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Ashoor IF, Al-Akash S, Kizilbash S, Moudgil A, Puliyanda D, Ranabothu S, Shi Y, Dharnidharka V. Effect of pre-emptive rituximab on EBV DNA levels and prevention of post-transplant lymphoproliferative disorder in pediatric kidney transplant recipients: A case series from the pediatric nephrology research consortium. Pediatr Transplant 2024; 28:e14743. [PMID: 38566336 DOI: 10.1111/petr.14743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 02/16/2024] [Accepted: 03/05/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND There are scant data on the effect of rituximab on EBV DNA levels and prevention of post-transplant lymphoproliferative disorder (PTLD) in pediatric kidney transplant recipients with EBV DNAemia. METHODS Kidney transplant recipients with EBV DNAemia treated with rituximab to prevent PTLD between 7/1999 and 7/2019 at five pediatric centers were included. Those with confirmed PTLD at the onset of rituximab were excluded. Primary outcomes included percentage change in EBV DNAemia and occurrence of PTLD post rituximab. RESULTS Twenty-six pediatric kidney transplant recipients were included. Median age at transplant was 4 years (IQR 2.1-10.3). EBV DNA load monitoring by qPCR was performed at 1-3 month intervals. EBV DNAemia onset occurred at a median of 73 days post-transplant (IQR 52-307), followed by DNAemia peak at a median of 268 days (IQR 112-536). Rituximab was administered at a median of 9 days post peak (IQR 0-118). Rituximab regimens varied; median dose 375 mg/m2 (IQR 375-439) weekly for 1-4 doses per course. Following rituximab, EBV DNA load decreased to <10% of baseline at 120 days in 20/26 patients; however, only 30% achieved complete resolution at last follow-up (median 2094 days post-transplant [IQR 1538-3463]). Two (7%) developed PTLD at 915 and 1713 days post rituximab. All recipients had functioning grafts. One death occurred in a child with PTLD following remission due to unrelated reasons. CONCLUSIONS In the largest pediatric kidney transplant recipient case series with EBV DNAemia given rituximab to prevent PTLD, rituximab achieved a short-term reduction in DNA load; however, recurrent DNAemia is common.
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Affiliation(s)
- Isa F Ashoor
- Division of Nephrology, Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Samhar Al-Akash
- Division of Nephrology, Department of Pediatrics, The University of Texas Health Sciences Center at Houston, Houston, Texas, USA
| | - Sarah Kizilbash
- Division of Nephrology, Department of Pediatrics, University of Minnesota Children's Hospital, Minneapolis, Minnesota, USA
| | - Asha Moudgil
- Division of Nephrology, Department of Pediatrics, Children's National Medical Center, Washington, DC, USA
| | - Dechu Puliyanda
- Division of Nephrology, Department of Pediatrics, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Saritha Ranabothu
- Division of Nephrology, Department of Pediatrics, Arkansas Children's Hospital, Little Rock, Arkansas, USA
| | - Yi Shi
- Division of Nephrology, Department of Pediatrics, Children's National Medical Center, Washington, DC, USA
| | - Vikas Dharnidharka
- Division of Nephrology, Department of Pediatrics, Washington University in St. Louis, St. Louis, Missouri, USA
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Varnell C, Harshman LA, Liu C, Smith L, Al-Akash S, Barletta GM, Brakeman P, Chaudhuri A, Fadakar P, Galea L, Garro R, Gluck C, Kershaw DB, Matossian D, Patel HP, Peterson C, Pruette C, Ranabothu S, Rodig N, Singer P, Sebestyen VanSickle J, Weng PL, Danziger-Isakov L, Seifert ME, Hooper DK. COVID-19 in pediatric kidney transplantation: a follow-up report of the Improving Renal Outcomes Collaborative. Pediatr Nephrol 2023; 38:537-547. [PMID: 35538239 PMCID: PMC9090538 DOI: 10.1007/s00467-022-05570-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 03/30/2022] [Accepted: 03/30/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND We report follow-up data from an ongoing prospective cohort study of COVID-19 in pediatric kidney transplantation through the Improving Renal Outcomes Collaborative (IROC). METHODS Patient-level data from the IROC registry were combined with testing, indication, and outcomes data collected to describe the epidemiology of COVID testing, treatment, and clinical outcomes; determine the incidence of a positive COVID-19 test; describe rates of COVID-19 testing; and assess for clinical predictors of a positive COVID-19 test. RESULTS From September 2020 to February 2021, 21 centers that care for 2690 patients submitted data from 648 COVID-19 tests on 465 patients. Most patients required supportive care only and were treated as outpatients, 16% experienced inpatient care, and 5% experienced intensive care. Allograft complications were rare, with acute kidney injury most common (7%). There was 1 case of respiratory failure and 1 death attributed to COVID-19. Twelve centers that care for 1730 patients submitted complete testing data on 351 patients. The incidence of COVID-19 among patients at these centers was 4%, whereas the incidence among tested patients was 19%. Risk factors to predict a positive COVID-19 test included age > 12 years, symptoms consistent with COVID-19, and close contact with a confirmed case of COVID-19. CONCLUSIONS Despite the increase in testing and positive tests over this study period, the incidence of allograft loss or death related to COVID-19 remained extremely low, with allograft loss or death each occurring in < 1% of COVID-19-positive patients and in less than < 0.1% of all transplant patients within the IROC cohort. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Charles Varnell
- Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 7022, Cincinnati, OH, 45229, USA.
