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Nieuwenhuijs-Moeke GJ, van den Berg TAJ, Bakker SJL, van den Heuvel MC, Struys MMRF, Lisman T, Pol RA. Preemptively and non-preemptively transplanted patients show a comparable hypercoagulable state prior to kidney transplantation compared to living kidney donors. PLoS One 2018; 13:e0200537. [PMID: 30011293 PMCID: PMC6047796 DOI: 10.1371/journal.pone.0200537] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Accepted: 06/26/2018] [Indexed: 12/14/2022] Open
Abstract
To prevent renal graft thrombosis in kidney transplantation, centres use different perioperative anticoagulant strategies, based on various risk factors. In our centre, patients transplanted preemptively are considered at increased risk of renal graft thrombosis compared to patients who are dialysis-dependent at time of transplantation. Therefore these patients are given a single dose of 5000 IU unfractionated heparin intraoperatively before clamping of the vessels. We questioned whether there is a difference in haemostatic state between preemptively and non-preemptively transplanted patients and whether the distinction in intraoperative heparin administration used in our center is justified. For this analysis, citrate samples of patients participating in the VAPOR-1 trial were used and several haemostatic and fibrinolytic parameters were measured in 29 preemptively and 28 non-preemptively transplanted patients and compared to 37 living kidney donors. Sample points were: induction anaesthesia (T1), 5 minutes after reperfusion (T2) and 2 hours postoperative (T3). At T1, recipient groups showed comparable elevated levels of platelet factor 4 (PF4, indicating platelet activation), prothrombin fragment F1+2 and D-dimer (indicating coagulation activation) and Von Willebrand Factor (indicating endothelial activation) compared to the donors. The Clot Lysis Time (CLT, a measure of fibrinolytic potential) was prolonged in both recipient groups compared to the donors. At T3, F1+2, PF4 and CLT were higher in non-preemptively transplanted recipients compared to preemptively transplanted recipients. Compared to donors, non-preemptive recipients showed a prolonged CLT, but comparable levels of PF4 and D-dimer. In conclusion pre-transplantation, preemptively and non-preemptively transplanted patients show a comparable enhanced haemostatic state. A distinction in intraoperative heparin administration between preemptive and non-preemptive transplantation does not seem justified.
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Affiliation(s)
- Gertrude J. Nieuwenhuijs-Moeke
- Department of Anaesthesiology, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
- * E-mail:
| | - Tamar A. J. van den Berg
- Department of Surgery, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | - Stephan J. L. Bakker
- Department of Nephrology, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | - Marius C. van den Heuvel
- Department of Pathology, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | - Michel M. R. F. Struys
- Department of Anaesthesiology, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
- Department of Anesthesia, Ghent University, Ghent, Belgium
| | - Ton Lisman
- Department of Surgery, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | - Robert A. Pol
- Department of Surgery, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
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Case report of cadaveric kidney transplantation with renal-portal venous drainage: A feasible way for a venous drainage in a complex generalized thrombosed vessels setting. Int J Surg Case Rep 2016; 28:192-195. [PMID: 27718439 PMCID: PMC5061305 DOI: 10.1016/j.ijscr.2016.09.047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Revised: 09/27/2016] [Accepted: 09/27/2016] [Indexed: 11/23/2022] Open
Abstract
One of the frequent complications suffered by patients with chronic renal failure is the lack of vascular access due to venous thrombosis. Patients with vascular structural alteration are technicaly challenging. Kidney transplant with portal venous drainage is an alternative in a general thrombosed vessels setting. The implant of the renal graft was undertaken via an anastomosis at the lateral side of the renal vein to the portal vein.
Introduction One of the frequent complications suffered by patients with chronic renal failure is the lack of vascular access due to venous thrombosis. This means that the transplant surgeon must have a detailed knowledge of the intra-abdominal venous system, and other alternative surgeries, at the time of performing the renal graft implant, in order to ensure a good venous drainage. Presentation of the case This article provides a case report regarding a patient with no vascular access and with surgical difficulties at the time of the kidney transplant, in whom a renal-portal venous drainage was performed with very good outcome. Discusion Renal-portal venous drainage is a way to performe kidney transplant with good outcome. In Fundación Valle del Lili we have overcome the lack of vascular access in patients that need a renal transplant by new surgical technics that improve the patients quality of life and survival. Conclusion We can conclude that new surgical alternatives exist for those patients with chronic renal failure that have no vascular access. These patients are a priority for kidney transplants and the surgeon must take in to account the need for a new surgical assessment.
