[Kidney transplantation in pediatric patients : 18-year experience at Hotel-Dieu de France]

Introduction: During the period from September 1993 to March 2011, 79 kidney transplants in children and adolescents less than 18 years old were performed in our department; fifty-six in the familial group and 13 in the cadaveric group. We report in this study: immunosuppression protocols, medical and surgical complications [including rejection episodes], graft and patient survival

Material and methods: Immunosuppression protocol has been modified throughout those eighteen years. Induction therapy includes serum antilymphocyte + cyclosporine + azathioprine and prednisone. Since 2000, azathioprine was replaced by mycophenolate mofetil and since January 2005 cyclosporine was given as well as tacrolymus according to EBV status. Basiliximab- Simulect [Registered Sign] was included in the protocol since 2010

Results: Surgical complications were only two lymphoceles, reversible after surgical drainage in the peritoneum. Medical complications were mainly infections or rejections. Thirty-six episodes of rejection occurred: 7 in the commercial group, 16 in the familial group and 13 in the cadaveric group. At the end of the study, 9 patients returned to dialysis, 5 from the cadaveric group, 2 from the familial group and 2 from the commercial group

Conclusion: After eighteen years experience in kidney transplant, we believe that kidney transplant remains the optimal treatment for terminal renal failure even for children weighing less than 10 kg. The follow-up of pediatric patients with kidney transplant revealed different positive effects on growth, regular school attendance and psychomotor development. At the end of the study: 24 are at school, 12 at universities, 5 are attending specialized schools and 9 are active workers

[Successful familial kidney transplant in an infant weighing less than 10 kg : case report and review of the literature]

We report the case of a Lebanese infant born by normal delivery at 40 weeks of gestation. Weight and height at birth were 3200 grams and 49 cm respectively. Serum creatinine in the first week of life was 323 mmol/l [normal value for age is less than 20 mmol/L]. Kidney ultrasound confirmed diagnosis of hypoplastic small kidneys. Conservative treatment of renal failure was initiated from the first days of life. Conservative management of renal failure included careful attention to fluid balance, maintenance of adequate nutrition and correction of hyperkalemia, acidosis, hyperphosphatemia and prevention of renal osteodystrophy by the use of dietary phosphate binders and vitamin D analogs. After a slight decrease of serum creatinine in the first three months of life, creatininemia increased progressively despite conservative treatment associated to hyperkalemia and severe pruritis due to hyperphosphatemia. Faced with the progression of renal failure, we decided to start automated peritoneal dialysis at seven months of life. Weight and height were respectively 6200 g and 63 cm. Serum creatinine was 432 mmol/L. Pruritis improved after starting peritoneal dialysis as well as appetite. At 20 months of life and a weight of 9.7 kg, a familial kidney transplant was performed. Immunosuppressive treatment included Simulect[Registered sign], on day 1 and day 4, associated to mycophenolate mofetil, tacrolymus and prednisolone. The immediate post-transplant period was complicated by urinay tract infection due to BSLE E. coli. After four episodes of urinary tract infection due to resistant E. coli associated to a non obstructive stone of 15 mm in the allograft kidney, we performed two sessions of lithotripsy and placed a double J stent. Biochemical urinary analysis did not reveal any causes for lithiasis. Stone disappeared as well as infection after lithotripsy. Renal function is normal for age one year after the kidney transplant. To our knowledge, this is the first reported case of a successful kidney transplant in a Lebanese infant with kidney failure since birth with kidney transplant performed at less than 10 kg of weight on the transplant day. Peritoneal dialysis is the treatment of choice for infants with chronic kidney failure. Familial or cadaveric kidney transplant should be encouraged and performed even in infants weighing less than 10 kg allowing them to have normal growth as well as social and school integration

Living donor nephrectomy : Open vs laparoscopy. Renal function and complications

This study is to compare the short and long-term renal function between adult recipients of living laparoscopic and open donors [LR vs OR] to highlight the effect of the surgical technique on graft function. Moreover, we chose to compare the organic [hypertension, proteinuria, serum creatinine] and psychological [aspect of libido, need for anxiolytics] long-term effect of the surgery between laparoscopic and open donors [LD vs OD]

Methods: After census of adult recipients and living donors between 2003 and 2012, and after application of exclusion criteria and selection of homogeneous groups of donors and recipients, a retrospective cohort study was conducted between October 2008 and January 2012. In recipients, renal function in the short term was reported by the value of serum creatinine at +/- D5 post-op and the long-term values of serum creatinine at 6 and 12 months after surgery. Delayed graft function was defined by a serum creatinine value >/= 2.5 mg/dl on D5 post-op. A questionnaire for donors was established

