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Abstract
Data on protocol biopsies (PBs) after pediatric kidney transplantation are rare.We evaluated 6-month post-transplantation renal function in 86 children after PB as observational study. Patients were divided into 3 groups:Glomerular filtration rate (GFR) and delta GFR were determined.PBs 6 months post-kidney transplantation did not influence the clinical course in stable pediatric patients and are therefore of questionable value. Decreased kidney function may however be stabilized by therapeutic intervention according to results of PB.
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Affiliation(s)
| | | | | | - Jan H. Bräsen
- Department of Pathology, Hannover Medical School, Hannover, Germany
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Kanzelmeyer NK, Maecker-Kolhoff B, Zierhut H, Lerch C, Verboom M, Haffner D, Pape L. Graft outcomes following diagnosis of post-transplant lymphoproliferative disease in pediatric kidney recipients: a retrospective study. Transpl Int 2017; 31:367-376. [PMID: 28906028 DOI: 10.1111/tri.13071] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2017] [Revised: 07/27/2017] [Accepted: 09/06/2017] [Indexed: 12/13/2022]
Abstract
Data related to graft outcomes following post-transplant lymphoproliferative disease (PTLD) in pediatric kidney transplantation are scarce. Data were analyzed retrospectively from 12 children (eight boys) for 3 years after diagnosis of PTLD, with a loss of follow-up after 2 years in two of 12. In all cases, intensity of immunosuppressive therapy was reduced, which switched from calcineurin inhibitor to a mammalian target of rapamycin (mTOR) inhibitor in ten cases. Nine children were treated with six doses of rituximab according to the PED-PTLD-2005 protocol, with additional treatment in one child as per protocol. One patient received EuroNet-PHL C1. In four patients, donor-specific antibodies were detected after PTLD diagnosis at 3, 4, 5 and 7 years, respectively. One patient developed chronic antibody-mediated rejection (cAMR) 12 years after diagnosis, losing the graft 1 year later. Three patients with recurrence of the original disease also lost their grafts, one at the time of diagnosis of PTLD, and two after 4 years. Range-based analysis of variance showed that there was no decrease in estimated GFR at 1, 2, or 3 years after diagnosis of PTLD (P = 0.978). In conclusion, treatment of PTLD with reduced immunosuppression is safe and efficient. This may be due to B-cell-depleting therapy of PTLD with rituximab.
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Affiliation(s)
- Nele K Kanzelmeyer
- Department of Pediatric Nephrology, Hannover Medical School, Hannover, Germany.,IFB Tx, Hannover Medical School, Hannover, Germany
| | - Britta Maecker-Kolhoff
- IFB Tx, Hannover Medical School, Hannover, Germany.,Department of Pediatric Oncology, Hannover Medical School, Hannover, Germany
| | - Henriette Zierhut
- Department of Pediatric Oncology, Hannover Medical School, Hannover, Germany
| | - Christian Lerch
- Department of Pediatric Nephrology, Hannover Medical School, Hannover, Germany.,IFB Tx, Hannover Medical School, Hannover, Germany
| | - Murielle Verboom
- Department of Transfusion Medicine, Hannover Medical School, Hannover, Germany
| | - Dieter Haffner
- Department of Pediatric Nephrology, Hannover Medical School, Hannover, Germany.,IFB Tx, Hannover Medical School, Hannover, Germany
| | - Lars Pape
- Department of Pediatric Nephrology, Hannover Medical School, Hannover, Germany.,IFB Tx, Hannover Medical School, Hannover, Germany
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Lerch C, Kanzelmeyer NK, Ahlenstiel-Grunow T, Froede K, Kreuzer M, Drube J, Verboom M, Pape L. Belatacept after kidney transplantation in adolescents: a retrospective study. Transpl Int 2017; 30:494-501. [PMID: 28166398 DOI: 10.1111/tri.12932] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 01/19/2017] [Accepted: 01/30/2017] [Indexed: 12/28/2022]
Abstract
Regardless of recipient age at kidney transplantation (KTx), patients are at greatest risk for graft loss in adolescence, partly due to nonadherence to an oral immunosuppressive regimen. Belatacept, a non-nephrotoxic, first-in-class immunosuppressant that inhibits costimulation of T cells requires intravenous application only every 4 weeks, potentially leading to better adherence. However, it is only approved for use in adults. We report here the findings of the first study of belatacept in adolescents, comprising all patients in our department switched to belatacept post-KTx. Six patients (median age 15.5 years) were switched after a median of 7.5 months (range 23 days to 12 years), treatment range 3-28 months (cumulative 83 months): Three patients switched early (<3 months after KTx) had increased estimated glomerular filtration rate (GFR); one patient switched 12 years post-KTx has stable GFR; two patients were switched following rapid decline of and with markedly impaired GFR, changing slope in one patient. One patient had one acute rejection. In addition of two patients who received belatacept for other conditions, the only relevant adverse event was neutropenia (after a cumulative 109 months). Belatacept as primary immunosuppression is an option in Epstein-Barr virus-seropositive nonadherent adolescents if administered sufficiently early before deterioration of graft function.