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ElSheemy MS, Shouman AM, Shoukry AI, Soaida S, Salah DM, Yousef AM, Morsi HA, Fadel FI, Sadek SZ. Surgical complications and graft function following live-donor extraperitoneal renal transplantation in children 20 kg or less. J Pediatr Urol 2014; 10:737-43. [PMID: 24495971 DOI: 10.1016/j.jpurol.2013.12.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2013] [Accepted: 12/13/2013] [Indexed: 10/25/2022]
Abstract
OBJECTIVES To evaluate the effect of patient, surgical, and medical factors on surgical complications and graft function following renal transplantation (Tx) in children weighing ≤ 20 kg, because the number of this challenging group of children is increasing. PATIENTS AND METHODS Between June 2009 and October 2013, 26 patients received living donor renal allotransplant using the extraperitoneal approach (EPA). The immunosuppression regimen was composed of prednisolone, mycophenolate mofetil, and ciclosporin or tacrolimus. RESULTS The mean weight was 16.46 ± 2.61 kg. Mean cold ischemia time was 53.85 ± 12.35 min. The graft survival rate (GSR) and patient survival rate (PSR) were 96% at 3 years. Acute rejection episodes (AREs) occurred in eight patients (30%). Postoperative surgical complications were ureteral leakage (3), vesicoureteric reflux (2), and renal vein thrombosis (2) (with one graft nephrectomy). Mean follow-up was 37.5 ± 7.4 months. CONCLUSION Excellent PSR and GSR can be achieved in low weight (<20 kg) recipients. Even in very low weight patients, the EPA was used. No cases were reported with primary graft non-function due to use of living donors, increasing pre-Tx body weight to at least 10 kg and maintaining adequate filling pressure before graft reperfusion. The presence of related donors and use of induction therapy and tacrolimus decreased the rate of ARE while the presence of pre-Tx lower urinary tract surgical interventions increased the rate of ureteric complications, but this was statistically insignificant.
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Affiliation(s)
- Mohammed S ElSheemy
- Division of Pediatric Urology, Aboul-Riche Children's Hospital, Cairo University, Cairo, Egypt.
| | - Ahmed M Shouman
- Division of Pediatric Urology, Aboul-Riche Children's Hospital, Cairo University, Cairo, Egypt
| | - Ahmed I Shoukry
- Division of Pediatric Urology, Aboul-Riche Children's Hospital, Cairo University, Cairo, Egypt
| | - Sherif Soaida
- Division of Pediatric Anesthesia, Aboul-Riche Children's Hospital, Cairo University, Cairo, Egypt
| | - Doaa M Salah
- Division of Pediatric Nephrology, Aboul-Riche Children's Hospital, Cairo University, Cairo, Egypt
| | - Ali M Yousef
- Division of Pediatric Urology, Aboul-Riche Children's Hospital, Cairo University, Cairo, Egypt
| | - Hany A Morsi
- Division of Pediatric Urology, Aboul-Riche Children's Hospital, Cairo University, Cairo, Egypt
| | - Fatina I Fadel
- Division of Pediatric Nephrology, Aboul-Riche Children's Hospital, Cairo University, Cairo, Egypt
| | - Sameh Z Sadek
- Urology Department, Kasr Al-Ainy Hospital, Cairo University, Cairo, Egypt
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Gomes AL, Koch-Nogueira PC, de Camargo MFC, Feltran LDS, Baptista-Silva JCC. Vascular anastomosis for paediatric renal transplantation and new strategy in low-weight children. Pediatr Transplant 2014; 18:342-9. [PMID: 24646422 DOI: 10.1111/petr.12248] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/04/2014] [Indexed: 11/28/2022]
Abstract
The technical aspects of RT in low-weight children should be specific, particularly with regard to VA. This retrospective study assesses the main VA options in paediatric RTs and proposes a new strategy for renal artery trajectory when using the Ao and the right iVC. The sample included 81 patients and was categorized into a group of children weighing <16 kg and the other group of children weighing 16 kg or more. The smaller children received the graft predominantly on the Ao and iVC (63%); however, the VA options varied in children weighing more than 16 kg, with anastomoses predominantly to the common iliac vessels (46%). In the first group, when the Ao was the selected vessel for anastomosis on the right side, the trajectory adopted for the transplanted kidney artery was posterior to the iVC. This strategy may reduce the risk of compression of the iVC by the renal artery of the donor kidney and may reconstitute the normal anatomy of the renal artery. Moreover, it did not represent a risk factor for graft loss in this sample.
