Association of age with risk of first and subsequent allograft failure and mortality among young kidney transplant recipients in the USA - a retrospective cohort study

Adolescent age may be a high-risk period for kidney allograft failure. However, the knowledge on this topic is limited mostly to the first transplant. Among 20 960 patients aged ≤21 years at the first kidney transplantation from the US Renal Data System, we evaluated the association of age at the first kidney transplant with risk for the first and subsequent graft failures (1st, 2nd, and 3rd) using the conditional risk set model for recurrent time-to-event data. The median age was 15 (interquartile range: 9-18) years, and 18% received transplants twice or more during a median follow-up of 9.7 years. The risk for graft failures was highest in 16 to <18 years old with an adjusted hazard ratio (aHR) of 1.93 (95% CI, 1.73-2.15; reference: <3 years). When separately analyzed, the highest risk was observed in 17, 19, and 21 years old for the first, second, and third transplant, respectively. Those 16 to <18 years were also strongly associated with the highest risk for death after returning to dialysis (aHR, 4.01; 95% CI, 2.82-5.71). Adolescent recipients remain at high risk for allograft failure for a long time, which may result in high mortality risk, even though they surpass this high-risk period soon after the first transplant.

A Survey of Practitioner’s Knowledge of Psychiatric Medication Costs

Introduction. Escalating medical costs continue to be an issue facing contemporary medicine. One factor contributing to this escalation may be physicians’ knowledge of medication costs. As physicians increasingly face opportunities to treat a variety of symptoms and conditions in a single patient, including co-morbid psychiatric disorders or complications, accurate knowledge of medication costs becomes increasingly important. Methods. Resident and attending physicians (N = 16) across the disciplines of internal medicine, psychiatry, and combined internal medicine/psychiatry from a large, mid-western medical school were surveyed on the costs of several medications that are used to manage physical and psychiatric symptoms. Results. Differences were found in the perceived estimated cost of medications among practitioners particularly with specialty internal medicine training as compared to those with additional psychiatric training/experience. Trends also were noted across practitioners with psychiatric and internal medicine/psychiatry training. Conclusions. The breadth of training and experience can affect accuracy in estimating anticipated costs of medication regimens.

Initial comparison of robotic-assisted laparoscopic versus open pyeloplasty in children

OBJECTIVES

To compare the initial results of robotic-assisted laparoscopic versus open pyeloplasty in children with ureteropelvic junction obstruction.

METHODS

From June 2002 to July 2004, 8 pediatric patients underwent robotic-assisted laparoscopic pyeloplasty and were matched by age group with patients undergoing conventional open pyeloplasty. The mean age was 11.5 years (range 6.4 to 16.5) in the robotic-assisted group and 9.8 years (range 6.0 to 15.6) in the open group. A four-port transperitoneal technique was used to perform the Anderson-Hynes pyeloplasty with the da Vinci Surgical System.

RESULTS

The mean operative time and estimated blood loss was 363 minutes (range 255 to 522) and 13.1 mL (range 5 to 25) in the robotic-assisted group versus 248 minutes (range 144 to 375) and 53.8 mL (range 5 to 200) in the open group, respectively. The mean length of hospitalization and pain medication use was 2.4 days (range 1 to 5) and 7.4 mg morphine (range 0 to 23) in the robotic-assisted group compared with 3.3 days (range 1 to 8) and 22.0 mg morphine (range 0 to 100) in the open group, respectively. At a mean follow-up of 14.7 months (range 2 to 24), all robotic procedures were successful as determined by subjective data using pain scales and radiologic data.

CONCLUSIONS

Robotic-assisted laparoscopic pyeloplasty appears to decrease the length of hospitalization and use of pain medication, but has a longer operative time. Additional clinical experience is required to determine the long-term efficacy of this method.

Laparoscopic retroperitoneal renal and adrenal surgery in children

OBJECTIVE

To retrospectively assess the use of a retroperitoneal laparoscopic approach for simple nephrectomy and adrenalectomy in children.

PATIENTS AND METHODS

All retroperitoneal laparoscopic renal and adrenal procedures carried out in children and completed between 1993 and March 2000 were reviewed retrospectively. Analgesic requirements, hospital stay, complications and blood loss were reviewed. The technique is described in detail.

