysis treatment for patients with end-stage renal disease. However, kidney transplantation in children differs in many aspects from adult kidney transplantation. This review focuses on specific issues of surgical care associated with kidney transplantation in children, including timing of transplantation, technical considerations, patient and graft survival, growth retardation and post-transplant malignancy. At the same time, there is a large discrepancy between the number of available donor kidneys and the number of patients on the waiting list for kidney transplantation. There is a general reluctance to use paediatric donor kidneys, because of relatively frequent complications such as graft thrombosis and early graft failure. We review the specific aspects of kidney transplantation from paediatric donors such as the incidence of graft thrombosis, hyperfiltration injury and 'en bloc' transplantation of two kidneys from one donor with an excellent long-term outcome, which is comparable with adult donor kidney transplantation. We also discuss the potential use of paediatric non-heart-beating donor kidneys, from donors whose heart stopped beating with the preservation techniques used.
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20
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Ponticelli C, Moia M, Montagnino G. Renal allograft thrombosis. Nephrol Dial Transplant 2009; 24:1388-93. [DOI: 10.1093/ndt/gfp003] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
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21
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22
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Abstract
Induction therapy to prevent the acute rejection of mismatched allografts with the ultimate aim of prolonging the life of the allograft has been the cornerstone of immunosuppression since the introduction of renal transplantation. Agents used for induction therapy have changed over time. Their role in transplantation is expanding to include corticosteroid avoidance and immunosuppression minimization. This review provides an overview of induction therapies for renal transplantation including historic therapies such as total lymphoid irradiation and Minnesota antilymphocyte globulin, and current therapies with polyclonal and monoclonal antibodies and chemical agents, with special emphasis on children. Data from adult studies, and pediatric studies whenever available, are summarized. A brief summary of experimental therapies with fingolimod and belatacept is provided. Historically, induction therapies were targeted at T cells. The role of induction therapies targeted at B cells is emerging in select groups of patients that include highly sensitized recipients and those receiving transplants from blood group incompatible donors. With the advent of newer maintenance immunosuppressive medications and with very low rates of acute rejection, induction protocols for renal transplantation need to be targeted so that excessive immunosuppression and infections are avoided. Several single-center and registry data analyses in children suggest that the addition of an interleukin (IL)-2 receptor antagonist may improve graft survival compared with no induction. The safety profile of IL-2 receptor antagonists is indistinguishable from that of placebo, with no apparent difference in the incidence of infection or post-transplant lymphoproliferative disease. IL-2 receptor antagonists and polyclonal lymphocyte-depleting antibodies offer equivalent efficacy in standard-risk populations. However, in high-risk patients, acute rejection rates and graft outcomes may be improved with the use of lymphocyte-depleting agents such as Thymoglobulin. However, cytomegalovirus infection and other infections may be more common with this therapy. Therefore, in patients at high risk of graft loss, Thymoglobulin may be the preferred choice for induction therapy, while for all other patients, IL-2 receptor antagonists should be considered the first-line choice for induction therapy. Newer lymphocyte-depleting agents such as alemtuzumab may be better utilized in minimization regimens involving one or two oral maintenance immunosuppressive agents.
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Affiliation(s)
- Asha Moudgil
- Department of Nephrology, Children's National Medical Center, Washington, District of Columbia 20010, USA.
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23
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24
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Silverstein DM, Leblanc P, Hempe JM, Ramcharan T, Boudreaux JP. Tracking of blood pressure and its impact on graft function in pediatric renal transplant patients. Pediatr Transplant 2007; 11:860-7. [PMID: 17976120 DOI: 10.1111/j.1399-3046.2007.00753.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
We studied tracking of BP and its impact on GFR in 44 PRTP followed for 56 months. Three months PT 77% had elevated SBP percentile. First year SBP and DBP correlated positively with final values (p < 0.0001, 0.0002, respectively). Pretransplant and three month PT SBP correlated positively (p = 0.02). At one yr, SBP and DBP were inversely associated with GFR (p = 0.002, p < 0.0001, respectively). SBP and BMI were positively associated at all time points. DBP was significantly higher in deceased recipients throughout the study period. Final DBP was higher (p = 0.03) and GFR lower (p = 0.04) in African-American patients. Patients with end-stage renal disease caused by glomerular disease had higher SBP (p = 0.03) and DBP (p = 0.04) than those with congenital malformations. GFR at one-yr PT (p = 0.02) and end of study (p = 0.003) was significantly lower in patients with high BP. Moreover, patients who maintained a normal systolic BP throughout the study had a significantly higher final GFR than those who were hypertensive at both time points [84 (normal BP throughout) vs. 52 mL/min/1.73 m(2) (high BP throughout), p = 0.02]. We conclude that PT hypertension is common in PRTP and predicts lower GFR.
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Affiliation(s)
- Douglas M Silverstein
- Division of Nephrology, Department of Pediatrics, Louisiana State University Health Sciences Center, New Orleans, LA, USA.
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25
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Smith JM, Stablein DM, Munoz R, Hebert D, McDonald RA. Contributions of the Transplant Registry: The 2006 Annual Report of the North American Pediatric Renal Trials and Collaborative Studies (NAPRTCS). Pediatr Transplant 2007; 11:366-73. [PMID: 17493215 DOI: 10.1111/j.1399-3046.2007.00704.x] [Citation(s) in RCA: 170] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This summary of the NAPRTCS 2006 Annual Report of the Transplant Registry highlights the significant impact the registry has had in advancing knowledge in pediatric renal transplantation worldwide. This cooperative group has collected clinical information on children undergoing a renal transplantation since 1987 and now includes over 150 participating medical centers in the USA, Canada, Mexico, and Costa Rica. Currently, the NAPRTCS transplant registry includes information on 9837 renal transplants in 8990 patients (NAPRTCS 2006 Annual Report). Since the first data analysis in 1989, NAPRTCS reports have documented marked improvements in outcome after renal transplantation in addition to identifying factors associated with both favorable and poor outcomes. The registry has served to document and influence practice patterns, clinical outcomes, and changing trends in renal transplantation.
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Affiliation(s)
- Jodi M Smith
- Department of Pediatrics, University of Washington, Seattle, WA, USA.
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26
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Abstract
This report reviews the immunosuppressive regimens that are used in pediatric transplantation. There are predominant themes developing in the field involving the minimization of the total exposure of immunosuppression through limiting the number of agents and newer pharmacokinetic modeling. Calcineurin inhibitors are the foundation of most immunosuppressive regimens. However, there are new pharmacologic monitoring techniques to reduce the potential for long-term side effects of this class of agents. Although tacrolimus remains one of the mainstays of current protocols, there are strides being made to reduce the patient's long-term exposure to it with transitioning to sirolimus. Corticosteroids are still used predominantly, but there is growing evidence of successful steroid-sparing protocols that are as effective and avoid the chronic morbidity of steroids. Antibody induction therapy remains a standard with clearer evidence of the efficacy of IL-2 receptor antagonists. There is preliminary clinical evidence that polyclonal antibody therapy is efficacious in pediatric transplantation. Future studies will determine the best way to assess the functional immune status of a pediatric transplant recipient to maintain the fine balance and avoid the complications of either excessive or inadequate immunosuppression.
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Affiliation(s)
- Avinash Agarwal
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana 46202, USA
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