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Affiliation(s)
- Adriano Luís Gomes
- Paediatric Renal Transplantation Group, Hospital Samaritano, São Paulo, SP, Brazil
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Cauley RP, Potanos K, Fullington N, Lillehei C, Vakili K, Kim HB. Reno-portal anastomosis as an approach to pediatric kidney transplantation in the setting of inferior vena cava thrombosis. Pediatr Transplant 2013; 17:E88-92. [PMID: 23461835 DOI: 10.1111/petr.12059] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/05/2012] [Indexed: 11/29/2022]
Abstract
In pediatric renal transplantation in the setting of IVC thrombosis, the retrohepatic IVC or gonadal veins are often used for outflow. However, if use of systemic venous outflow is unsuccessful, options become limited. We report the use of the portal vein for venous outflow in kidney retransplantation in the setting of IVC thrombosis. The patient is a 19-month-old male who developed end-stage renal failure at seven months of age secondary to hypotension after spontaneous rupture of an accessory renal vein. The IVC was occluded during emergent laparotomy, and the patient developed extensive IVC thrombosis. The first two transplant attempts used the retrohepatic IVC for venous outflow. Despite good initial flow, in both instances the renal vein thrombosed on post-operative day 1. In an unsuccessful salvage attempt of the second transplant, a reno-portal anastomosis was performed. With few options for vascular access, a third transplant was attempted. The reno-portal stump from the second transplant was used for outflow. The patient recovered well from his third transplant (creatinine 0.6 mg/dL 35 months post-surgery), demonstrating that the portal vein can be used for outflow in cases of extensive IVC thrombosis.
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Affiliation(s)
- R P Cauley
- Department of Surgery, Boston Children's Hospital, Boston, MA 02115, USA
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Huang PC, Yang CY, Lee CY, Yeh CC, Lai IR, Tsau YK, Hu RH, Tsai MK, Lee PH. Pediatric renal transplantation: results and prognostic factors. Asian J Surg 2013; 36:53-7. [PMID: 23522755 DOI: 10.1016/j.asjsur.2012.09.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2012] [Revised: 07/04/2012] [Accepted: 09/06/2012] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Po-Cheng Huang
- Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
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Identification of risk factors for vascular thrombosis may reduce early renal graft loss: a review of recent literature. J Transplant 2012; 2012:793461. [PMID: 22701162 PMCID: PMC3369524 DOI: 10.1155/2012/793461] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2012] [Accepted: 04/08/2012] [Indexed: 12/17/2022] Open
Abstract
Renal graft survival has improved over the past years, mainly owing to better immunosuppression. Vascular thrombosis, though rare, therefore accounts for up to one third of early graft loss. We assess current literature on transplantation, identify thrombosis risk factors, and discuss means of avoiding thrombotic events and saving thrombosed grafts. The incidence of arterial thrombosis was reported to 0.2–7.5% and venous thrombosis 0.1–8.2%, with the highest incidence among children and infants, and the lowest in living donor reports. The most significant risk factors for developing thrombosis were donor-age below 6 or above 60 years, or recipient-age below 5-6 years, per- or postoperative hemodynamic instability, peritoneal dialysis, diabetic nephropathy, a history of thrombosis, deceased donor, or >24 hours cold ischemia. Multiple arteries were not a risk factor, and a right kidney graft was most often reported not to be. Given the thrombosed kidney graft is diagnosed in time, salvage is possible by urgent reoperation and thrombectomy. Despite meticulous attentions to reduce thrombotic risk factors, thrombosis cannot be entirely prevented and means to an early detection of this complication is desirable in order to save the kidneys through prompt reoperation. Microdialysis may be a new tool for this.