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Affiliation(s)
- Christian Lerch
- Department of Pediatric Nephrology, Hannover Medical School, Hannover, Germany
| | - Nele K Kanzelmeyer
- Department of Pediatric Nephrology, Hannover Medical School, Hannover, Germany
| | | | - Kerstin Froede
- Department of Pediatric Nephrology, Hannover Medical School, Hannover, Germany
| | - Martin Kreuzer
- Department of Pediatric Nephrology, Hannover Medical School, Hannover, Germany
| | - Jens Drube
- Department of Pediatric Nephrology, Hannover Medical School, Hannover, Germany
| | - Murielle Verboom
- Department of Transfusion Medicine, Hannover Medical School, Hannover, Germany
| | - Lars Pape
- Department of Pediatric Nephrology, Hannover Medical School, Hannover, Germany
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Ahlenstiel-Grunow T, Kanzelmeyer NK, Froede K, Kreuzer M, Drube J, Lerch C, Pape L. Switching from immediate- to extended-release cysteamine in nephropathic cystinosis patients: a retrospective real-life single-center study. Pediatr Nephrol 2017; 32:91-97. [PMID: 27350621 DOI: 10.1007/s00467-016-3438-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Revised: 04/28/2016] [Accepted: 05/16/2016] [Indexed: 12/01/2022]
Abstract
BACKGROUND Nephropathic cystinosis is a rare lysosomal storage disease which is characterized by the accumulation of free cystine in lysosomes and subsequent intracellular crystal formation of cystine throughout the body. If not treated with cysteamine, a cystine-depleting agent, end-stage renal disease will develop early, followed by multiple organ failure as the disease progresses. The established cysteamine formulation requires a strict dosing regimen at 6-h intervals. An extended release (ER) twice-daily formulation has recently been developed. The aim of our study was to evaluate the implementation and outcomes of this option in routine care. METHODS All pediatric cystinosis patients' records in Hannover Medical School were screened, and data on cysteamine therapy, tolerability, dosing, estimated glomerular filtration rates (eGFR), white blood cell cystine levels, and proton pump inhibitor (PPI) use were extracted for the period January 2014 to January 2016. RESULTS The median age of the 12 patients enrolled in the study was 12.5 (range 1-18) years. At the end of the study period ten of these patients received ER-cysteamine. There were no additional side effects. Halitosis/bad breath was often subjectively judged as improved or eliminated, and PPI use could be stopped in one of three patients. The main reasons for switching to the ER formulation were difficult night-time administration and uncontrolled disease. Mean eGFR values remained stable with a median of 67 ml/min/1.73 m2 before and after the transition. White blood cell (WBC) cystine values remained low after the switch (1 nmol/mg protein before and after transition; p = 0.64). CONCLUSIONS In this single-center cohort, the switch from IR- to ER-cysteamine was safe and effective over the short term and provided advantages in terms of frequency of administration and less halitosis/bad breath. The long-term benefit of this option needs to be evaluated in future studies.
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Affiliation(s)
- Thurid Ahlenstiel-Grunow
- Department of Pediatric Nephrology, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany
| | - Nele K Kanzelmeyer
- Department of Pediatric Nephrology, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany
| | - Kerstin Froede
- Department of Pediatric Nephrology, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany
| | - Martin Kreuzer
- Department of Pediatric Nephrology, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany
| | - Jens Drube
- Department of Pediatric Nephrology, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany
| | - Christian Lerch
- Department of Pediatric Nephrology, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany
| | - Lars Pape
- Department of Pediatric Nephrology, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany.
