[Kidney transplantation in pediatric age.] / Trasplante renal pediátrico.

Kidney transplantation (KT) is the best treatment for children in end-stage renal disease. KT has less mortality than dialysis and provides a better quality of life. Thus, the inclusion criteria have been progressively broadened. Histocompatibility and the source of donation are the most relevant factors that influence graft survival. Graft and patient survival have improved dramatically in recent decades, coming close to the results of KT in adults. Some of the specific factors that differentiate it from the adult are: donor-recipient size mismatch,the impact on growth and therapeutic non-compliance. Overall graft survival at 5-years is 90% for living donor KT and 70% for cadaveric donor KT.The most frequent cause of graft loss is chronic rejection.Mortality in the first post-transplant years is less than 6.5%. Infections and cardiovascular complications are the main causes of transplant-related death.Despite the good results, it is imperative to continue investigating how to achieve immunological tolerance. In order to improve the long-term results of the kidney graftis necessary to reduce immunosuppressive treatment and its side effects, such as chronic rejection.

El Trasplante Renal (TR) es el tratamiento de elección para los niños que se encuentran en insuficiencia renal terminal. Los criterios de inclusión se han ido ampliando de manera progresiva al conocerse que su mortalidad es menor que la que ocurre en diálisis y proporciona una mejor calidad de vida. La histocompatibilidad y la fuente de donación son, de entre los numerosos factores que influyen en la supervivencia del injerto, los de mayor relevancia. La supervivencia del injerto y la del paciente han mejorado de forma espectacular en las últimas décadas, aproximándose a los resultados del TR en el adulto. La diferencia de tamaño entre donante y receptor, la afectación del crecimiento y la falta de cumplimiento terapéutico, son algunos de los factores específicos que lo diferencian del adulto.La supervivencia global del injerto a los 5 años es del 90% para el TR de donante vivo y del 70% para el TRde donante cadáver.La causa más frecuente de pérdida del injerto es el rechazo crónico. La mortalidad en los primeros años post-trasplante es inferior al 6,5%. La infección y las complicaciones cardiovasculares son las causas principales de muerte relacionada con el trasplante.Sin embargo, a pesar de estos buenos resultados, es preciso continuar investigando en cómo alcanzar la tolerancia inmunológica, que permita reducir el tratamiento inmunosupresor y sus efectos colaterales, entre los que se encuentra el rechazo crónico; y así poder mejorar los resultados a largo plazo del injerto renal.

Trasplante renal pediátrico / Pediatric kidney transplant

El Trasplante Renal (TR) es el tratamientode elección para los niños que se encuentran en insufi-ciencia renal terminal. Los criterios de inclusión se hanido ampliando de manera progresiva al conocerse quesu mortalidad es menor que la que ocurre en diálisis yproporciona una mejor calidad de vida. La histocompatibilidad y la fuente de donación son, de entre losnumerosos factores que influyen en la supervivencia delinjerto, los de mayor relevancia. La supervivencia delinjerto y la del paciente han mejorado de forma espectacular en las últimas décadas, aproximándose a losresultados del TR en el adulto. La diferencia de tamañoentre donante y receptor, la afectación del crecimientoy la falta de cumplimiento terapéutico, son algunos delos factores específicos que lo diferencian del adulto. La supervivencia global del injerto a los 5 años es del90% para el TR de donante vivo y del 70% para el TRde donante cadáver.La causa más frecuente de pérdida del injerto es elrechazo crónico. La mortalidad en los primeros añospost-trasplante es inferior al 6,5%. La infección y lascomplicaciones cardiovasculares son las causas principales de muerte relacionada con el trasplante.Sin embargo, a pesar de estos buenos resultados, espreciso continuar investigando en cómo alcanzar latolerancia inmunológica, que permita reducir el tratamiento inmunosupresor y sus efectos colaterales, entrelos que se encuentra el rechazo crónico; y así podermejorar los resultados a largo plazo del injerto renal.(AU)

Kidney transplantation (KT) is the besttreatment for children in end-stage renal disease. KT hasless mortality than dialysis and provides a better qualityof life. Thus, the inclusion criteria have been progressively broadened. Histocompatibility and the source ofdonation are the most relevant factors that influence graftsurvival. Graft and patient survival have improved dramatically in recent decades, coming close to the resultsof KT in adults. Some of the specific factors that differentiate it from the adult are: donor-recipient size mismatch,the impact on growth and therapeutic non-compliance.Overall graft survival at 5-years is 90% for living donorKT and 70% for cadaveric donor KT.The most frequent cause of graft loss is chronic rejection. Mortality in the first post-transplant years is less than 6.5%. Infections and cardiovascular complications arethe main causes of transplant-related death.Despite the good results, it is imperative to continue investigating how to achieve immunological tolerance. Inorder to improve the long-term results of the kidney graftis necessary to reduce immunosuppressive treatment andits side effects, such as chronic rejection.(AU)

Long-term outcomes of adult-size and size-matched kidney transplants in small pediatric recipients.

