Renal transplantation in infants and children.

Renal transplantation is the treatment of choice in children with end stage renal disease. Advances in organ retrieval and preservation, improved surgical techniques and postsurgical care, newer immunosuppressive drugs and prevention and treatment of infections have significantly improved survival of the renal allograft. The absolute requirements for a transplant are compatible blood group and a negative cytotoxic crossmatch. HLA identical grafts have a longer half-life than those that are less well matched. The immunosuppressive drugs most often used are cyclosporin A (or tacrolimus), azathioprine (or mycophenolate mofetil) and prednisone. Complications following transplantation include episodes of acute rejection, serious bacterial and viral infections, hypertension and recurrence of primary disease in the allograft. Each centre must have standard protocols for pre-transplant evaluation, and monitoring during surgery and in the post-operative period. Socio-economic factors should be evaluated before offering renal transplantation to children in developing countries.

Evaluation and treatment of chronic renal failure.

Chronic renal failure (CRF) is the irreversible deterioration of renal function that gradually progresses to end stage renal disease (ESRD). The chief causes of CRF include obstructive uropathy, primary glomerular diseases, reflux nephropathy and hypoplastic or dysplastic kidneys. Progressive hyperperfusion and hyperfiltration causes increasing glomerular injury and further renal damage. Symptoms of CRF are usually seen when GFR is between 10-25% of normal. Children with severe CRF often suffer from failure to thrive, growth retardation, acidosis, anemia and renal osteodystrophy. Management of CRF aims at retarding progression of renal damage and treatment of complications related to renal dysfunction. Measures suggested to retard progression include protein restriction, strict control of hypertension, use of angiotensin converting enzyme inhibitors and control of hyperlipidemia. Appropriate amounts of protein and calories are recommended to prevent growth failure. Nutritional supplements are often required. The availability of recombinant erythropoietin, calcitriol and human growth hormone has significantly improved the management of these patients. Once ESRD supervenes, renal replacement therapy in the form of chronic peritoneal or hemodialysis and transplantation is necessary.

Role of fibronectin in diagnosis of malignant ascites.

The aim of the study was to evaluate the role of ascitic fluid fibronectin in the diagnosis of malignant ascites. Fibronectin is a glycoprotein which plays an important role in regulating the organisation of the cell cytoskeleton and cell morphology. Ascitic fluid samples from 35 patients, 20 with portal hypertension (Group-I) and 15 with malignant ascites (Group-II) were analysed for proteins, cell counts, fibronectin levels and malignant cell cytology. Mean ascitic fluid fibronectin level was found to be significantly higher in malignant ascites as compared to portal hypertension (p < 0.001). At a cut off value of 94.67 microg/ml, the sensitivity, specificity, positive accuracy, negative accuracy and overall diagnostic accuracy was found to be 100%, 95%, 93.8%, 100% and 97.1% respectively.

Peripheral blood lymphocyte subsets in idiopathic nephrotic syndrome of childhood.

Lymphocyte subsets in the peripheral blood were examined in 34 patients with nephrotic syndrome [27 with minimal change nephrotic syndrome (MCNS), 7 with significant lesions] and 10 normal children. The investigations were done at the onset of disease before administering corticosteroids (n = 34), during the subsequent remission (n = 27), and the first relapse (n = 12). The proportions of T cell subsets (CD3, CD4 and CD8) were determined by immuno-alkaline phosphatase staining; interleukin-2 receptor (IL-2 R) positive cells, natural killer (NK) cells and B cells were studied by indirect immunofluorescence. No significant differences were found in the proportion of CD3, CD4, CD8 and IL-2 R positive cells in patients with MCNS as compared to controls. An increased proportion of NK and B cells was not specific to MCNS and was detected even in those with significant renal lesions. Our findings suggest that T lymphocyte subsets in MCNS are similar to those in normal children.

Acute renal failure in north Indian children.

The spectrum and outcome of acute renal failure (ARF) were studied in 205 children aged between 1 month and 12 yr. There were 145 boys and 60 girls; 23 per cent were below 1 yr and 49 per cent between 1 and 4 yr. The main causes of ARF were haemolytic uraemic syndrome (HUS) in 36 per cent, serious infections in 19 per cent, acute gastroenteritis and dysentery in 17 per cent, glomerulonephritis (GN) in 13 per cent and intravascular haemolysis (IVH) in 6 per cent. Most patients with HUS, serious infections and gastroenteritis were below 5 yr, whereas GN and IVH occurred in older children. HUS was mostly associated with dysentery; Shigella and several other pathogens were isolated from stools in 35 per cent. In most patients with HUS disseminated intravascular coagulation and renal cortical necrosis were present, with a high mortality. The outcome was also poor in infants with serious infections. IVH occurred in patients with G-6-PD deficiency. In such patients and in those with post-streptococcal GN the prognosis was good. Crescentic GN had a poor outcome. Our observations highlight the common and serious nature of ARF in India. However, most of the underlying causes are preventable.