- University of Cincinnati College of Medicine, Cincinnati, OH, USA.
| | | | - Chunyan Liu
- Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 7022, Cincinnati, OH, 45229, USA
| | - Laurie Smith
- Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 7022, Cincinnati, OH, 45229, USA
| | | | | | - Paul Brakeman
- Department of Pediatrics, University of California, San Francisco, CA, USA
| | - Abanti Chaudhuri
- Lucile Packard Children's Hospital, Stanford University, Stanford, CA, USA
| | - Paul Fadakar
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Lauren Galea
- Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Rouba Garro
- Children's Healthcare of Atlanta, Emory School of Medicine, Atlanta, GA, USA
| | - Caroline Gluck
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA
| | | | - Debora Matossian
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | | | - Caitlin Peterson
- Primary Children's Hospital, The University of Utah, Salt Lake City, UT, USA
| | - Cozumel Pruette
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Nancy Rodig
- Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Pamela Singer
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Brooklyn, NY, USA
| | | | | | - Lara Danziger-Isakov
- Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 7022, Cincinnati, OH, 45229, USA
- University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Michael E Seifert
- University of Alabama at Birmingham, Children's of Alabama, Birmingham, AL, USA
| | - David K Hooper
- Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 7022, Cincinnati, OH, 45229, USA
- University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Maniar A, Hooper DK, Sethna CB, Singer P, Traum A, Benoit E, Kotzen E, Verghese P, Garro R, Kamel M, Ranch D, Shih W, Jain NG, Al-Akash S. Re-transplantation in pediatric patients with failure of primary transplant due to recurrent focal segmental glomerulosclerosis: A pediatric nephrology research consortium study. Pediatr Transplant 2021; 25:e14085. [PMID: 34247442 PMCID: PMC8968923 DOI: 10.1111/petr.14085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 05/20/2021] [Revised: 06/20/2021] [Accepted: 06/29/2021] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Recurrent focal and segmental glomerulosclerosis (FSGS) in kidney transplant recipients is associated with lower graft survival and increased morbidity. There are limited data to guide the decision to re-transplant patients with transplant failure due to FSGS recurrence. We aimed to evaluate outcomes in patients re-transplanted after having initial graft failure due to recurrent FSGS and to study physician attitudes and practice patterns. METHODS Retrospective data from 10 centers were collected on 20 patients transplanted between January 1997 and September 2018. A survey was sent to nephrologist members of the Pediatric Nephrology Research Consortium. RESULTS Mean patient age (years) was 9.8 ± 4.8 at first transplant and 15.9 ± 4.9 at re-transplantation. Pre-transplant plasmapheresis was used in 1 (5.3%) primary transplant vs. 7 (38.9%) re-transplants (p = .03). Nephrotic syndrome recurred in 14 patients (70%) after re-transplantation and was severe in 21.1% vs. 64.7% after first transplant (p = .04). Graft survival was significantly higher in the second transplant (p .009) with 70% having functioning grafts at a median of 25.2 months. Thirty-one physicians from 21 centers completed the survey, 94% indicated they would re-transplant such patients, 44.4% preferred a minimum waiting period before re-transplantation, 36.4% preferred living donors, and 22.2% indicated having protocols for re-transplantation at their centers. CONCLUSIONS Consideration for re-transplantation is high among pediatric nephrologists. Pre-transplant plasmapheresis was more frequent in re-transplanted patients. Nephrotic syndrome recurrence was less severe, with better graft survival. More data and a larger population are necessary to further evaluate outcome determinants and best practices in this special population.