Results: The two groups OR and LR were homogeneous concerning age, sex and body mass index [BMI]. Different groups OD and LD, chosen according to the variable of interest, were made homogeneous. Despite a different warm ischemia time between the 2 groups [175.54 seconds in LR vs 44.67 seconds in OR, p < 0.001], renal function in the short- and long-term in recipients was not statistically different [At day 5, 1.54 vs 1.50 mg/dl, p = 0.781; at 6 months, 1.37 vs 1.38, p = 0.871; at 12 months, 1.34 vs 1.36, p = 0.569, in OR and LR respectively]. Similarly, there was no significant statistical difference concerning organic and psychological complications between OD and LD except for a shorter period between hospital discharge and return to work in LD

Conclusion: In our center, renal function in the shortand long-term was similar in OR and LR. Apart from the advantages offered by the laparoscopic technique, organic and psychological long-term effects were similar between OD and LD. Nevertheless, laparoscopy seemed to facilitate kidney donation and is requested by almost all living donors independently of their social status

[Immunosuppressive protocols in kidney transplantation : with or without induction?]

Kidney transplantation is the treatment of choice of end stage kidney disease. Over the years, kidney transplantation progressed tremendously, mainly by the improvement of immunosuppressive drugs used in the prevention of acute rejection. Since the introduction of cyclosporine in the 80s, many immunosuppressive protocols have been established. These protocols are characterized by two strategies: with or without induction. The agents used in induction therapies can be polyclonal or monoclonal antibodies. The decision of using induction therapy relies mainly on the evaluation of the immunological risk in the recipient. Even if protocols with induction have improved early results concerning acute rejection, the protocols without induction seem justified in some candidates. The optimal immunosuppressive protocol is not yet established, and individualization of immunosuppressive treatment is necessary

Donor specific anti-HLA antibodies detection and impact in kidney transplantation

Kidney transplantation is now accepted to be the best treatment for end-stage renal disease. Despite the improvement of immunosuppressive therapy, there is still actually substantial loss of allografts, in part due to uncontrolled humoral immunity. For many years, the primary technique for the detection of anti-HLA antibodies was the CDC [complement dependent cytotoxicity]. The recent use of solid phase assays, mainly the Luminex technology allowed detection of antibodies at much lower levels, and it has been shown that these antibodies have negative impact on the graft survival. We herein review the principal techniques for anti-HLA detection and the different presentations of humoral rejection

Cytomegalovirus infection post kidney transplant: What should we know now

Cytomegalovirus [CMV] remains one of the most important pathogen responsible for the morbidity and mortality of transplantation patients. The impact on recipients depends on the form of CMV infection knowing that 10% to 50% develop symptomatic disease while solid organ involvement if presumed [e.g. CMV nephritis] may have deleterious outcome and requires histopathology testing. Treatment with antivirals IV ganciclovir and valganciclovir is managed according to early diagnostic tools with quantitative nucleic acid testing [QNAT] and antigenemia that will indicate the extent of disease and monitor response to treatment. CMV prevention in particular conditions of high risk patients has proven to be beneficial, resistance to antivirals and CMV vaccines along with novel therapies are thoroughly discussed in this review describing the new perspectives of CMV infection management

[Cardiogenic shock revealing heart disease in infancy and childhood]

Diagnosis, initial workup and immediate prognosis in congenital or acquired heart diseases revealed by cardiogenic shock [CS] in a Lebanese paediatric multicentric study. During a six-year period [is. January 1999 to 31 December 2004], 56 paediatric patients aged between 0 and 7 years have been admitted to the emergency departments or neonatal and intensive care units in ten different Lebanese hospitals, for high degree of CS suspicion with underlying cardiac disease. All diagnoses were confirmed by echocardiography.All children were initially in a critical condition with signs of CS. Congenital heart diseases [CHD], specially left obstructive diseases [coarctation of the aorta, critical aortic stenosis, hypoplastic left heart syndrome] were the main etiologies found in newborns, followed by dilated cardiomyopathies in infants and children. Mortality was higher in the following two groups of patients : intubation, no diuresis after the first hour of admission despite therapeutic measures [prostaglandines in newborns, dopamine, dobutamine and furosemide]. Beside those pathologies necessitating specific treatment, all the CHD [excluding hypoplastic left heart syndrome, one case of critical aortic coarctation and one case of congenital mitral regurgitation] were transferred to the catheterization laboratory or to surgery in a good hemodynamic condition. CS remains a notable medical problem observed in the emergency and paediatric intensive care units in Lebanon. Immediate prognosis is related to : immediate recognition of the CS, nature of the car-diopathy and initial response to therapeutic procedures such as rapid improvement of respiratory status and rapid diuresis. Echocardiography is a reliable, quick and non-invasive procedure for initial diagnosis

[Salmonella Typhi in a child with urinary tract infection and Urolithiasis]