INTRODUCTION: Adult-size kidneys are usually used for kidney transplantation in small pediatric recipients, but the influence of graft size in transplant outcome remains controversial. Our aim is to compare long-term transplant outcomes of using adult-size and size-matched kidneys in small pediatric recipients. MATERIALS AND METHODS: Since 1999, 61 of 226 kidney transplants were achieved in recipients weighing <20 kg with 5 years of follow-up. Patients were analyzed according to the graft size received: (group-A) adult-size (n = 32), (group-B) size-matched (n = 29). Kidney size (KS), glomerular filtration rate (GFR) proteinuria and rejection were compared between groups at transplant time (T0), at one (T1), two (T2), five years (T5), and at the end of the follow-up (TF) (median follow-up 8.47(0-17) years). Graft and patient survival were determined and compared between groups. RESULTS: Mean KS was significantly different between groups at T0 (A:11.3 ± 1.1 cm, B:8.8 ± 0.9 cm), (pT0<0.01), group-B evidenced graft growth, reaching similar sizes to group-A at T5 (A:11.7±1 cm, B:11.2±1 cm; pT5 = 0.13) and TF (A:12.2 ± 1.1 cm, B:12.4 ± 1.2 cm; pTF = 0.63), and group-A had a slight graft growth at TF (pT0-TF<0.01). Mean Schwartz-GFR at T0 was greater in group-A (138 ± 33 ml/min/1.73 m2) than group-B (109 ± 34 mL/min/1.73 m2) (pT0 = 0.01); during follow-up, it evidenced a reduction in group-A (T5:90 ± 27, TF:71 ± 24 mL/min/1.73 m2; pT0-T5<0.01; pT0-TF<0.01), meanwhile in group-B was stable until T5 (104 ± 33 mL/min/1.73 m2; pT0-T5 = 0.54), declining at TF (76 ± 31 mL/min/1.73 m2; pT0-TF<0.01); with no significant differences at T1, T2, T5, and TF between groups. Similar results were observed in mean Filler-GFR of both groups (Figure). Proteinuria and episodes of rejection were no significantly different between groups during the follow-up (p > 0.01; p = 0.23). Graft and patient survival at 5 and 10 years did not show significant differences (p = 0.45; p = 0.10). DISCUSSION: Despite the initial kidney size difference between groups, we have demonstrated that they tended to the same size during the follow-up. Adult-size kidneys presented a slight size increase in the long-term, suggesting that they have some growth potential in small recipients, in contrast to previous literature. Mean GFR between groups showed no significant differences in the long-term, suggesting that optimal graft perfusion and function can be achieved despite the size of the graft. We have demonstrated that there were no significant differences in long-term graft and patient survival; this results were similar to the most recent literature about this topic and different from the 90-2000s decades literature. CONCLUSIONS: Adult-size kidneys may be transplanted to small recipients (<20 kg) with comparable outcomes to size-matched kidneys, with no significant differences in long-term KS, GFR, proteinuria, rejection, graft or patient survival.

Displasia renal multiquística segmentaria asociada a ureterocele y quistes renales simples en un recién nacido / Multicystic segmentary renal displasia associated to ureterocele and simple renal cysts in a newborn

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[Medium-term results of the endourological management with balloon dilatation of the ureteropelvic junction stenosis in infants]. / Resultados a medio plazo del tratamiento endourológico retrógrado con balón de la estenosis pieloureteral en niños menores de 1 año.

AIM: In the last years it has spread minimally invasive therapeutic for the treatment of pyeloureteral junction obstruction in children. Some of them have got poor outcomes in 4-year-old minor children. We show our experience in the retrograde dilatation with balloon of high pressure in infants. METHODS: It's a retrospective study of 16 infants treated in our hospital. The average follow-up after the intervention is 27.4 +/- 10.0 months. The diagnostic protocol included abdominal ultrasound, cystogram and diuretic renography. The treatment was realized by endourology retrograde balloon dilatation under fluoroscopy. The balloons were in all the cases semicompliant, with a profile of 5 mm, 6 mm 6 7 mm. After the expansion there was placed stents type double J with profile and length depending on the weight of the patient. To obtain the results, we do ultrasound scans and diuretic renography at least 1 year after the intervention. RESULTS: The mean duration of the intervention was 36.4 +/- 15.5 minutes. During the intervention, in 2 patients the placement of the stent was not possible. The time of revenue was 48 hours in all the patients except in 1 of them. The analgesic needs were exclusively non steroid antiinflammatorys. The double J stent was withdrawn with cystoscopy. In 3 patients there were postoperatory complications: a migration of the stent, a urinary infection and an urinoma. In 1 patient with worsening of hydronephrosis was needed of pyeloplasty. In the controls the disappearance of the hydronephrosis was observed in all the cases, eliminating likewise the expansion of the renal calyces. The diuretic renography improved in all babies, being the boss of the curve normal in 14 cases and semi obstructively in 2. The mean time of elimination was 9.8 +/- 2.8 minutes. CONCLUSIONS: We think that the balloon dilatation of pyeloureteral junction obstruction is a minimally aggressive technique that is possible to realize in infants with good results and scanty complications.

