Novel influenza (H1N1) infection in pediatric renal transplant recipients: a single center experience

In 2009, novel influenza A H1N1 caused significant morbidity and mortality worldwide, particularly in children. Because they are immunocompromised, pediatric transplant recipients are presumed to be at high risk. This study assessed epidemiological characteristics, presenting symptoms, and clinical course among pediatric renal transplant recipients with confirmed H1N1 infection. A retrospective review was conducted in renal transplant recipients followed at The Hospital for Sick Children (Toronto) who contracted H1N1 infection between June and November, 2009. Epidemiological, clinical, and laboratory features at presentation, and clinical course were analyzed. Of 59 children, 14 (23.7%) developed H1N1 infection. Children with H1N1 infection had undergone kidney transplantation more recently than their uninfected counterparts. The most common symptoms included fever (92.9%), cough (85.7%), headache (42.9%), and vomiting (42.9%). Fifty percent of patients required hospitalization, of median duration 3.0 (1.0-5.0) days. No child required intensive care treatment. Half the H1N1-infected children had acute renal dysfunction, with serum creatinine elevated >10% above basal values (median increase 21.6 [14.3-46.2]%). In five of the seven children, serum creatinine returned to baseline within two wk. These findings indicate that H1N1 influenza infection in pediatric kidney transplant recipients followed at our center was surprisingly mild, and produced no lasting sequelae.     

Changes in natural killer cell subsets in pediatric liver transplant recipients

NK cells are important in the immune response against tumors and virally infected cells. A balance between inhibitory and activating receptors controls the effector functions of NK cells. We examined the fate of circulating NK cells and the expression of the NK cell-activating receptors in pediatric liver transplant recipients. Blood specimens were collected from 38 pediatric liver transplant recipients before transplant, and at one wk, one, three, six, and nine months, and one yr post-transplant. PBMCs were isolated and analyzed for the levels of NK cell activation receptors NKp30, NKp46, and NKG2D in the CD56(dim) CD16(+) and CD56(bright) CD16(+/-) subsets of NK cells. We demonstrated that there is a significant decrease in the percentage of circulating NK cells post-transplant (pretransplant 7.69 ± 1.54 vs. one wk post-transplant 1.73 ± 0.44) in pediatric liver transplant recipients. Interestingly, NKp30 expression is significantly increased, while NKp46 and NKG2D levels remain stable on the NK cells that persist at one wk post-transplant. These data indicate that the numbers and subsets of circulating NK cells are altered in children after liver transplantation.     

Factors predicting persistent thrombocytopenia after living donor liver transplantation in pediatric patients

Thrombocytopenia is common after LT for pediatric end-stage liver diseases. Seventy-six pediatric patients (≤15 yr old) who underwent LDLT were evaluated for the incidence and predictive factors of post-transplant thrombocytopenia (PLT <100, 000/mm(3) ). The prevalence of thrombocytopenia at two wk and at 12 months post-transplant was 22/76 (28.9%) and 11/62 (17.7%), respectively. Thrombocytopenia at two wk after LDLT was significantly associated with age at transplant, preoperative PLT, GRWR, acute rejection, and CMV infection in univariate analysis. Moreover, preoperative PLT, GRWR, and acute rejection had a strong correlation in multivariate analysis. Thrombocytopenia at 12 months after LDLT was associated only with preoperative PLT. We also demonstrated that vascular complications caused thrombocytopenia and that successful treatment recovered the PLT. These results showed that, in addition to considering the preoperative PLT, post-operative monitoring of platelets is very helpful for the early detection of adverse events related to the graft liver in pediatric liver transplant patients.     

