Kidney transplantation in children with bladder augmentation or ileal conduit diversion

INTRODUCTION

Various congenital and acquired diseases of the lower urinary tract can lead to chronic renal failure requiring renal replacement therapy.

AIM

The aim of the study was to assess problems and results of kidney transplantation in children with significant lower urinary tract dysfunction.

MATERIALS AND METHODS

Between 1984 and 2007, there were 33 kidney transplantations in children with end-stage renal disease and severe lower tract dysfunction out of 539 kidney transplantations performed in our department. The patients were 23 males and 10 females. Thirty patients received a kidney from a deceased donor, the remaining 3 from a living related donor. The age at transplantation ranged from 2.25 years to 19 years. In 26 patients an ileal conduit modo Bricker was created (in 21 patients at transplant operation). Bladder augmentation was performed in 6 patients and a continent urinary reservoir was created in 1.

RESULTS

Post-transplant follow-up ranged from 7 to 88 months (mean 32 months). Overall patient survival is 100% and graft survival is 97%. Creatinine concentrations ranged from 0.3 to 3.4 mg% (mean 0.92 mg%). Surgical complications were diagnosed in 16 patients. All surgical complications were treated successfully and none of them caused graft loss. Urinary tract infections (UTI) were the most commonly observed complication, occurring in 26/33 (78%) patients, but the majority of these UTI were asymptomatic and had no influence on graft function.

CONCLUSIONS

Kidney transplantation in children with lower urinary tract dysfunction and end-stage renal failure offers excellent medium term results in our experience, despite the creation of non-standard urinary drainage. Recurrent urinary tract infections are the most common complications in these patients, but in the majority of cases this does not lead to impairment of graft function.

Patient survival and causes of death on hemodialysis and peritoneal dialysis--single-center study

Survival and causes of death in children dialyzed in a single center were analyzed. During the last 12 years a chronic dialysis program was introduced in 146 children in our center and 125 of them, eligible for observation, were included in this analysis; 58 patients were on hemodialysis (HD) and 67 on peritoneal dialysis [continuous ambulatory peritoneal dialysis/automated peritoneal dialysis (CAPD/APD)]. Mean age at the start of dialysis was 13.1 years in HD and 9.8 years in CAPD/APD patients. Overall, 16 patients died (12.5%); 6 (10.3%) on HD and 10 (14.9%) on CAPD/APD; 4 HD patients died of hemorrhagic stroke and 2 were killed in road traffic accidents. Of 10 CAPD/APD patients, 7 died of heart failure, ischemic stroke, and/or disseminated thromboembolic disease. Another was killed in a road traffic accident and 2 died during the course of severe infections. The 1-year patient survival rate was 96.6% in HD patients and 95% in CAPD/APD patients, 2-year survival 94% and 93% and 5-year survival 91% and 78%, respectively (P=0.2, NS). In conclusion, the survival rate for HD and CAPD patients is similar, although after 2 years of therapy, it is lower in CAPD patients. The main causes of death are cardiovascular. However, in CAPD/APD patients, heart failure with low cardiac output and thromboembolic complications are major causes of death, and in HD patients the main cause is hemorrhagic stroke.

[Epidemiology of HBV infections and possibilities for therapeutic actions in children and adolescents with end-stage renal failure treated with dialysis]

Wide spreading of prophylaxis principles of HBV infections in dialysis centers decreased the HBV infection rate in general population of dialyzed patients in Poland last years. There is neither data concerned with HBV infection epidemiology in children and adolescents, nor data about anti-viral treatment possibilities and effects in this group of dialyzed patients. The aim of the study was evaluating of HBV infection rate in patients of pediatric dialysis centers and analysis of causes of infection and efficacy of treatment. Study was based on data sent in a query-answer by 8 biggest pediatric dialysis centers, all of them treating 210 patients. HBV infection was found much more often (16.6%) than in population of all hemodialyzed patients in Poland. More than 75% non-vaccinated patients was infected before dialysis therapy, remaining were infected during vaccination, before the protecting level of antibodies was gained. Big differences in HBV infection rate among centers are observed. Nowadays HCV infections (more than 40% patients infected) are a bigger issue. Only 10 patients in 5 centers had anti-viral treatment (5 with isolated HBV infection, 5 with mixed HBV/HCV infection). In 9 patients interferon-alpha and in 1 patient lamivudine was administered. Efficacy of interferon-alpha treatment was similar to the population of non-uremic children (33.3% vs. 50% of HBeAg elimination). Majority of patients quite well tolerated the drug. Only in 1 case interferon-alpha treatment had to be ceased because of side effects. In a boy treated with lamivudine, after 3 months elimination of viremia and decrease of ALAT activity was observed. HBV infection in patients of pediatric dialysis centers is still a serious matter. More strict applying of vaccination against hepatitis B before dialysis treatment is needed. The possibility of HBV infections therapy is limited, mostly for economical reasons.

