Pediatric kidney transplantation: Siriraj Hospital experience.

We reported six children with end stage renal disease (ESRD) who received kidney transplantation in our unit from 1996 to 2000. They were 5 boys and 1 girl and their mean age was 9.7 +/- 2.7 years (range 6.8 to 13.2). Etiologies of ESRD were congenital anomalies (3 patients), chronic glomerulonephritis (2 patients), and rapidly progressive glomerulonephritis (1 patient). Prior to the transplantation, chronic peritoneal dialysis was used in 5 patients, including one who had to switch to hemodialysis due to chronic exit site infection and 1 had preemptive kidney transplantation. All children received a kidney from living-related donors, 4 from their fathers, 1 from his mother, and 1 from his elder brother. Triple immunosuppressive drug therapy (prednisolone, azathioprine, and cyclosporine A) was initially given to all patients. Serum creatinine returned to normal within the first week in all patients and 4 patients were discharged home by the end of the second week post operation. Immediate complications included severe hypertension (all patients), ureteral leakage (2 patients), neutropenia (3 patients) and nephrotic syndrome (1 patient). Azathioprine was discontinued in 2 patients due to persistent neutropenia. Cyclosporine A was discontinued in 1 patient due to hepatotoxicity, this patient was maintained on mycophenolate mofetil and prednisolone. Serum creatinine levels at last follow-up (mean 24.3 +/- 19.0 months, range 8-55) were normal in 5 patients and slightly increased (1.5 mg/dl) in one. Five patients returned to school full time within 1 year after kidney transplantation. Height standard deviation score improved markedly as early as 6 months post transplant. The cost of maintenance of the immunosuppressive drugs was similar to adults, i.e. 6,859.1 +/- 1,151.8 Baht per month at 6 months post kidney transplantation. We concluded that kidney transplantation can be performed successfully in selected Thai children with very good results and similar cost of treatment as for adults.

Chronic renal failure in Thai children: etiology, cost, and outcome.

We studied the epidemiology, cost and outcome of chronic renal failure (CRF) in Thai children by sending questionnaires to all university hospitals, all government general service hospitals and all pediatric nephrologists in the country. A total of 238 cases (107 from 8 university hospitals and 131 from 70 government general service hospitals) were diagnosed from 1996 to 1998. Mean age of the patients was 8.3 +/- 4.9 yr, male to female ratio was 1.4:1. Congenital KUB anomalies (obstructive uropathy and hypo/dysplasia) were the main causes of CRF in these patients, especially in the under five age group. Only a small number of patients received renal replacement therapy (chronic dialysis and kidney transplant) and the mortality rate was 18.7 per cent in university hospitals. Renal transplantation was performed in only 5 patients in 2 pediatric units and another 2 patients in adult renal units. The outcome of renal transplantation in this small group of patients was very satisfactory. The cost of CRF treatment in children was comparable to adults. The main problems in the management of CRF in Thai children included the lack of experienced personnel, lack of equipment and funding. We conclude that in order to improve the care of CRF in Thai children, a training program for health personnel and budget allocation should be established.

Renal pathology and long-term outcome in childhood SLE.

Renal histology is increasingly used as a guide for therapy and prognosis in SLE but data in children are few and/or short-term. We assessed renal histological features in 19 children with SLE to determine whether these features are useful in predicting long-term outcome. Mean age at biopsy was 10 +/- 1.7 years old, male to female ratio was 1:2.8. Fourteen patients (73%) had diffuse proliferative lupus nephritis. Renal histology was evaluated using an activity index (AI) and chronicity index (CI). Clinical assessment of renal function at biopsy and outcome were graded according to urinalysis and serum creatinine. Renal function at biopsy correlated well with AI (p < 0.001) but not CI. At short-term follow-up (30 months), 3 patients had died from sepsis and another 2 reached end-stage renal disease. CI predicted poor clinical outcome, i.e. death or renal failure (p < 0.005) but AI did not. At long-term follow-up (mean 92.1 +/- 26.8 months) only one more patient reached end-stage renal disease. In others renal function assessment showed improvement or were stable. Neither CI nor AI correlated with clinical outcome. We conclude that although AI correlates well with renal function at biopsy and CI with short-term prognosis, neither can predict long-term outcome. Treatment may have altered the natural course of disease in these patients.

Adrenal function after prednisolone treatment in childhood nephrotic syndrome.

Nephrotic syndrome in children is a very common disease in Thailand. Most of the patients respond well to oral prednisolone treatment but side effects of the drug especially adrenal insufficiency remains a threat to all. We studied the adrenal function by studying the response to ACTH stimulation test in 14 Thai children, nine girls and five boys, with idiopathic nephrotic syndrome: immediately, 3, 6 and 9 months after discontinuation of oral prednisolone treatment. Average age on entry to the study was 104.4 months (25-183 months). Prednisolone was given every day for 29 days (6-64 days) then every other day for 542 days (178-1,562 days). Side effects of steroid treatment were gross obesity BMI > 30 (one patient), moderate hypertension (one patient), and marked cushingoid features (two patients). ACTH stimulation tests were normal in 64 per cent of patients within 7 days, 64 per cent at 3 months, 73 per cent at 6 months, and 90 per cent at 9 months after discontinuation of oral prednisolone. We suggest that adrenal insufficiency has to be considered in all children on prolonged prednisolone unit at least 9 months of treatment-free period.