Impact of donor cardiopulmonary resuscitation on pediatric heart transplant outcome

Mortality is the highest of any solid organ in pediatric patients awaiting heart transplantation. Strategies to increase the donor pool are needed if survival to transplant is to improve. There can be reluctance to accept pediatric hearts for transplantation if the donor has received cardiopulmonary resuscitation (CPR). This study asked if donor CPR impacts the survival of pediatric heart transplant recipients. Analysis of the UNOS database was performed for all cardiac transplants performed in patients aged 0-18 yr, with donors classified as to whether they received CPR (CPR+) or not (CPR-). We compared overall survival and survival at 30 days, one yr, and five yr between groups. Within the CPR+ group, the impact of duration of CPR on survival was compared. The need for inotropic support and ejection fraction was compared between donor groups as a measure of organ function. Overall survival and survival at 30 days, one yr, and five yr did not differ in the CPR+ compared to the CPR- group. Within the CPR+ group, duration of CPR was unrelated to post-transplant survival. The need for inotropic support at procurement was similar, and ejection fraction did not differ between the CPR+ and CPR- groups. Donor CPR does not have a negative impact on pediatric heart transplant survival.     

Five years' experience with thymoglobulin induction in a pediatric renal transplant population

Antibody induction therapy is used in the majority of pediatric patients undergoing renal transplantation. Our center has previously reported short-term outcomes with TMG as induction therapy. We now present our experience over the last five yr. Patients received TMG intra- and post-operatively at a dose of 1.5 mg/kg/day. The dose was decreased to 0.75 mg/kg/day or held dependent on the patient's WBC and platelet counts. Post-transplant immunosuppression also included corticosteroids, MMF, and either TAC or CSA. Patient and graft survival, number of acute rejection episodes, creatinine clearance, incidence and type of infections, and trough levels of calcineurin inhibitor drugs were monitored during the follow-up period. Thirty-four renal transplants were performed in 33 pediatric patients ranging in age from 1.7 to 17.8 yr. Seventeen rejection episodes occurred during the time of follow-up with three patients having more than one episode, but only three episodes occurred within the first year after transplantation. Three patients had graft loss in the first week after transplantation from primary non-function (1) or technical failure/thrombosis (2). Graft losses occurred in seven additional patients during the time of follow-up with the first loss occurring at 17.7 months. Among patients with functional grafts at one wk after transplant, graft survival at one and three yr was 100% and 73% respectively. There were no patient deaths. There were no cases of post-transplant lymphoproliferative disease or other malignancy. One patient had symptomatic CMV disease. TMG is safe and effective as induction therapy in pediatric renal transplant patients. Late graft loss remains a challenge in the pediatric patient population, particularly in adolescents.     

Outcomes of Pneumocystis jiroveci pneumonia infections in pediatric heart transplant recipients

PJP is known to cause significant morbidity and rarely death in immunosuppressed patients. The prevalence and outcomes of PJP in pediatric solid-organ transplant patients are not well established. This study utilizes data from the PHTS to establish the prevalence and outcome of PJP in pediatric heart transplant recipients. We conducted a retrospective cohort study using data from the PHTS, including data from 24 institutions between January 1, 1993, and December 31, 2004. Infections that occur in PHTS subjects are recorded in a standardized data collection form. The prevalence and outcomes of PJP in pediatric heart transplant recipients were determined. There were a total of 18 patients (1%) with PJP out of the 1854 pediatric heart transplant recipients in the PHTS database. A majority of PJP occurred two months to two yr post-transplant, and patients with PJP had a significantly decreased mortality compared with other fungal infections. PJP is an infrequent complication experienced by pediatric heart transplant recipients. Patients that have experienced PJP have an increased survival compared to patients with other fungal infections, and most PJP occurred within two yr of transplant.     