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Pape L, Ahlenstiel T, Kanzelmeyer NK. Consequences of the change in Eurotransplant allocation system on kidney allocation in children. Clin Transplant 2013; 27:650-1. [PMID: 23991746 DOI: 10.1111/ctr.12216] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Lars Pape
- Department of Pediatric Nephrology, Hannover Medical School, Hannover, Germany.
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Kanzelmeyer NK, Ahlenstiel T, Kreuzer M, Becker JU, Pape L. Correlations with six-month protocol biopsy findings in pediatric transplant recipients on low- and regular-dose CNI regimens. Clin Transplant 2013; 27:319-23. [DOI: 10.1111/ctr.12092] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/13/2012] [Indexed: 11/28/2022]
Affiliation(s)
- Nele K. Kanzelmeyer
- Department of Pediatric Nephrology; Hannover Medical School; Hannover; Germany
| | - Thurid Ahlenstiel
- Department of Pediatric Nephrology; Hannover Medical School; Hannover; Germany
| | - Martin Kreuzer
- Department of Pediatric Nephrology; Hannover Medical School; Hannover; Germany
| | - Jan U. Becker
- Institute of Pathology; Hannover Medical School; Hannover; Germany
| | - Lars Pape
- Department of Pediatric Nephrology; Hannover Medical School; Hannover; Germany
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Kanzelmeyer NK, Pape L. State of pediatric kidney transplantation in 2011. Minerva Pediatr 2012; 64:205-211. [PMID: 22495194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Fifty years ago children with renal failure died due to the lack of adequate therapy. Today, the implementation of dialysis procedures, such as peritoneal dialysis and hemodialysis as well as kidney transplantation, has become almost standard care for pediatric patients. Even infants can now be dialyzed or receive transplants. A kidney transplant allows for a 20-year patient survival in >90% of patients and almost age-appropriate mental and physical development. A better transplant survival is achieved with a living organ donation than with a post-mortem donation. It has been shown that kidneys from deceased juvenile and young adult donors should be allocated primarily to children as they obtain significantly better transplant function in the short and medium term than adults. Unfortunately, the problem of a long waiting period for a postmortem donated kidneys for children in the Eurotransplant area remains. Although, the allocation system for children was amended in December 2010, it remains to be seen whether this change will positively influence waiting times. New immunosuppressive regimens have resulted in significantly improved long-term transplant function and transplant survival. The main challenge, however, concerns chronic humoral transplant rejection, therapy for recurrence of the underlying disease, and the execution of AB0 incompatible transplantations.
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Affiliation(s)
- N K Kanzelmeyer
- Department of Pediatric Kidney, Hannover Medical School, Hannover, Germany.
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Kanzelmeyer NK, Ahlenstiel T, Hallensleben M, Pape L. Therapie bei donorspezifischen HLA-Antikörpern nach Nierentransplantation. Klin Padiatr 2011. [DOI: 10.1055/s-0031-1273859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Kanzelmeyer NK, Ahlenstiel T, Drube J, Froede K, Kreuzer M, Broecker V, Ehrich JHH, Melk A, Pape L. Protocol biopsy-driven interventions after pediatric renal transplantation. Pediatr Transplant 2010; 14:1012-8. [PMID: 20846241 DOI: 10.1111/j.1399-3046.2010.01399.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The therapeutic value of protocol biopsies (PBs) in renal transplant recipients remains unclear. We performed protocol biopsies in 57 children six months after transplantation. We increased the CNI dose in patients with borderline findings. In cases of Banff grade Ia, six prednisolone IV-pulses were given and the CNI dose was increased. CNI toxicity and polyomavirus nephropathy led to a reduction in the CNI dose. GFR was compared with a control group of 51 children with no PBs transplanted in the same period. Forty-two percent of PBs had no pathological changes, 24% IF/TA. Borderline findings were detected in 11%, Banff grade Ia in 15% (CNI), toxicity in 8%, and one case showed polyomavirus nephropathy. GFR after 1.5 and 2.5 yr was similar in both groups. GFR 3.5 yr after transplantation was significantly higher in the intervention group (57 ± 17 vs. 46 ± 20). Patients treated with low-dose CNI and everolimus had a significantly lower number of pathological findings in PBs. The performance of protocol biopsies followed by a standardized treatment algorithm led to better graft function 3.5 yr after transplantation. Prospective randomized studies to confirm our findings are needed.