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Affiliation(s)
- Aesha Maniar
- Cohen Children’s Medical Center, New Hyde Park, NY, USA
| | - David K. Hooper
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | | | - Pamela Singer
- Cohen Children’s Medical Center, New Hyde Park, NY, USA
| | | | | | | | - Priya Verghese
- Ann and Robert H. Lurie Children’s Hospital, Chicago, IL, USA
| | - Rouba Garro
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Margaret Kamel
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Daniel Ranch
- University of Texas Health Science Center, San Antonio, TX, USA
| | - Weiwen Shih
- C.S. Mott Children’s Hospital, Ann Arbor, Michigan, USA
| | - Namrata G. Jain
- Columbia University Irving Medical Center, New York, NY, USA
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Verghese PS, Luckritz KE, Moudgil A, Chandar J, Ranch D, Barcia J, Lin JJ, Grinsell M, Zahr R, Engen R, Twombley K, Fadakar PK, Jain A, Al-Akash S, Bartosh S. Practice patterns and influence of allograft nephrectomy in pediatric kidney re-transplantation: A pediatric nephrology research consortium study. Pediatr Transplant 2021; 25:e13974. [PMID: 33512738 DOI: 10.1111/petr.13974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 10/08/2020] [Revised: 12/14/2020] [Accepted: 12/19/2020] [Indexed: 11/28/2022]
Abstract
INTRODUCTION There are no guidelines regarding management of failed pediatric renal transplants. MATERIALS & METHODS We performed a first of its kind multicenter study assessing prevalence of transplant nephrectomy, patient characteristics, and outcomes in pediatric renal transplant recipients with graft failure from January 1, 2006, to December 31, 2016. RESULTS Fourteen centers contributed data on 186 pediatric recipients with failed transplants. The 76 recipients that underwent transplant nephrectomy were not significantly different from the 110 without nephrectomy in donor or recipient demographics. Fifty-three percent of graft nephrectomies were within a year of transplant. Graft tenderness prompted transplant nephrectomy in 91% (P < .001). Patients that underwent nephrectomy were more likely to have a prior diagnosis of rejection within 3 months (43% vs 29%; P = .04). Nephrectomy of allografts did not affect time to re-listing, donor source at re-transplant but significantly decreased time to (P = .009) and incidence (P = .0002) of complete cessation of immunosuppression post-graft failure. Following transplant nephrectomy, recipients were significantly more likely to have rejection after re-transplant (18% vs 7%; P = .03) and multiple rejections in first year after re-transplant (7% vs 1%; P = .03). CONCLUSIONS Practices pertaining to failed renal allografts are inconsistent-40% of failed pediatric renal allografts underwent nephrectomy. Graft tenderness frequently prompted transplant nephrectomy. There is no apparent benefit to graft nephrectomy related to sensitization; but timing / frequency of immunosuppression withdrawal is significantly different with slightly increased risk for rejection following re-transplant.
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Affiliation(s)
- Priya S Verghese
- Division of Pediatric Nephrology, Department of Pediatrics, Northwestern University Feinberg School of Medicine and Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Kera E Luckritz
- Department of Pediatrics, C.S. Mott Children's Hospital Michigan Medicine, Ann Arbor, MI, USA
| | - Asha Moudgil
- Division of Pediatric Nephrology, Children National Hospital, Washington, DC, USA
| | - Jayanthi Chandar
- Division of Pediatric Nephrology, Department of Pediatrics, University of Miami Miller School of Medicine and Miami Transplant Institute, Miami, FL, USA
| | - Daniel Ranch
- Department of Pediatrics, Division of Pediatric Nephrology, Joe R. and Teresa Lozano Long School of Medicine, University of Texas Health at San Antonio, San Antonio, TX, USA
| | - John Barcia
- Division of Pediatric Nephrology, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Jen-Jar Lin
- Department of Pediatrics Nephrology, Wake Forest University Baptist Health, Winston-Salem, NC, USA
| | - Matthew Grinsell
- Division of Nephrology and Hypertension, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Rima Zahr
- Division of Pediatric Nephrology, Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Rachel Engen
- Division of Pediatric Nephrology, Department of Pediatrics, Northwestern University Feinberg School of Medicine and Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Katherine Twombley
- Acute Dialysis Units, Pediatric Kidney Transplant, Medical University of South Carolina, Charleston, SC, USA
| | - Paul K Fadakar
- Pediatric Nephrology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Amrish Jain
- Division of Pediatric Nephrology, Department of Pediatrics, Central Michigan University College of Medicine and Children's Hospital of Michigan, Detroit, MI, USA
| | - Samhar Al-Akash
- Division of Pediatric Nephrology, Department of Pediatrics, Driscoll Children's Hospital, Corpus Christi, TX, USA
| | - Sharon Bartosh
- Division of Pediatric Nephrology, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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Varnell Jr C, Harshman LA, Smith L, Liu C, Chen S, Al-Akash S, Barletta GM, Belsha C, Brakeman P, Chaudhuri A, Fadakar P, Garro R, Gluck C, Goebel J, Kershaw D, Matossian D, Nailescu C, Patel HP, Pruette C, Ranabothu S, Rodig N, Smith J, Sebestyen VanSickle J, Weng P, Danziger-Isakov L, Hooper DK, Seifert M. COVID-19 in pediatric kidney transplantation: The Improving Renal Outcomes Collaborative. Am J Transplant 2021; 21:2740-2748. [PMID: 33452854 PMCID: PMC8013281 DOI: 10.1111/ajt.16501] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 12/17/2020] [Accepted: 01/10/2021] [Indexed: 01/25/2023]
Abstract
There are limited data on the impact of COVID-19 in children with a kidney transplant (KT). We conducted a prospective cohort study through the Improving Renal Outcomes Collaborative (IROC) to collect clinical outcome data about COVID-19 in pediatric KT patients. Twenty-two IROC centers that care for 2732 patients submitted testing and outcomes data for 281 patients tested for SARS-CoV-2 by PCR. Testing indications included symptoms and/or potential exposures to COVID-19 (N = 134, 47.7%) and/or testing per hospital policy (N = 154, 54.8%). Overall, 24 (8.5%) patients tested positive, of which 15 (63%) were symptomatic. Of the COVID-19-positive patients, 16 were managed as outpatients, six received non-ICU inpatient care and two were admitted to the ICU. There were no episodes of respiratory failure, allograft loss, or death associated with COVID-19. To estimate incidence, subanalysis was performed for 13 centers that care for 1686 patients that submitted all negative and positive COVID-19 results. Of the 229 tested patients at these 13 centers, 10 (5 asymptomatic) patients tested positive, yielding an overall incidence of 0.6% and an incidence among tested patients of 4.4%. Pediatric KT patients in the United States had a low estimated incidence of COVID-19 disease and excellent short-term outcomes.