RESULTS

Forty-eight retroperitoneal laparoscopic procedures were completed in 48 patients (mean age 5.5 years, range 0.5-16). The procedures included nephrectomy (22), nephroureterectomy (15), renal biopsy (six), cyst ablation (two) and simple adrenalectomy (three). In all, 11 procedures were undertaken in children aged < 2 years. Forty-one (91%) of the children undergoing renal procedures were discharged in < 24 h. Two patients underwent three adrenalectomies. Two children required conversion to open surgery, one undergoing a right-sided adrenalectomy and one a nephrectomy. The mean operative duration for nephrectomy and nephroureterectomy was 75 min, and for adrenalectomy was 115 min.

CONCLUSION

Renal and adrenal surgery in children is a safe and rapid procedure with retroperitoneal laparoscopy. The operative duration for nephrectomy and nephroureterectomy are frequently < 1 h. In addition, laparoscopic surgery offers significant advantages in terms of cosmesis and a quicker recovery.

Retroperitoneal laparoscopic nephrectomy in children

PURPOSE

We report our experience with retroperitoneal laparoscopic nephrectomy and nephroureterectomy in children, and describe our surgical technique.

MATERIALS AND METHODS

Five and 15 children 9 months to 17 years old underwent nephrectomy with cystoscopy plus intravesical ureteral stump fulguration for ureteral ablation and nephrectomy only, respectively. Surgical indications were unilateral multicystic dysplastic kidney in 8 cases (parental preference for surgery), a refluxing, chronic pyelonephritic kidney in 5, renal vascular hypertension in 2, and hydronephrosis and chronic pyelonephritis in 5, including 3 in whom a nephrostomy tube was placed percutaneously before laparoscopic nephrectomy. Access was obtained by a 10 mm. incision made posterior to the anterosuperior iliac spine with dissection into the retroperitoneal space and trochar placement. Two and sometimes 3 additional 5 mm. ports were placed retroperitoneally.

RESULTS

Average operative time was 1 hour 42 minutes. The most recent cases were performed in less than 1 hour and in 3 nephrectomy only required 30 minutes. All but 1 procedure were completed laparoscopically. One case was converted to open surgery secondary to obscured visibility due to bleeding. Blood loss in all cases was less than 30 cc (average 5 to 10). A total of 13 children were discharged home immediately postoperatively. Five children underwent concomitant procedures, including contralateral ureteroneocystotomy in 4, circumcision in 1 and cystoscopic fulguration of the ureteral stump in 5. Those who underwent ureteral reimplantation were hospitalized for 48 hours. One patient remained hospitalized for 3 days due to fever of unknown origin and 2 were admitted to the hospital for 23-hour observation. All children returned to full activity within 1 week of surgery. Analgesia consisted of 1 dose of ketorolac, bupivacaine injections at the incisional sites at the completion of the procedure, and acetaminophen postoperatively.

CONCLUSIONS

As confirmed by parent questionnaire, patient satisfaction was excellent.

Applications of the KTP laser in the treatment of posterior urethral valves, ureteroceles, and urethral strictures in the pediatric patient

PURPOSE

We describes our experience using the potassium titanyl phosphate (KTP)-532 laser in treating posterior urethral valves, ureteroceles, and urethral strictures in the pediatric patient.

METHODS

A retrospective chart review was performed from 1987 to 1997 on a total of 33 pediatric patients who underwent retrograde endoscopic treatment for posterior urethral valves (PUV), ureteroceles (UC), and urethral strictures using a KTP-532 laser.

RESULTS

Overall, our success rate was excellent in the treatment of valves and ureteroceles. With a mean follow-up of three years in the PUV group, no urethral strictures of micturation abnormalities were seen. The majority of ureteroceles were decompressed and only half of our patients required and additional procedure. Our experience with urethral strictures, however, was not as promising. All of these patients ultimately required open urethral reconstruction.

CONCLUSION

The desirable thermal characteristics of the KTP laser, along with minimal complications and the availability of delicate pediatric endoscopic instruments have made this operation optimally suited for treating posterior urethral valves and ureteroceles in infants. However, the advantages for treating urethral strictures in children with the laser still remains to be established.