Oseltamivir-resistant 2009 H1N1 influenza pneumonia during therapy in a renal transplant recipient

The emergence of oseltamivir-resistant 2009 H1N1 influenza virus (conferred by the H275Y substitution in NA) during therapy or prophylaxis in immunocompromised patients is a serious concern. The optimal therapy for immunosuppressed patients with oseltamivir-resistant 2009 H1N1 influenza virus is unknown and few options exist. We report a 10-yr-old recipient of kidney transplant who was hospitalized with oseltamivir-resistant 2009 H1N1 influenza pneumonia complicated by severe respiratory failure, ARDS, and renal failure requiring institution of ECMO and CRRT. On presentation, treatment with oseltamivir (second course) and broad-spectrum antibiotics was initiated. Immunosuppressive agents were stopped on hospital day (d) 2. On hospital d 7, given his critical status, immunocompromised state, and difficulty in obtaining intravenous zanamivir, after obtaining ethical approval and parental consent, he was treated with intravenous peramivir (through an Emergency Investigational New Drug Application) for two wk. He tolerated the regimen well and his clinical status improved gradually. Several factors may have contributed to virus clearance and survival including recovery of the immune system, aggressive critical care support, and administration of peramivir. Ongoing surveillance is essential to monitor how oseltamivir-resistant H275Y mutant viruses may evolve in the future.     

Sirolimus in pediatric gastrointestinal transplantation: the use of sirolimus for pediatric transplant patients with tacrolimus-related cardiomyopathy

Hypertrophic obstructive cardiomyopathy (HOCM) associated with the use of tacrolimus is a rare complication of liver and intestinal transplantation seen almost exclusively among pediatric patients. Reduction of tacrolimus dosage or conversion to cyclosporin A (CsA) has been used as an effective treatment in reviewed cases. We present three pediatric transplant recipients who developed hypertrophic obstructive cardiomyopathy while under tacrolimus immunosuppression and were treated with conversion to sirolimus (Rapamycin). The patients (ages 6 yr, 12 yr and 11 months) were transplant recipients (liver, n = 2; liver and intestine, n = 1) who developed significant cardiomyopathy 15 and 96 months post-transplant. One patient died of post-transplant lymphoproliferative disorder 21 days after starting sirolimus. One patient had received two liver transplants and had been on CsA for 12 yr before conversion to tacrolimus at 60 months post-transplant for acute and chronic rejection. The surviving patients were receiving mycophenolate mofetil, tacrolimus and steroids at the time of diagnosis. Dose reduction of tacrolimus and treatment with beta blockers failed to alleviate the hemodynamic changes. The patients were converted to sirolimus 1.6, 37 and 148 months post-transplant and maintained a whole-blood trough level of 15-20 ng/mL 21 days after starting sirolimus. Repeat echocardiograms in the surviving patients showed improvement in cardiomyopathy. One patient had one rejection episode (intestinal biopsy, mild acute cellular rejection) after starting sirolimus that responded to a transient increase in steroids. The early demise of the third patient after sirolimus conversion prevented an adequate assessment of cardiomyopathy. Conversion to sirolimus was associated with a reduction in the cardiomyopathy of the two surviving patients while still providing effective immunosuppression. To our knowledge this observation has not been previously reported.     

Neurologic adverse events following influenza A (H1N1) vaccinations in children

Background: Since the monovalent pandemic influenza A (H1N1) vaccine was recommended worldwide in October 2009, there has been a shortage of pediatric clinical data for post‐vaccine neurologic adverse events (NAE), including Guillain–Barré syndrome. We reviewed pediatric NAE data following H1N1 vaccinations and for patients with peripheral neuropathy, we followed their progress. Methods: In our single‐center study, we retrospectively reviewed 14 cases of children who visited the Division of Pediatric Neurology in the Department of Pediatrics of Chonnam National University Hospital due to NAE following monovalent influenza A (H1N1) vaccination between November 2009 and March 2010. Results: Clinical diagnoses for major NAE included: polyneuropathy in the extremities (11/14, 78.6%), sensory mononeuropathy with numbness in the left fibula area (1/14, 7.1%), Bell's palsy (1/14, 7.1%) and recent‐onset acute headache only (1/14, 7.1%). Therefore, most patients were diagnosed as having peripheral neuropathy (13/14, 92.9%), and two met the Brighton Collaboration Guillain–Barré syndrome definition criteria for level 3 (the lowest level of diagnostic certainty). Conclusions: Post‐vaccine NAE were mainly motor weakness due to polyneuropathy, which had a good prognosis of complete improvement within a few months without sequelae.     