[Secondary hyperparathyroidism as a cause of delayed functioning of renal graft. Reports of two cases]

Parathormone (PTH) exerts vasomodulatory effect. In patients with severe hyperparathyroidism (HPTx) post transplant (Tx) PTH level decreases slowly and this could be a reason of delayed graft function. Case 1: 19 years old female; 2 years of CAPD-renal Tx lost after 8 years--6 years on hemodialysis (HD), clinical symptoms of severe HPTx (iPTH > 1300 pg/ml). Elective parathyroidectomy was cancelled as patient received the second graft. Then she was oliguric and required regular HD from the 4th day after Tx. We observed increasing resistance index (RI) and finally no diastolic blood flow in graft USG-Doppler scan. Ten days after Tx, the patient was revised surgically and renal biopsy was performed. No pathology but slight ATN was found. At the same time iPTH level was 1225 pg/ml. Plasmapheresis (PF) was introduced, decreasing iPTH level to 850 pg/ml, 995 pg/ml, and 345 pg/ml respectively. After the second PF urine output increased (to 600 ml). Serum creatinine level decreased from 7.3 to 1.3 mg/dL within the next 10 days. Actually (5 months post Tx) graft function remains stable (creatinine 1.2 mg/dl). The level of iPTH at the second month after Tx was 756 pg/ml, at 4th month--439 pg/ml. Case 2: M.P. 20 years old female initially on HD, then Tx, lost after 5 months because of FSGS recurrence--again HD therapy. She developed severe secondary HPTx (iPTH level > 1300 pg/ml). Planned parathyroidectomy was cancelled as she received a second transplant. After Tx she was anuric for 5 weeks and was treated with HD. She had high RI index in repeated USG-Doppler scans, blood flow in renal cortex was deceleration. Repeated renal biopsy showed no pathology and PF therapy was introduced. After the first PF the patient started to urinate, after the 5th--the urine output was 1000 ml. Overall 10 PFs were done. Now, 13 months after Tx, graft function is satisfactory (creatinine level 2.1 mg/dL). The level of iPTH in 4th month after Tx was 772 pg/ml, in 10th month--631 pg/ml. We suggest that disturbances in graft blood flow were influenced by high level of iPTH, decreased successfuly by PF therapy.

A single pediatric center experience with 1025 children with hypertension

Between January 1982 and December 1989 1025 patients aged between one month and 18 years with increased blood pressure were referred for evaluation. Borderline hypertension was found in 389 children; 636 had sustained significant hypertension. In 351 patients, hypertension was secondary to a known disease. Renal parenchymal diseases were present in 68% of patients while renovascular and endocrine disorders were found in 10% and 11%, respectively. Of the 258 children aged less than 15 years, all but six children had known causes of hypertension, while 75% of adolescents had essential hypertension. In the 389 children with borderline hypertension, 65% developed fixed hypertension over a period of 2-3 years.

A single pediatric center experience with 1025 children with hypertension

Between January 1982 and December 1989 1025 patients aged between one month and 18 years with increased blood pressure were referred for evaluation. Borderline hypertension was found in 389 children; 636 had sustained significant hypertension. In 351 patients, hypertension was secondary to a known disease. Renal parenchymal diseases were present in 68% of patients while renovascular and endocrine disorders were found in 10% and 11%, respectively. Of the 258 children aged less than 15 years, all but six children had known causes of hypertension, while 75% of adolescents had essential hypertension. In the 389 children with borderline hypertension, 65% developed fixed hypertension over a period of 2-3 years.