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Fonouni H, Tahmasbi Rad M, Golriz M, Faridar A, Esmaeilzadeh M, Jarahian P, Hafezi M, Jafarieh S, Macher-Goeppinger S, Longerich T, Orakcioglu B, Sakowitz O, Schmidt J, Mehrabi A. Using microdialysis for early detection of vascular thrombosis after kidney transplantation in an experimental porcine model. Nephrol Dial Transplant 2011; 27:541-7. [PMID: 21719714 DOI: 10.1093/ndt/gfr308] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND In kidney transplantation (KTx), vascular thrombosis has a major impact on morbidity and graft survival. The ischaemia, caused by thrombosis, can lead to interstitial metabolite changes. The aim of this experimental study was to create conditions in which the graft would be prone to vascular thrombosis following KTx and then to evaluate the role of microdialysis (MD) for its early detection. METHODS Sixteen randomized pigs in the control group received heparin and immunosuppressive drugs, while the case group received none. Based on histopathological evidence of vascular thrombosis, the case group was subdivided into mildly and severely congested subgroups. Using MD, we evaluated the interstitial concentrations of glucose, lactate to pyruvate ratio, glutamate and glycerol in the transplanted grafts during different phases of KTx. RESULTS Following reperfusion, we noted considerable changes. The severely congested subgroup showed a low and decreasing level of glucose. Only in this group did the lactate to pyruvate ratio continue to increase until the end of monitoring. The glycerol level increased continuously in the entire case group and this increase was most significant in the severely congested subgroup. In all of the study groups, glutamate concentration remained in a low steady state until the end of monitoring. CONCLUSION MD can be an appropriate method for early detection of vascular complications after KTx. Decreasing glucose levels, increased lactate to pyruvate ratio and increased glycerol levels are appropriate indicators for early detection of vascular thromboses following KTx. Particularly, the glycerol level could predict the necessity and urgency of intervention needed to ultimately save the transplanted kidney.
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Affiliation(s)
- Hamidreza Fonouni
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
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Khan Z, Sciveres M, Salis P, Minervini M, Maggiore G, Cintorino D, Riva S, Gridelli B, Emma F, Spada M. Combined split liver and kidney transplantation in a three-year-old child with primary hyperoxaluria type 1 and complete thrombosis of the inferior vena cava. Pediatr Transplant 2011; 15:E64-70. [PMID: 19793227 DOI: 10.1111/j.1399-3046.2009.01241.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
PH1 is an inborn error of the metabolism in which a functional deficiency of the liver-specific peroxisomal enzyme, AGT, causes hyperoxaluria and hyperglycolic aciduria. Infantile PH1 is the most aggressive form of this disease, leading to early nephrocalcinosis, systemic oxalosis, and end-stage renal failure. Infantile PH1 is rapidly fatal in children unless timely liver-kidney transplantation is performed to correct both the hepatic enzyme defect and the renal end-organ damage. The surgical procedure can be further complicated in infants and young children, who are at higher risk for vascular anomalies, such as IVC thrombosis. Although recently a limited number of children with IVC thrombosis have underwent successful kidney transplantation, successful multi-organ transplantation in a child with complete IVC thrombosis is quite rare. We report here the interesting and technically difficult case of a three-yr-old girl with a complete thrombosis of the IVC, who was the recipient of combined split liver and kidney transplantation for infantile PH1. Although initial delayed renal graft function with mild-to-moderate acute rejection was observed, the patient rapidly regained renal function after steroid boluses, and was soon hemodialysis-independent, with good diuresis. Serum and plasma oxalate levels progressively decreased; although, to date they are still above normal. Hepatic and renal function indices were at, or approaching, normal values when the patient was discharged 15-wk post-transplant, and the patient continues to do well, with close and frequent follow-up. This is the first report of a successful double-organ transplant in a pediatric patient presenting with infantile PH1 complicated by complete IVC thrombosis.