Prevalence and clinical significance of human herpesviruses 6 and 7 active infection in pediatric liver transplant patients

Recent studies in adult liver transplant patients have suggested that both human herpesvirus (HHV)-6 and HHV-7 infection are important causes of morbidity following liver transplantation. However, the impact of HHV-6 and -7 infection in pediatric liver transplant patients remains largely unknown. The aims were to determine the prevalence of HHV-6 and -7 infection in pediatric liver transplant patients and to determine whether there is an association between HHV-6 and -7 infection with episodes of graft rejection and cytomegalovirus (CMV) infection. A total of 46 pediatric liver transplant patients transplanted at Mayo Clinic between January 1994 and January 2000 were evaluated. Quantitative polymerase chain reaction (PCR) assays for CMV, HHV-6 and HHV-7 were performed on stored sera obtained prior to transplant, weekly for 8 wk and at 4 months and 1 yr post-transplant. Pretransplant sera were tested for HHV-6 antibodies by indirect immunofluorescence assay. A total of 215 blood samples were tested (mean 6.5 +/- 3.1, range 3-18). CMV infection occurred in 11 of 33 (33.3%) patients, while CMV disease occurred in 4 of 33 (12%) patients. Infection with HHV-6 (variant B) was detected in three of 33 (9.1%) patients. HHV-7 infection was not detected. Case 1 and 2 were infants (10- and 11-month old, respectively). Both were seronegative for HHV-6 pretransplant. In both cases, HHV-6 infection was associated with concurrent episodes of moderate to severe acute graft rejection. Case 3 was a 16-yr-old girl who was seropositive for HHV-6 pretransplant. No clinical events were recorded and a liver biopsy performed per protocol showed no evidence of rejection. None of the three patients had concomitant CMV infection or disease. In this study, HHV-6 infection occurred in 9% of pediatric liver transplant patients while HHV-7 was not detected. A potential association between primary HHV-6 infection and allograft rejection warrants further investigation.     

Perioperative renal failure in pediatric heart transplant recipients: outcome and risk factors

PRF is encountered in 10-13% of adult heart transplants. Only one study of a single center's experience with PRF has been reported in pediatric patients. This study examines the effect of PRF on pediatric heart transplant outcome using the UNOS database. A total of 3598 patients met inclusion criteria, of whom 254 (7%) had PRF. The PRF group comprised 31 recipients requiring PRE and 223 recipients requiring POST. Compared with No-PRF patients, PRE patients had similar survival rate and POST patients had decreased survival rate at 30 days, one, five, and 10-yr post-transplant (p < 0.001). PRF patients also had significantly lower graft survival at one, five, and 10 yr (p < 0.001). Risk factors for developing PRF included ECMO, ventilator, and inotropic support at listing and CHD as the listing diagnosis. PRF increased the duration of hospital stay and the incidence of chronic severe renal dysfunction. PRF that requires POST (whether or not it began pretransplant) has a significant negative impact on pediatric heart transplant outcome. Specific characteristics identify patients at particular high risk of developing PRF.     