Salmonella species are a rare cause of urinary tract infections in children. They have been associated with a higher incidence of structural abnormalities or immunosuppressive status. We report the case of an 11-year-old girl with urinary tract infection [UTI] secondary to Salmonella typhi and associated with urolithiasis. A review of the subject is then discussed

[Erythropoietin: dosage forms and therapeutic indications]

Erythropoietin is a growth factor specific of the erythroid cells. The erythropoietin gene was first cloned in 1985, and very rapidly the first clinical studies started. The drug was first used in France in 1988 for the treatment of the anemia of hemodialysis patients with end-stage renal disease. Then the indication also included the treatment of the anemia in children on hemodialysis, the anemia of the adults on peritoneal dialysis, and the renal anemia of the adults on peritoneal dialysis, and the renal anemia of adults with renal diseases suffering from chronic renal failure. In addition to renal insufficiency, the recombinant human erythropoietin has other indications: -treatment and prevention of anemia in premature babies.- To increase autologous blood donation before elective surgery. - Prevention and treatment of anemia in adult patients with solid tumors treated with chemotherapy

Current therapeutic indications for ciclosporin

Ciclosporine was launched in therapeutic use in 1978. It marked the transplantation era due to the success of organ transplantation. Ciclosporine is actually used in bone marrow transplantation and in the transplantation of solid organs such as kidney, liver, heart, lungs, lung-heart, pancreas and bowel. It was proven also efficient in the treatment of auto-immune diseases especially in the treatment of psoriasis and nephrotic syndrome. Pharmacokinetic and drug interactions of ciclosporine have to be taken in consideration in order to allow an optimal use of the medication. However, the drug presents a long list of side effects: hypertension, increased level of serum creatinine, hypomagnesemia, severe gingivitis, maxillary modification, which can restrict the therapeutic use of the drug

transplantation renale chez l'enfant experience de l'h tel-Dieu de France

A retrospective study was conducted on all kidney transplantations performed between January 1993 and June 1996 in our multidisciplinary pediatric department, Thirteen children with a mean age of 6 years [3.5 -12] were transplanted during the study period after an average waiting time of 2 years on dialysis for cadaveric transplants and 3.5 months for living related ones. No urologic complication was noted; however, intraabdominal approach was decided to be performed only in children less than 9 kg. This decision was taken after the occurrence of one intestinal intussusceptions and two ileal obstructions. During these 3.5 years, five rejection episodes were treated: three were steroid responsive, two were resistant but responded respectively to plasmapheresis and to okT3. The actuarial survival of the grafts and recipients were 100% for an average mean time of follow-up of 18 months. The latest serum creatinine and creatinine clearance averages were respectively 66 micro mol/I and 105 ml/min/I73 m 2.in seven transplanted children for more than 18 months growth was satisfactory. Eleven children returned to school kidney transphuitnfiun is the optimal treatment for children and infants with chronic renal failure: however this technique needs a highly experienced team and a permanent close follow-up. Some children with end stage renal disease can directly have preemptive transplantation which is becoming our recent choice to avoid the hemodialysis strain

Etide multicentrique des enfants en insuffisance renale terminale liban

A retrospective study was conducted in june 1997 concerning all Lebanese children with end stage renal failure. This study was able to recognize 20 children and infants [age less than 15] dialysed regularly in 8 hemodialysis centers. The other 23 centers are not following children. Thirteen children are dialysed on bicarbonate and seven on acetate. Children receive erythropoietin occasionally; 30% of them are polytransfused, 60% of them suffer from anemia four children have never received immunization against hepatitis B and three are seropositive for hepatitis C. none of these children has regular school attendance and psychological support for the child and his family do not exist. We conclude that the situation of children on hemodialysis in Lebanon is alarming. Solutions are possible and available; they need to be undertaken urgently

Reversible severe vascular rejection after plasmpheresis

Vascular rejection in a transplanted child is frequently associated with bad prognosis on the short and long term. All threrapeutic modalities available nowadays as monoclonal antibodies, intravenous cyclosporine or plasma exchange have given conflicting results. We report the case of a boy who was transplanted from his mother at the age of three. His primary disease was a cortico resistant rapidly progressive glomerulonephritis; the immediate postoperative period was satisfactory but he developed a severe vascular rejection on day 5 post transplantation while on triple immunosuppression therapy associating antithymocyte globuline prednisolone and azathioprine. Acute vascular rejection was corticoresistant but responded well to plasma exchange. In our patients we believe that plasmaphersis was efficacious on the reversibility of vascular rejection and moreover that he had not responded to corticotherapy even a week post methylprednisolone in the absence of any change in immunosuppression during plasmapheresis. No randomized study was realized until now to prove the efficacy of plasmapheresis in children with vascular rejection. The sporadic cases reported on the reversibility of such rejection after plasmapheresis, the innocuity of this therapy, if well performed in children encourage us to consider this treatment modality in resistant vascular rejection