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Affiliation(s)
- Charles Varnell Jr
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- University of Cincinnati College of Medicine, Cincinnati, Ohio
| | | | - Laurie Smith
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Chunyan Liu
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Shiran Chen
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | | | | | - Craig Belsha
- SSM Health Cardinal Glennon Children’s Hospital, Saint Louis, Missouri
| | - Paul Brakeman
- Department of Pediatrics, University of California, San Francisco, California
| | - Abanti Chaudhuri
- Lucile Packard Children’s Hospital, Stanford University, Stanford, California
| | - Paul Fadakar
- UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Rouba Garro
- Children’s Healthcare of Atlanta, Emory School of Medicine, Atlanta, Georgia
| | - Caroline Gluck
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware
| | - Jens Goebel
- Children’s Hospital Colorado, Aurora, Colorado
- Present address Jens Goebel, Helen DeVos Children’s Hospital, Grand Rapids, MichiganMichigan, USA
| | | | - Debora Matossian
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Corina Nailescu
- Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana
| | | | - Cozumel Pruette
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Nancy Rodig
- Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jodi Smith
- Seattle Children’s Hospital, Seattle, Washington
| | | | - Patricia Weng
- UCLA Mattel Children’s Hospital, Los Angeles, California
| | - Lara Danziger-Isakov
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - David K. Hooper
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Michael Seifert
- University of Alabama at Birmingham, Children’s of Alabama, Birmingham, Alabama
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Marlais M, Wlodkowski T, Al-Akash S, Ananin P, Bandi VK, Baudouin V, Boyer O, Vásquez L, Govindan S, Hooman N, Ijaz I, Loza R, Melgosa M, Pande N, Pape L, Saha A, Samsonov D, Schreuder MF, Sharma J, Siddiqui S, Sinha R, Stewart H, Tasic V, Tönshoff B, Twombley K, Upadhyay K, Vivarelli M, Weaver DJ, Woroniecki R, Schaefer F, Tullus K. COVID-19 in children treated with immunosuppressive medication for kidney diseases. Arch Dis Child 2020; 106:archdischild-2020-320616. [PMID: 33355203 PMCID: PMC7754669 DOI: 10.1136/archdischild-2020-320616] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 11/06/2020] [Accepted: 11/16/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Children are recognised as at lower risk of severe COVID-19 compared with adults, but the impact of immunosuppression is yet to be determined. This study aims to describe the clinical course of COVID-19 in children with kidney disease taking immunosuppressive medication and to assess disease severity. METHODS Cross-sectional study hosted by the European Rare Kidney Disease Reference Network and supported by the European, Asian and International paediatric nephrology societies. Anonymised data were submitted online for any child (age <20 years) with COVID-19 taking immunosuppressive medication for a kidney condition. Study recruited for 16 weeks from 15 March 2020 to 05 July 2020. The primary outcome was severity of COVID-19. RESULTS 113 children were reported in this study from 30 different countries. Median age: 13 years (49% male). Main underlying reasons for immunosuppressive therapy: kidney transplant (47%), nephrotic syndrome (27%), systemic lupus erythematosus (10%). Immunosuppressive medications used include: glucocorticoids (76%), mycophenolate mofetil (MMF) (54%), tacrolimus/ciclosporine A (58%), rituximab/ofatumumab (11%). 78% required no respiratory support during COVID-19 illness, 5% required bi-level positive airway pressure or ventilation. Four children died; all deaths reported were from low-income countries with associated comorbidities. There was no significant difference in severity of COVID-19 based on gender, dialysis status, underlying kidney condition, and type or number of immunosuppressive medications. CONCLUSIONS This global study shows most children with a kidney disease taking immunosuppressive medication have mild disease with SARS-CoV-2 infection. We therefore suggest that children on immunosuppressive therapy should not be more strictly isolated than children who are not on immunosuppressive therapy.