Resultados a medio plazo del tratamiento endourológico retrógrado con balón de la estenosis pieloureteral en niños menores de 1 año / Medium-term results of the endourological management with balloon dilatation of the ureteropelvic junction stenosis in infants

Introducción: En los últimos años se han extendido terapéuticas mínimamente invasivas para el tratamiento de la estenosis pieloureteral en niños. Algunas de ellas con pobres resultados en niños menores de 4 años. Presentamos nuestra experiencia en el tratamiento mediante dilatación endourológica retrógrada con balón de alta presión en lactantes. Material y métodos: Presentamos un estudio retrospectivo de 16 pacientes menores de 1 año tratados en nuestra unidad. El seguimiento medio tras la intervención es de 27,4±10,0 meses. El protocolo diagnóstico incluyó ecografía abdominal, gammagrafía renal, cistouretrografía miccional y renograma diurético. El tratamiento se realizó mediante dilatación endoscópica retrógrada bajo control radioscópico. Los balones utilizados eran en todos los casos semicompliantes, con un perfil de 5 mm, 6 mm ó 7 mm. Tras la dilatación se colocó stents tipo doble J de calibre y longitud en función del peso del paciente. Para obtener los resultados se analizan las ecografías y los renogramas diuréticos por lo menos 1 año después de la intervención. Resultados: La duración media de la intervención fue de 36,4±15,5 minutos. Durante la intervención, en 2 pacientes no fue posible la colocación del stent, El tiempo de ingreso fue de 48 horas en todos los pacientes excepto en 1 de ellos. Las necesidades analgésicas fueron exclusivamente AINES. El stent tipo doble J fue retirado mediante cistoscopia de manera ambulatoria. En 3 pacientes hubo complicaciones postoperatorias: una migración del stent, una ITU y un urinoma. La técnica fracasó en 1 paciente que necesitó de pieloplastia desmembrada. En los controles se observó la desaparición de la hidronefrosis en todos los casos, desapareciendo así mismo la dilatación de los cálices renales. El renograma diurético MAG-3 mejoró en todos los lactantes, siendo el patrón de la curva normal en 14 casos y semiobstructivo en 2. El tiempo medio de eliminación fue de 9,8±2,8 minutos. Conclusiones: Pensamos que la dilatación con balón es una técnica mínimamente agresiva que es posible realizar en pacientes menores de 1 año con buenos resultados y escasas complicaciones (AU)

Aim: In the last years it has spread minimally invasive therapeutic for the treatment of pyeloureteral junction obstruction in children. Some of them have got poor outcomes in 4-year-old minor children. We show our experience in the retrograde dilatation with balloon of high pressure in infants. Methods: It´s a retrospective study of 16 infants treated in our hospital. The average follow-up after the intervention is 27.4±10.0months. The diagnostic protocol included abdominal ultrasound, cystogram and diuretic renography. The treatment was realized by endourology retrograde balloon dilatation under fluoroscopy. The balloons were in all the cases semicompliant, with a profile of5 mm, 6 mm ó 7 mm. After the expansion there was placed stents type double J with profile and length depending on the weight of the patient. To obtain the results, we do ultrasound scans and diuretic renography at least 1 year after the intervention. Results: The mean duration of the intervention was 36.4±15.5 minutes. During the intervention, in 2 patients the placement of thestent was not possible. The time of revenue was 48 hours in all the patients except in 1 of them. The analgesic needs were exclusively non steroid antiinflammatorys. The double J stent was withdrawn with cystoscopy. In 3 patients there were postoperatory complications: a migration of the stent, a urinary infection and an urinoma. In 1 patient with worsening of hydronephrosis was needed of pyeloplasty. In the controls the disappearance of the hydronephrosis was observed in all the cases, eliminating likewise the expansion of the renal calyces. The diuretic renography improved in all babies, being the boss of the curve normal in 14 cases and semi obstructively in 2. The mean time of elimination was 9.8±2.8 minutes. Conclusions: We think that the balloon dilatation of pyeloureteral junction obstruction is a minimally aggressive technique that is possible to realize in infants with good results and scanty complications (AU)