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Affiliation(s)
- N K Kanzelmeyer
- Department of Pediatrics, Hannover Medical School, Hannover, Germany.
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Lücke T, Tsikas D, Kanzelmeyer NK, Boerkoel CF, Clewing JM, Vaske B, Ehrich JHH, Das AM. Vaso-occlusion in Schimke-immuno-osseous dysplasia: is the NO pathway involved? Horm Metab Res 2006; 38:678-82. [PMID: 17075778 DOI: 10.1055/s-2006-954584] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Schimke-immuno-osseous dysplasia (SIOD) is an autosomal recessive disorder with the main clinical findings of spondyloepiphyseal dysplasia, nephrotic syndrome, and defective cellular immunity. Vaso-occlusive processes, especially generalized atherosclerosis, are a life-limiting complication in patients with severe SIOD. The nitric oxide synthase (NOS) oxidizes L-arginine to nitric oxide (NO). NO is a potent vasodilator with inhibitory effects on platelet aggregation and the development of atherosclerosis. We hypothesized that reduced NO production due to antagonism of NOS by asymmetric dimethylarginine (ADMA) would be a possible pathophysiological mechanism for vaso-occlusion in SIOD. We tested this hypothesis in 10 patients with SIOD and 10 age-matched healthy controls. Plasma and urine levels of nitrite and nitrate, the indicators of NO synthesis, and of ADMA, an endogenous NOS inhibitor, in children suffering from SIOD were not significantly different from those in the age-matched healthy controls. Our results suggest that the L-arginine/NO pathway is not altered in SIOD. Antagonism of NOS by ADMA does not seem to be the cause of premature general atherosclerosis in SIOD. The underlying pathology of vaso-occlusion in SIOD still remains unclear.
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Affiliation(s)
- T Lücke
- Department of Pediatrics, Hanover Medical School, Carl-Neuberg-Strasse 1, 30623 Hanover, Germany.
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Lücke T, Marwedel KM, Kanzelmeyer NK, Hori A, Offner G, Kreipe HH, Ehrich JHH, Das AM. Generalized atherosclerosis sparing the transplanted kidney in Schimke disease. Pediatr Nephrol 2004; 19:672-5. [PMID: 15054643 DOI: 10.1007/s00467-004-1426-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2003] [Revised: 12/31/2003] [Accepted: 01/02/2004] [Indexed: 10/26/2022]
Abstract
Schimke-immuno-osseous dysplasia (SIOD) is a multisystem disorder caused by a mutation of the chromatin remodeling protein. The main clinical findings are spondyloepiphyseal dysplasia with disproportional growth deficiency, nephrotic syndrome with focal and segmental glomerulosclerosis, and defective cellular immunity. Transitory ischemic attacks due to vaso-occlusive processes are still an untreatable and life-limiting complication in patients with SIOD. The underlying pathophysiology of vaso-occlusive processes in SIOD is unclear. We report the clinical and pathological findings of the eldest published patient with the severe form of SIOD, who died at the age of 23 years due to pulmonary hypertension with subsequent right heart failure. The autopsy revealed a severe generalized atherosclerosis including the brain, heart, and pulmonary arteries. However, the kidney that was transplanted at the age of 5 years showed a good graft function without glomerular sclerosis and with only minimal nephrosclerosis on histology. Thus, the absence of severe vaso-occlusive processes in the transplanted organ and in the severely atherosclerotic host may indicate that the vaso-occlusive processes in SIOD are not caused by post-transplant cardiovascular morbidity such as arterial hypertension and hyperlipidemia. Instead, vascular factors of the host such as endothelial dysfunction may explain the pathophysiology of atherosclerosis in SIOD.
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Affiliation(s)
- Thomas Lücke
- Department of Pediatrics, Hanover Medical School, 30623 Hannover, Germany.
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