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Affiliation(s)
- Matko Marlais
- UCL Great Ormond Street Institute of Child Health, University College London, London, UK
- Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Tanja Wlodkowski
- Division of Pediatric Nephrology, Heidelberg University Hospital, Heidelberg, Germany
| | - Samhar Al-Akash
- Driscoll Children's Kidney Center, Driscoll Children's Hospital, Corpus Christi, Texas, USA
| | - Petr Ananin
- Pediatric Nephrology, National Medical Research Center for Children's Health, Moscow, Russian Federation
| | - Varun Kumar Bandi
- Dr. Pinnamaneni Siddhartha Institute of Medical Sciences and RF, Vijayawada, India
| | | | - Olivia Boyer
- Service de Néphrologie pédiatrique, Centres de référence MARHEA et SNI, Université de Paris, Inserm U1163, Hôpital Necker-Enfants malades, AP-HP, Paris, France
| | - Luciola Vásquez
- Pediatric Nephrology Transplant Department, G.Almenara Hospital, Lima, Peru
| | - Sukanya Govindan
- Department of Paediatric Nephrology, Mehta Multispecialty Hospitals, Chennai, India
| | - Nakysa Hooman
- Aliasghar Clinical Research Development Center, Aliasghar Children hospital, Iran University of Medical Sciences (IUMS), Tehran, Iran (the Islamic Republic of)
| | - Iftikhar Ijaz
- Children's Kidney Centre, King Edward Medical University, Mayo Hospital, Lahore, Pakistan
| | - Reyner Loza
- Nephrology Paediatric Unit, Department of Pediatrícs, Cayetano Heredia National Hospital, Lima, Peru
| | - Marta Melgosa
- Pediatric Nephrology Department, La Paz University Hospital, Madrid, Spain
| | - Nivedita Pande
- Department of Pediatrics, Topiwala National Medical College & B. Y. L. Nair Charitable Hospital, Mumbai, India
| | - Lars Pape
- Department of Paediatrics II, University Hospital Essen, Essen, Germany
| | - Anshuman Saha
- Pediatric Nephrology, Institute Of Kidney Diseases And Research Center And Institute Of Transplantation Sciences (IKDRC-ITS), Ahmedabad, India
| | | | | | | | - Sahar Siddiqui
- Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Rajiv Sinha
- ICH, Institute of Child Health, Kolkata, India
| | - Heather Stewart
- Dwaine & Cynthia Willet Children's Hospital, Savannah, Georgia, USA
| | - Velibor Tasic
- Paediatric Nephrology, University Children's Hospital, Skopje, North Macedonia
| | - Burkhard Tönshoff
- Department of Pediatrics I, University Children's Hospital, Heidelberg, Germany
| | | | - Kiran Upadhyay
- Division of Pediatric Nephrology, University of Florida, Gainesville, Florida, USA
| | - Marina Vivarelli
- Division of Nephrology and Dialysis, Department of Pediatric Subspecialties, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
| | - Donald J Weaver
- Division of Pediatric Nephrology and Hypertension, Atrium Health Levine Children's, Charlotte, North Carolina, USA
| | | | - Franz Schaefer
- Division of Pediatric Nephrology, Heidelberg University Hospital, Heidelberg, Germany
| | - Kjell Tullus
- Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
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Piburn KH, Al-Akash S. Use of intravenous immunoglobulin in a highly sensitized pediatric renal transplant recipient with severe BK DNAemia and rising DSA. Pediatr Transplant 2020; 24:e13600. [PMID: 31657100 DOI: 10.1111/petr.13600] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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: 06/14/2019] [Revised: 08/24/2019] [Accepted: 09/13/2019] [Indexed: 01/15/2023]
Abstract
BK DNAemia in renal transplant recipients is a significant cause of allograft dysfunction and can lead to graft loss due to BK polyomavirus-associated nephropathy or to graft rejection due to immunosuppression reduction. Currently, the first-line treatment for BK DNAemia is immunosuppression reduction. Second-line treatment for BK DNAemia has not been well-established. In this report, we present a case of a highly sensitized second-time pediatric renal transplant recipient with severe and persistent BK DNAemia and rising DSA, who was treated with IVIG and subsequently found to have clearance of BK viremia with concomitant reduction in DSA.