Cholelithiasis in infant and pediatric heart transplant patients

There have been numerous studies which demonstrate a relatively high incidence of gallstones in adult solid-organ transplant recipients receiving cyclosporin A (CsA) immunosuppression. The purpose of the present study was to investigate our experience with cholelithiasis in babies and children undergoing heart transplant (HTx). From May 1985 to December 1998, 311 neonatal and pediatric cardiac transplants were performed at our institution. Routine abdominal ultrasound was performed at 3 months, 1 yr, and bi-annually thereafter on all transplant recipients. Asymptomatic or symptomatic gallstone development was detected during abdominal ultrasound in 10 of 311 patients (3.2%). Eight of these 10 patients (80%) were transplanted when younger than 3 months of age. Eight per cent of all infants transplanted at < 3 months of age developed cholelithiasis (p < 0.05 compared to older age at HTx). Fifty per cent of gallstones were detected and treated within 6 months post-HTx, while the remaining 50% of patients with gallstones underwent cholecystectomy 3-6 yr later. Only 20% (two of 10) had symptoms of cholelithiasis/cholecystitis. Five patients (50%) underwent laparoscopic cholecystectomy. Only one patient older than 1 yr of age, who was symptomatic, underwent open cholecystectomy. There were no complications from surgery. There were no differences in liver function tests or cholesterol levels in transplant recipients with or without gallstones, and all mean values were within normal limits. Hence, although the incidence of pediatric post-transplant cholelithiasis in infant and pediatric heart transplant recipients is low, almost all occurrences are associated with HTx during early infancy and, because of this, patients in this group should be routinely screened. Laparoscopic or open cholecystectomy are extremely well tolerated and we recommend that surgery be performed when cholelithiasis is found in pediatric heart treatment patients.     

Assessment of parental report for 2009-2010 seasonal and monovalent H1N1 influenza vaccines among children in the emergency department or hospital

ObjectiveTo assess the validity of parental report for seasonal and monovalent H1N1 influenza vaccinations among children 6 months to <18 years who were recommended to receive both vaccines in 2009–2010.MethodsChildren with fever or respiratory symptoms were prospectively enrolled in both emergency departments in Forsyth County, North Carolina, and the only pediatric hospital in the region. Enrollment occurred from September 1, 2009, through April 12, 2010, during the H1N1 influenza pandemic. A parental questionnaire was administered by trained interviewers to ascertain the status of seasonal and monovalent H1N1 influenza vaccines. Parental report was compared with that documented in the medical record and/or the North Carolina immunization registry.ResultsAmong 297 enrolled children 6 months to <18 years of age, 174 (59%) were 6 months to 4 years, 67 (23%) were 5–8 years, and 56 (19%) were 9 to <18 years. Parents reported that 140 (47%) children had received ≥1 dose of 2009–2010 influenza vaccine—128 (43%) for seasonal vaccine and 63 (21%) for H1N1 vaccine. Confirmed vaccination data indicated that 156 (53%) children had received ≥1 dose of any 2009–2010 vaccine—120 (40%) for seasonal vaccine and 53 (18%) for H1N1 vaccine. Parental report of any seasonal influenza vaccination was 92% sensitive and 86% specific and had a kappa of 0.76. Parental report for any H1N1 influenza vaccination was 88% sensitive and 92% specific with a kappa of 0.71.ConclusionsParental report of 2009–2010 seasonal and monovalent H1N1 influenza vaccinations was sensitive and specific and had reasonable agreement with the medical record and/or immunization registry.     

儿童2009甲型H1N1流感危重症14例临床特征

目的 分析儿童2009甲型H1N1流感危重症的临床特征.方法 对2009年10月1日至12月25日,我院儿科重症监护病房(PICU)14例2009甲型H1N1流感危重症患儿的临床特征及其预后进行分析.结果 14例平均年龄(4.91±4.14)岁,男女各7例,发病到入院时间为(3.09±1.30)d,从入院到入PICU时间为(0.95±0.96)d,所有患儿均表现出明显的低氧血症,入ICU时平均PaO2/FiO2(氧合指数)为(191.27±80.58)mm Hg(1 mm Hg=0.133 kPa),11例(78.6%)出现ARDS,10例(71.4%)行机械通气,平均通气时间为(12.51±10.03)d,平均ICU住院时间为(12.58±10.65)d,平均rRT-PCR检测甲型H1N1核酸呈阳性时间(17.27±5.57)d;8例(57.1%)患儿有缺铁性贫血、脑瘫和先天性心脏病等基础疾病;CK(肌酸激酶)、CK-MB(肌酸激酶同工酶)、cTnI(肌钙蛋白)和LDH(乳酸脱氢酶)在这些患儿中都有不同程度的升高;入院时第3代死亡危险评分(PRISM Ⅲ)较高和危重病例评分(PCIS)较低的患儿机械通气时间和ICU住院时间较长(P＜0.05).结论 苏州地区儿童2009甲型H1N1流感危重症病情进展快,短时间内即出现显著的低氧血症,甚至ARDS,并伴有不同程度的心肌损害,早期发现不利因素加以干预,是治疗成功的关键.     