Effects of conventional peritoneal dialysates on leukocyte adhesion and CD11b, CD18 and CD14 expression

Bacterial peritonitis is the most important complication of peritoneal dialysis (PD), limiting its widespread application. Conventional glucose-based peritoneal dialysates (G-PDS) depress oxygen consumption, chemiluminescence, superoxide production, phagocytosis, bacterial killing and actin polymerization in neutrophils (PMN) in vitro. Expression of adhesion receptors is critical to leukocyte activation, adhesion, migration and phagocytosis. The effects of G-PDS on basal and stimulated leukocyte adhesion molecule expression and leukocyte adhering capacity is unknown. We examined the effect of a five minutes incubation of whole blood in either HEPES-buffered saline or G-PDS containing 1.5% (83 mM), 2.5% (139 mM) or 4.25% (236 mM) glucose, at pH = 5.2, and pH = 7.4. PMN intracellular pH was measured spectrofluorometrically. Leukocyte CD11b, CD18 and CD14 were measured by flow cytometry using monoclonal antibodies in otherwise unstimulated cells or 60 minutes after lipopolysaccharide (LPS) stimulation. In addition, leukocyte adhering capacity to nylon wool was tested. In an attempt to dissect the effect of high glucose concentrations from that of the attendant hyperosmolality, the experiments were repeated with dialysates in which glucose was substituted by sodium chloride (NaCl-PDS) to attain identical osmolalities. G-PDS, as well as the mixtures of spent and fresh G-PDS, significantly depressed the basal PMN expression of adhesion receptors CD11b and CD18 and monocyte expression of CD14, and substantially mitigated the LPS-mediated up-regulation of CD11b and CD18. Likewise, G-PDS significantly inhibited leukocyte adhering capacity without affecting cell viability. Similar results were observed with NaCl-PDS. The observed abnormalities were primarily osmolality-dependent, and largely intra- and extracellular pH-independent. Impaired adhesion receptor expression and cell adhesion capacity shown here reveal another dimension of the G-PDS-induced leukocyte abnormalities.

Childhood AIDS nephropathy: a 10-year experience

The objective of this study was to define the demographic, immunologic, and clinical characteristics of children with acquired immunodeficiency syndrome (AIDS) and AIDS nephropathy, and contrast this with the existing adult data. Data from 62 pediatric patients with AIDS who were treated at SUNY Health Science Center, Brooklyn, New York, between 1983 and 1993 were analyzed. Human immunodeficiency virus (HIV) infection was acquired during the neonatal period by vertical transmission (n = 60) or blood transfusion (n = 2). All children with AIDS who exhibited clinical nephropathy died (n = 16), with mean survival of 55.3 months. In contrast, 32 of 56 AIDS patients (70%) who did not manifest nephropathy were alive at the end of the study period. Patients with nephropathy were noted to have significantly lower CD4+ lymphocyte counts than those without nephropathy. These observations suggest that the predominant renal lesion in pediatric patients who acquired HIV infection during the perinatal period is focal segmental glomerulosclerosis, although a variety of other histological lesions were present. As in adults, the survival in children is dismal following the onset of clinical renal disease. In contrast to the adult population in whom multiple risk factors can potentially contribute to AIDS-associated nephropathy, occurrence of nephropathy in children with vertical HIV transmission provides convincing evidence for the pathogenetic role of HIV infection.

Strategies for optimizing growth in children with kidney transplants

Children with a well-functioning graft continue to show growth retardation even with low-dose prednisone. We have attempted to utilize the steroid-sparing effect of cyclosporine by discontinuing prednisone after graft stabilization. Since 1983, 53 children have received cyclosporine as primary immunosuppressant for renal graft maintenance. The children, aged 6 months to 18 years, received 60 transplants. One-year and four-year patient survival for cadaveric transplants was 91% and 91%, compared with 96% and 96% for living related transplants. One-year and four-year graft survivals were 82% and 65% for cadaveric transplants (n = 25), compared with 91% and 63% for living related transplants (n = 35). Of 53 patients, 23 were able to discontinue prednisone and be maintained on monodrug cyclosporine therapy, and 21 of the 53 patients had growth hormone measured using L-dopa stimulation. In patients receiving more than 5 mg of prednisone daily, growth hormone levels were lower than normal (less than 10 ng/ml). Of 15 patients who had discontinued prednisone for more than 6 months, 13 showed accelerated growth by improvement in their standard deviation scores. In 4 pubescent children with growth retardation and need for maintenance prednisone, accelerated growth occurred following growth hormone administration for 3-6 months. Based on these data we suggest that (1) discontinuation of even very small doses of prednisone may be essential for normalizing growth hormone response to L-dopa and (2) further studies are needed to exploit the growth stimulation effect of recombinant growth hormone in transplanted children.