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Affiliation(s)
- Kim Huynh Piburn
- Pediatric Residency Program, Driscoll Children's Hospital, Corpus Christi, TX, USA
| | - Samhar Al-Akash
- Division of Pediatric Nephrology, Driscoll Children's Hospital, Corpus Christi, TX, USA
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Wang CS, Travers C, McCracken C, Leong T, Gbadegesin R, Quiroga A, Benfield MR, Hidalgo G, Srivastava T, Lo M, Yadin O, Mathias R, Araya CE, Khalid M, Orjuela A, Zaritsky J, Al-Akash S, Kamel M, Greenbaum LA. Adrenocorticotropic Hormone for Childhood Nephrotic Syndrome: The ATLANTIS Randomized Trial. Clin J Am Soc Nephrol 2018; 13:1859-1865. [PMID: 30442868 PMCID: PMC6302334 DOI: 10.2215/cjn.06890618] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Accepted: 08/28/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES There is renewed interest in adrenocorticotropic hormone (ACTH) for the treatment of nephrotic syndrome. We evaluated the efficacy and safety of ACTH in children with frequently relapsing or steroid-dependent nephrotic syndrome in a randomized trial. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Participants aged 2-20 years old with frequently relapsing or steroid-dependent nephrotic syndrome were enrolled from 16 sites in the United States and randomized 1:1 to ACTH (repository corticotropin injection) or no relapse-preventing treatment. ACTH treatment regimen was 80 U/1.73 m2 administered twice weekly for 6 months, followed by 40 U/1.73 m2 administered twice weekly for 6 months. The primary outcome was disease relapse during the first 6 months. Participants in the control group were offered crossover to ACTH treatment if they relapsed within 6 months. Secondary outcomes were relapse after ACTH dose reduction and treatment side effects. RESULTS The trial was stopped at a preplanned interim analysis after enrollment of 31 participants because of a lack of discernible treatment efficacy. Fourteen out of 15 (93%) participants in the ACTH arm experienced disease relapse in the first 6 months, with a median time to first relapse of 23 days (interquartile range, 9-32), compared with 15 out of 16 (94%) participants and at a median of 21 days (interquartile range, 14-51) in the control group. There was no difference in the proportion of relapsed patients (odds ratio, 0.93; 95% confidence interval, 0.05 to 16.40; P>0.99) or time to first relapse (hazard ratio, 1.03; 95% confidence interval, 0.50 to 2.15; P=0.93). Thirteen out of 16 participants in the control group crossed over to ACTH treatment. Three out of 28 participants completed 12 months of ACTH treatment; the others exited the trial because of frequent relapses or side effects. There were no disease relapses after ACTH dose reduction among the three participants. Most side effects were mild and similar to side effects of corticosteroids. CONCLUSIONS ACTH at 80 U/1.73 m2 administered twice weekly was ineffective at preventing disease relapses in pediatric nephrotic syndrome.
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Affiliation(s)
- Chia-shi Wang
- Department of Pediatrics, Emory and Children’s Pediatric Institute, Atlanta, Georgia
| | - Curtis Travers
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Courtney McCracken
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Traci Leong
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Rasheed Gbadegesin
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
| | - Alejandro Quiroga
- Department of Pediatrics and Human Development, Helen DeVos Children’s Hospital, Grand Rapids, Michigan
| | | | - Guillermo Hidalgo
- Department of Pediatrics, East Carolina University, Greenville, North Carolina
| | - Tarak Srivastava
- Department of Pediatrics, Children’s Mercy Hospital, Kansas City, Missouri
| | - Megan Lo
- Department of Pediatrics, Medical College of Virginia School of Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Ora Yadin
- Department of Pediatrics, David Geffen School of Medicine, University of California, Los Angeles Mattel Children’s Hospital, Los Angeles, California
| | - Robert Mathias
- Department of Pediatrics, Nemours Children’s Hospital, Orlando, Florida
| | - Carlos E. Araya
- Department of Pediatrics, Nemours Children’s Hospital, Orlando, Florida
| | - Myda Khalid
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana
| | - Alvaro Orjuela
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Joshua Zaritsky
- Department of Pediatrics, A.I. DuPont Hospital for Children/ Nemours, Wilmington, Delaware; and
| | | | - Margret Kamel
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Larry A. Greenbaum
- Department of Pediatrics, Emory and Children’s Pediatric Institute, Atlanta, Georgia
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Munshi R, Sethna CB, Richardson T, Rodean J, Al-Akash S, Gupta S, Neu AM, Warady BA. Fungal peritonitis in the Standardizing Care to Improve Outcomes in Pediatric End Stage Renal Disease (SCOPE) Collaborative. Pediatr Nephrol 2018; 33:873-880. [PMID: 29313137 DOI: 10.1007/s00467-017-3872-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [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: 05/30/2017] [Revised: 11/12/2017] [Accepted: 12/02/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Fungal peritonitis is a serious complication among peritoneal dialysis (PD) patients. The Standardizing Care to Improve Outcomes in Pediatric End Stage Renal Disease (SCOPE) Collaborative is a North American multicenter quality improvement initiative with the primary aim to reduce catheter-related infections in children on chronic dialysis. OBJECTIVE To describe the epidemiology of fungal peritonitis and outcomes of affected patients among pediatric subjects receiving chronic PD and enrolled in SCOPE. METHODS Data pertaining to PD characteristics, peritonitis episodes and patient outcome were collected between October 2011 and September 2015 from 30 pediatric dialysis centers participating in the SCOPE collaborative. Peritonitis-related data were stratified by etiology, fungal versus bacterial/culture-negative peritonitis. Differences among groups were assessed by Chi-square analysis. RESULTS Of 994 patients enrolled in the registry, there were 511 peritonitis episodes of which 41 (8.0%) were fungal. Thirty-six individual patients with 39 unique catheters accounted for the fungal peritonitis episodes. Twenty-three (59%) of the episodes occurred in patients aged < 2 years (p = 0.03). Fungal peritonitis was the initial episode of peritonitis in 48.8% of affected patients, and only 17.1% of these patients had had a previous peritonitis episode within 30 days of the fungal infection. Insertion of the PD catheter at < 2 years of age was associated with an adjusted odds ratio of 2.8 (95% confidence interval 1.24, 6.31) for development of fungal peritonitis compared to older children (p = 0.01). Fungal peritonitis was associated with an increased rate of hospitalization (80.5 vs. 63.4%; p = 0.03), increased length of hospitalization (median of 8 vs. 5 days; p < 0.001) and increased rates of catheter removal (84.6 vs 26.9%; p = 0.001) and technique failure (68.3 vs. 8%; p = 0.001) compared to other causes of peritonitis. CONCLUSION Fungal infections were responsible for 8.0% of peritonitis episodes in the SCOPE collaborative, with the majority of fungal peritonitis episodes occurring in children aged < 2 years. Although no risk factors for infection other than young age were identified, fungal peritonitis was associated with an increased risk of hospitalization, longer hospital stay and an increased frequency of technique failure.