八例儿童重症甲型H1N1流感病例临床分析

目的 分析儿童重症甲型H1N1流感病例的临床特征.方法 总结8例重症甲型H1N1流感病例的临床表现和诊治经过.结果 8例患儿均否认传染病接触史.4例有基础疾病,分别为肾病综合征、先天性甲状腺功能低下症、支气管哮喘及贫血.8例均有咳嗽和发热,咳嗽有痰,高热为主(5例),均有气促,出现在病程0.5～6 d,且进行性加重,3～24 h后出现呼吸衰竭;X线胸片为局限性渗出病变,类似支原体肺炎表现;血常规示7例中性粒细胞比例升高,6例CRP明显升高;均伴有呼吸衰竭,2例并发中毒性脑病.8例患儿均予抗病毒药物和脏器支持治疗,均使用了丙种球蛋白,部分患儿使用了皮质激素治疗,6例需要呼吸机支持,机械通气时间3～6 d,无一例死亡.结论 儿童重症甲型H1N1流感多是以严重低氧血症为突出表现的重症肺炎,经过及时有效的干预可避免严重急性呼吸窘迫综合征的发生,降低病死率.     

Variability in tacrolimus blood levels increases the risk of late rejection and graft loss after solid organ transplantation in older children

Late graft rejection impairs the long-term function of organ transplants in children. Previous studies suggest patients with wide variation in tacrolimus levels may have higher rates of late kidney and liver graft rejection. The reproducibility of this finding and impact on graft and recipient survival have not been reported. We investigated factors associated with late rejection > 6 months post-transplant in 144 heart, kidney, liver, and lung transplant recipients (ages 8-18, ≥ 1-yr survivors, receiving tacrolimus-based immunosuppression), comparing late rejectors (n = 61, 42%) to non-rejectors (no rejection > 6 months); groups had similar mean tacrolimus concentrations ≤ 6 months post-transplant. For all organ types, increased standard deviation in intrapatient tacrolimus blood levels was an independent risk factor for late rejection (OR 1.6 [CI 1.1-2.1]; p = 0.02). Each 1-point increase in s.d. > 2 of tacrolimus level > 6 months post-transplant associated with 1.58 increase in hazard of graft loss (p = 0.003). Graft survival (conditional on one-yr survival) was significantly better for those with s.d. < 2 at > 6 months post-transplant: 98% at three and five yr, versus 88%, 70%, at three and five yr, in patients with s.d. > 2 (p = 0.003). In conclusion, high s.d. in serial tacrolimus concentrations associated with increased risk of late rejection and graft loss in pediatric organ transplant recipients, providing opportunities for screening and interventions.     

Immunogenicity of pandemic influenza A H1N1/2009 adjuvanted vaccine in pediatric solid organ transplant recipients

The aim of this study was to assess the immunogenicity of a vaccine against this virus in a prospective cohort of transplanted pediatric patients without previous influenza infection who received one dose of MF59^®‐adjuvanted pandemic H1N1/2009 vaccine. Seventeen patients who were being regularly followed up at the Outpatient Clinic of the Children's Transplant Unit (liver and kidney transplantation) in Hospital Universitari Vall d′Hebron (Barcelona) were included. Seroconversion was demonstrated in 15 of 17 (88.2%) vaccinated children. There were no rejection episodes or major adverse events. The MF59^®‐adjuvanted pandemic H1N1/2009 vaccine was safe and elicited an adequate response.     