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Affiliation(s)
- Zahida Khan
- University of Pittsburgh School of Medicine, Medical Scientist Training Program, Pittsburgh, PA, USA
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Keller AK, Jorgensen TM, Ravlo K, Nielsen TK, Olsen LH, Stolle LB. Microdialysis for detection of renal ischemia after experimental renal transplantation. J Urol 2009; 182:1854-9. [PMID: 19692033 DOI: 10.1016/j.juro.2009.03.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2008] [Indexed: 11/24/2022]
Abstract
PURPOSE We designed an experimental renal transplantation model and evaluated microdialysis as a detector of induced postoperative ischemia, a feared complication that when caused by vascular thrombosis most often causes renal graft loss. MATERIALS AND METHODS Two microdialysis catheters were placed in the left kidney in 16 pigs, including 1 superficially in the renal cortex and 1 fixed on the renal capsule. Two-hour baseline measurements were made at steady state, after which the kidney was removed and subjected to warm and cold ischemia. It was subsequently re-anastomosed end to end in situ and reperfused for 5 hours. Pigs were then randomized into a total renal artery occlusion and a control group. RESULTS At baseline there were no changes in local metabolites (glucose, glutamate, glycerol and lactate) and no significant difference between the groups. Glycerol increased 4-fold in each group during cold ischemia but there were no pivotal alterations in other metabolites. After kidney reperfusion glycerol decreased and all metabolites were in steady state after 1 hour. At 30 minutes after postoperative ischemia was introduced there were significant increases in all kidneys in ischemia vs steady state reperfusion levels of cortical lactate, glutamate, glycerol and the lactate-to-glucose ratio (each rank sum test p <0.001). No metabolic changes were seen in controls. CONCLUSIONS Microdialysis detected significant metabolic changes after postoperative ischemia in pigs with experimental renal transplantation, while no metabolic changes were observed in controls. In the future microdialysis may become a valuable tool for postoperative observation of transplanted kidneys, most probably with major impact on early graft survival.
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Affiliation(s)
- Anna Krarup Keller
- Institute of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
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Shenoy M, Pararajasingam R, Wright NB, Lewis MA, Parrott N, Riad H, Webb NJA. Successful renal transplantation in children in the presence of thrombosis of the inferior vena cava. Pediatr Nephrol 2008; 23:2261-5. [PMID: 18253760 DOI: 10.1007/s00467-007-0736-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2007] [Revised: 11/27/2007] [Accepted: 11/29/2007] [Indexed: 11/27/2022]
Abstract
Thrombosis of the inferior vena cava (IVC) has previously been considered to be a contraindication to renal transplantation in children because of the technical difficulties associated with surgery and the increased risk of graft thrombosis. We report three children with previous IVC thrombosis who underwent renal transplantation at our institution over the last 5 years. The pretransplant imaging of these patients included direct venography or magnetic resonance venography to evaluate venous outflow. Two children (19 kg and 36 kg) received deceased donor renal allografts with no surgical complications or delayed graft function. At the latest follow-up 3.0 and 4.6 years posttransplantation, respectively, they were well, with estimated glomerular filtration rates of 52 and 64 ml/min per 1.73 m(2), respectively. The third child underwent a live-related-donor renal transplant at the age of 4.9 years (weight 13.5 kg). There was primary graft nonfunction. Renal vein thrombosis was noted on postoperative day 12, with subsequent graft loss. Children with previous IVC thrombosis can be successfully transplanted with adult-sized kidneys provided detailed evaluation of the venous drainage has been performed. There is substantial risk of graft thrombosis, and detailed counselling regarding the specific risks of the procedure is essential.