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Affiliation(s)
- Raj Munshi
- Pediatric Nephrology, Seattle Children's, Seattle, WA, USA.
| | - Christine B Sethna
- Pediatric Nephrology, Cohen Children's Medical Center of New York, New Hyde Park, NY, USA
| | - Troy Richardson
- Biostatistics, Children's Hospital Association, Lenexa, KS, USA
| | - Jonathan Rodean
- Biostatistics, Children's Hospital Association, Lenexa, KS, USA
| | - Samhar Al-Akash
- Pediatric Nephrology, Driscoll Children's Hospital, Corpus Christi, TX, USA
| | - Sushil Gupta
- Pediatric Nephrology, University of Louisville, Louisville, KY, USA
| | - Alicia M Neu
- Pediatric Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Bradley A Warady
- Pediatric Nephrology, Children's Mercy Kansas City, Kansas City, MO, USA
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10
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Seshadri S, Al-Akash S, Gharaybeh S. Case 1: Rash, recalcitrant tachycardia, and hypertension in a 16-year-old girl. Pediatr Rev 2015; 36:31-2. [PMID: 25554109 DOI: 10.1542/pir.36-1-31] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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11
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Dolan NM, Borzych-Duzalka D, Suarez A, Principi I, Hernandez O, Al-Akash S, Alconchar L, Breen C, Fischbach M, Flynn J, Pape L, Piantanida JJ, Printza N, Wong W, Zaritsky J, Schaefer F, Warady BA, White CT. Ventriculoperitoneal shunts in children on peritoneal dialysis: a survey of the International Pediatric Peritoneal Dialysis Network. Pediatr Nephrol 2013; 28:315-9. [PMID: 22972407 DOI: 10.1007/s00467-012-2303-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [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] [Received: 05/01/2012] [Revised: 07/08/2012] [Accepted: 07/10/2012] [Indexed: 12/30/2022]
Abstract
OBJECTIVE The aim of this study was to inform best evidence-based practice by collating and disseminating the experiences of members of the International Pediatric Peritoneal Dialysis Network with children having concurrent ventriculoperitoneal shunts (VPS) and peritoneal dialysis catheters (PDC). METHODS An online questionnaire was created and distributed to all 135 centers participating in the International Pediatric Peritoneal Dialysis Network; the overall response rate was 56 %. RESULTS A total of 18 patients with a concurrent VPS and PDC were reported. The children were 0-12 (mean 6.8) years old at the time of placement of the second indwelling device (PDC or VPS). In 15 cases, the PDC was inserted post-VPS. On average, the two catheters were present concurrently for 23 (range 1-60) months. There were 20 episodes of peritonitis observed in 11 of the 18 patients during a period of 392 months at risk, which is a peritonitis rate of 1/19.6 months. Only one patient developed both a VPS infection and an episode of peritonitis, and these events were temporally unrelated. No episodes of an ascending shunt infection or meningitis occurred in association with any episode of peritonitis, and no other complications of catheter dysfunction were described. CONCLUSIONS The rate of peritonitis, the absence of any documented ascending or descending infections and the lack of catheter dysfunction during the period of observation suggests that the presence of, or need for, a VPS should not preclude PD as a safe option for children requiring renal replacement therapy.