Prospective, randomized, placebo-controlled evaluation of the safety and immunogenicity of three lots of intranasal trivalent influenza vaccine among young children.

BACKGROUND: Trivalent formulations of an experimental, cold-adapted, intranasal influenza (CAIV) vaccine have been shown to be safe, immunogenic and efficacious in young children. METHODS: We evaluated the safety and immunogenicity of three consistency lots of CAIV in children 12 to 36 months of age randomized to one of five groups: Groups 1, 2 and 3 received separate lots containing A/Shenzhen/227/95 (H1N1), A/Wuhan/359/95(H3N2) and B/Harbin/7/94-like viral strains. Group 4 received an earlier efficacy trial lot which included a different H1N1 strain (A/Texas/36/91-like); and Group 5 received placebo. We performed strain-specific serum hemagglutination inhibition antibody levels against type A (H3N2 or H1N1) or type B as appropriate. RESULTS: Overall 474 children received 2 doses, 2 months apart. Each lot was well-tolerated, and there were no significant group differences between consistency lots in the proportion of children with fever and local or systemic reactions after vaccination. The 3 consistency lots were not statistically different with regard to immunogenicity as measured by seroconversion or absolute geometric mean titer. Immune responses were more robust among initially seronegative children and for H3N2 and B strains than for H1N1 strains. After 2 doses of vaccine 97, 84 and 62% had hemagglutination inhibition titers > or = 1/32 against A/H3N2, B and H1N1 strains, respectively. For A/H3N2 only, immune responses after 1 dose of vaccine are similar to those seen after 2 doses. CONCLUSIONS: Each consistency lot of CAIV is as or more immunogenic than a lot used in a large efficacy trial.     

Live attenuated influenza vaccine induces cross-reactive antibody responses in children against an a/Fujian/411/2002-like H3N2 antigenic variant strain

Serum antibody titers against the A/Panama/2007/99(H3N2) and A/Fujian/411/2002(H3N2)-like viruses were determined in children 6-35 months of age who received either 1 dose of the inactivated influenza vaccine or the live attenuated influenza vaccine containing the A/Panama strain. Results indicated that the live vaccine induced higher antibody responses than the inactivated vaccine against the A/Panama and A/Fujian-like viruses.     

The profile of renal function over time in a cohort of pediatric heart transplant recipients

Abstract:  To assess the burden over time of renal dysfunction in pediatric heart transplant patients using an objective measure on an annual basis for serial comparison. GFR was measured at regular interval by nuclear medicine scintigraphy. Results were analyzed in relation to age, time post-transplantation, gender, and average calcineurin-inhibitor dose for the first two months post-transplantation. Results were compared with cGFR using the Schwartz equation. A total of 91 patients (56 males) transplanted between 1990 and 2004 underwent 373 GFR measurements. Median age at transplantation was 3.3 yr (birth – 17.8). Median first GFR at 0.7 yr (0.1–4.1) post-transplant was normal (94 mL/kg/1.73 m²). Freedom from at least mild renal insufficiency was 84% and 33% at one and five years post-transplant. Females had better renal function early post-transplant (GFR 105 mL/min/1.73 m²) but an increased probability of an abnormal GFR over time. Higher calcineurin inhibitor dose in the first two months post-transplantation was associated with an increasing probability of an abnormal GFR over time. The cGFR overestimated the measured GFR by 33 ± 26 mL/kg/1.73 m². Renal insufficiency is an important morbidity after pediatric transplantation with the majority of patients experiencing at least mild renal dysfunction. Calculated GFR significantly underestimates the burden of renal insufficiency in this patient population.