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Affiliation(s)
- Mohan Shenoy
- Department of Paediatric Nephrology, Royal Manchester Children's Hospital, Manchester, M27 4HA, UK
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Kranz B, Vester U, Nadalin S, Paul A, Broelsch CE, Hoyer PF. Outcome after kidney transplantation in children with thrombotic risk factors. Pediatr Transplant 2006; 10:788-93. [PMID: 17032424 DOI: 10.1111/j.1399-3046.2005.00483.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND According to the data from the North American Pediatric Renal Transplant Cooperative Study (NAPRTCS), vascular thrombosis accounts for 11.6% of graft losses in pediatric renal transplantation. In adults, inherited and acquired thrombophilic risk factors, e.g. factor V Leiden mutation, have been associated with early graft loss and increased rejection episodes. Data on the impact of these factors on the outcome of children after renal transplantation are rare. METHODS/PATIENTS Sixty-six pediatric patients awaiting renal transplantation (mean age 10.1 yr) were screened for inherited and acquired risk factors for hypercoagulable disorders (protein C, S, and antithrombin III deficiency, antiphospholipid antibodies, factor V Leiden, prothrombin, and MTHFR mutation) in order to intensify anticoagulation in those with an increased risk for thrombophilia: intravenous heparin was administered with a partial prothrombin time (PTT) prolongation of 50 s for 14 days and switched to low-molecular-weight heparin for another 8 wk before aspirin was introduced for the first year. Patients without hypercoagulable risk factors were treated with heparin without PTT prolongation for 14 days and switched to aspirin immediately afterwards. The results on graft survival, incidence of acute rejection episodes, and long-term renal graft function were analyzed between recipients with and without hypercoagulable risk factors. RESULTS Thrombophilic risk factors were identified in 27.3% of our patients. No thrombosis occurred. One serious bleeding complication led to a second surgical intervention. The rate of acute rejection episodes was not increased in patients with and without thrombotic risk factors after 90 days (16.7 vs. 25%), 1 yr (22.2 vs. 33.3%), and 3 yr (38.9 vs. 41.7%) of follow-up, respectively (p = n.s.). After a mean follow-up of 3 yr the kidney function was comparable in both groups, with 63.1 in recipients with and 69.8 mL/min/1.73 m(2) in recipients without hypercoagulable risk (p = n.s.). At latest follow-up, three graft losses were found not to be attributed to thrombotic risk factors. INTERPRETATION Children with thrombophilic risk factors were identified and treated with an intensified anticoagulation regimen after renal transplantation. An increased risk for graft failure, acute rejection episodes, or impaired renal function for pediatric renal transplant recipients with hypercoagulable status was not found.
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Affiliation(s)
- Birgitta Kranz
- Clinic of Pediatric Nephrology, University Clinic Essen, Essen, Germany.
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15
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Adams J, Mehls O, Wiesel M. Pediatric renal transplantation and the dysfunctional bladder. Transpl Int 2004; 17:596-602. [PMID: 15517166 DOI: 10.1007/s00147-004-0784-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2003] [Revised: 07/08/2004] [Accepted: 08/02/2004] [Indexed: 10/26/2022]
Abstract
We retrospectively reviewed our long-term experience with pediatric renal transplantation into a dysfunctional lower urinary tract to evaluate graft survival, function, and special urological complications. Between 1967 and March 2000, a total of 349 renal transplantations were performed in children younger than 18 years. Malformations of the lower urinary tract were the reasons for end-stage renal failure in 66 children (18.6%). The cause of urinary tract disorders included: meningomyelocele connected with neuropathic bladder (n = 4 transplantations); prune belly syndrome (n = 5 transplantations); VATER association (n = 2 transplantations); posterior urethral valves (n = 27 transplantations); and vesico-uretero-renal reflux (n = 28 transplantations). The majority of the patients underwent surgical interventions to preserve renal function or to prepare renal transplantation. The 1- and 5-year graft survival rate was evaluated with special reference to the underlying disease. The 1-year graft survival rate in all children with lower urinary tract malformations was 83.3%, compared with 88% for all children. In those children with vesico-ureteral reflux, it was 92.8% and in the children with Vater association and prune belly syndrome, it was 85.7%. One graft was lost in the children who had neurogenic bladder, so the 1-year graft survival rate was 75%. The worst 1-year graft survival rate was obtained for boys who had posterior urethral valves (1-year graft survival rate: 74%; 5-year graft survival rate: 62.9%). Concerning the 5-year graft survival rate, it was 70% for all children with malformations of the urinary tract. The best rate was obtained for children with reflux in the native kidneys (78.5%), followed by those with VATER association and prune belly syndrome. As an additional child with neurogenic bladder lost his graft, the 5-year graft survival rate was 50%. Pediatric renal transplantation into a dysfunctional bladder can be connected with high urological complication rates which may contribute to worse graft survival. The 1- and 5-year graft survival rate in children with malformations of the lower urinary tract is worse than in children without bladder dysfunction. We regarded a striking difference between graft survival and the urological disorders which led to renal insufficiency. We obtained the worst graft survival rates in children with posterior urethral valves which are usually connected with bladder emptying problems and dysfunctional voiding. Potential pediatric transplant recipients must be classified according to pathophysiological as well as anatomical abnormalities of the urinary tract and all urological problems have to be solved prior to transplantation. At our center, living donors are favored to plan transplantation of these children properly.
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Affiliation(s)
- J Adams
- Department of Urology, Ruprecht Karls University, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany.
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