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Affiliation(s)
- N M Dolan
- ACB K4-151, Nephrology, BC Children's Hospital, 4480 Oak St, Vancouver, B.C., V6H 3V4, Canada
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12
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Manenti L, Allinovi M, Vaglio A, Allegri L, Gnappi E, Simonetti G, Simonetti G, Vilalta R, Lapeyraque AL, Gruppo R, Sherwinter J, Smith J, Thornburg C, Jungraithmayr T, Wuehl E, Al-Akash S, Davin JC, Macher MA, Langman C, Camacho Diaz JA, Chin M, Goldsberry, Ms A, Hebbar S, Meyer C, Audhya P, Toto R, Warnock D, Pergola P, Chin M, Goldsberry, Ms A, Hebbar S, Meyer C, Audhya P, Imai E, Haneda M, Ito S, Kobayashi F, Yamasaki T, Chan J, Makino H. HUS and diabetic nephropathy. Nephrol Dial Transplant 2012. [DOI: 10.1093/ndt/gfs240] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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13
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Anyaegbu E, Al-Akash S. 28: Use of Intravenous Immunoglobulin (IVIG) in the Treatment of BK Viremia (TBKV) and Nephropathy in Pediatric Transplant (PTX) RECIPIENTS (REC). Am J Kidney Dis 2010. [DOI: 10.1053/j.ajkd.2010.02.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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14
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Abstract
Post-transplant lymphoproliferative disease (PTLD) is a well-recognized complication of the intense immunosuppression required in solid organ and bone marrow transplant recipients. The clinical presentation is varied and can range from a benign infectious mononucleosis-like syndrome to malignant lymphoma. PTLD manifesting as multiple myeloma occurs rarely. We report the unique occurrence of Epstein-Barr virus (EBV)-associated post-transplant multiple myeloma in a 16-year-old male. In contrast to previously described cases of PTLD-myeloma type, this patient was very young, had a clear association with EBV, and an indolent clinical course.
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Affiliation(s)
- Wendy Y Tcheng
- Gwynne Hazen Cherry Memorial Laboratories, Division of Pediatric Hematology-Oncology, UCLA, Los Angeles, California, USA.
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15
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16
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Abstract
BACKGROUND Mycophenolate mofetil (MMF) has emerged as a new agent for treatment of a variety of glomerular diseases. This study examines the safety and efficacy of MMF in treating pediatric patients with steroid-dependent (SD) and/or frequently relapsing (FR) nephrotic syndrome (NS). METHODS We retrospectively reviewed the medical records of 18 patients with SDNS and/or FRNS treated with MMF for at least 3 months. MMF was used in 11 patients with SDNS (n=10) and FRNS (n=1), including 7 males and 4 females. RESULTS Mean age at time of diagnosis of NS was 3.3 years (range, 1.1-8.5 years), and at the start of MMF 5.9 years (range, 2.9-10 years). Seven patients had a renal biopsy prior to starting MMF; all had mesangial proliferative glomerulonephritis. Mean follow-up after starting MMF was 12.2 months (range, 4-24 months). Mean MMF dose was 948 mg/m2/day (range, 500-1087 mg/m2/day). MMF resulted in improvement in 9 of 11 patients, with 8 patients weaned off steroids completely, with a reduction in the mean relapse rate from 4.7 relapses/patient/year (range, 2.4-6) before MMF to 1.05 relapses/patient/year (range, 0-4.5) after MMF therapy (P=0.0001). The relative risk for relapse before MMF was 4.7 (P=0.0002). None of the patients had significant adverse events or intolerance to MMFtherapy. CONCLUSION We conclude that MMF is a safe and effective option for treatment of children with SDNS and/or FRNS.
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Affiliation(s)
- Samhar Al-Akash
- King Faisal Specialist Hospital & Research Centre, Department of Pediatrics, Riyadh, Saudi Arabia.
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17
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Al-Meshari K, Al-Shaibani K, Hamawi K, Al-Akash S, Raza S, Tbakhi A, Chaballout A, Ahmadi I, Al-Saghier M, Al-Jedai A, Mohamed GED, Al-Talhi M, Sharaf M. The Kidney Transplant Program at King Faisal Specialist Hospital and Research Center. Clin Transpl 2005:119-29. [PMID: 17424730] [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] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
More than 1,000 kidney transplants were performed at King Faisal Specialist Hospital and Research Center (KFSH&RC) between 1981-2005. The majority were from living donors. The renal transplant program at KFSH&RC was fundamentally transformed in 2001 with the introduction of renal transplant physicians and the emphasis on multidisciplinary teamwork. This fundamental change has resulted in tripling of the size of the program and in expanding its scope of services to include high-risk patients (highly sensitized with a positive crossmatch). These achievements were coupled with excellent outcome data. The 5-year patient and graft survival rates for adult transplants performed during 2000-2005 were 97% and 94%, respectively, for 268 living donor transplants and 97% and 76%, respectively, for 73 deceased donor transplants. The kidney transplant program at KFSH&RC is now a leading center in the Region and it ranks among the leading kidney transplant centers in the world in terms of size, scope of services and outcomes.
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Affiliation(s)
- Khalid Al-Meshari
- Renal Transplant Program, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
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