Cross-sectional study of BK virus infection in pediatric kidney transplant recipients

BKV reactivation is associated with impaired graft function in adult kidney transplant patients. The clinical impact of BKV infection in the pediatric transplant population has not yet been fully evaluated. The objective of our study was to determine the prevalence of BKV infection in consecutive pediatric kidney transplant recipients in our center. Forty consecutive unselected pediatric kidney transplant recipients were studied. Mean age at screening was 15.6 +/- 5.3 yr and samples were obtained a median of 60.5 months after transplantation (3-123). BKV-DNA was analyzed in urine and plasma by qualitative nested-PCR. A review of the literature was performed. Prevalence of viruria and viremia was 50% and 12.5%, respectively. Viremia was associated with the presence of hematuria (p = 0.02). The mean creatinine level in children without BKV replication was 1.6 mg/dL, BKV viruria was 0.9 mg/dL, and BKV viremia was 0.8 mg/dL. A literature review showed that viruria and viremia were found in 28.2% and 8.5% of cases, respectively; BKV nephropathy was found in 3.8% and graft loss in 11% of the patients with BKV nephropathy and in 0.4% of the children studied. Recipient serostatus was the most important risk factor. The rate of BKV replication and nephropathy among pediatric kidney recipients is similar to that of adults, but the incidence of graft loss is significantly lower.     

BK virus nephropathy in a pediatric heart transplant recipient with post‐transplant lymphoproliferative disorder: A case report and review of literature

BKV is known to cause allograft failure in kidney transplant recipients. It has been recently recognized to cause native kidney nephropathy in non‐kidney transplant recipients. This is a case report BKVN in a 15‐yr‐old HTx recipient who had PTLD and a review of pediatric cases in the literature. The patient was diagnosed with BKVN +189 months after transplantation and died thirty days after diagnosis of BKVN. We identified five other cases of BKVN in pediatric non‐kidney solid organ transplantation, of which all were HTx recipients. Overall, outcome was poor and BKV clearance was not achieved with reduction of immunosuppression and with current therapies. We strongly recommend that pediatric HTx recipients be tested for BKV infection if there is evidence of kidney dysfunction. We also recommend that they have an annual screening for BKV viruria and viremia with the assessment of kidney function.     

Pretransplant serologic testing to identify the risk of polyoma BK viremia in pediatric kidney transplant recipients

This study investigated the age-related prevalence of a prior polyoma BKV infection at the time of transplantation and association with subsequent development of BKV viremia. We measured BKV-specific antibody titers in stored serum samples obtained before transplantation in 94 pediatric kidney transplant recipients (in a single-center, retrospective analysis) and 40 matched donors from 1986 to 2007. Titers were categorized as LOW or HIGH serostatus at titers of ≤ 1:2560 and ≥ 1:10 240, respectively. Of these, 36 recipients transplanted since 2002 were prospectively screened for BKV viremia. Seventeen percent of recipients aged 0-6 yr had HIGH BKV serostatus compared with 73% of older recipients (p < 0.002). The prevalence of HIGH donor BKV serostatus was 73%. Five prospectively screened patients (14%) developed early BKV viremia, and an additional 4 (11%) had late onset of BKV viremia. There were three cases (8%) of BKVAN. LOW BKV serostatus was significantly associated with early BKV viremia (p = 0.02). Donor HIGH to recipient LOW (HIGH/LOW) had the highest risk of BKV viremia (4/7; 57%), compared with LOW/LOW (0/3; 0%) and recipient HIGH (1/26; 4%) (p = 0.004). BKV IgG titers are low in young pediatric kidney transplant recipients, and LOW BKV serostatus is associated with an increased risk of early BKV infection post-transplant, particularly in the context of donor with HIGH BKV serostatus.     

BK viral infection in an Australian pediatric renal transplant population

BK virus (BKV) is recognized as a significant cause of renal allograft dysfunction in adults, and there is growing awareness of its importance in the pediatric population. Eighteen pediatric renal transplant recipients and 18 age-matched controls were prospectively studied. Anti-BKV immunoglobulin G (IgG) and IgM titres were assayed in all subjects at entry to the study. Polymerase chain reaction (PCR) for BKV DNA was performed on urine and serum at entry, and prospectively tested again at 4, 8 and 12 months. Mean age +/- s.d. of transplant recipients and controls was 14.6 +/- 3.3 and 13.9 +/- 0.33 yr respectively [not significant (NS)]. Transplant patients were studied at a mean time of 5.6 +/- 4.2 yr post-transplant. 56% of transplant patients and 39% of controls were seropositive (+ve BKV IgG) (NS). Plasma BKV PCR was positive in one transplant patient (who also had positive urine PCR) and in none of the controls. The prevalence of positive urine PCR in transplant patients was greater than in controls (33% vs. 0%, p = 0.02). Positive urine BKV PCR was more commonly found in patients treated with mycophenolate than azathioprine (p = 0.04). We conclude that the prevalence of BKV seropositivity and viral activation in this Australian pediatric renal transplant population is similar to that reported in adult and pediatric populations in other countries. BK viruria was more common in children with greater immunosuppression, suggesting that this group is at higher risk of BKV induced nephropathy.     

Prevalence of polyomavirus viruria (JC virus/BK virus) in children following liver transplantation

Brinkert F, Briem-Richter A, Ilchmann C, Kemper MJ, Ganschow R. Prevalence of polyomavirus viruria (JC virus/BK virus) in children following liver transplantation.
Pediatr Transplantation 2010: 14: 105–108. © 2009 John Wiley & Sons A/S.
Abstract:  BKV infection is a potential cause of renal dysfunction in non-renal organ transplant recipients. JCV is the causative agent of PML. Furthermore, polyomaviruses are tumor inducing viruses and molecular data suggest an association with malignancies among solid organ transplant patients. So far, there are no studies analyzing polyomavirus viruria following Ltx in children. We performed a prospective prevalence study at a mean of 2187 (range 20–5671) days after transplantation in 100 consecutive children admitted for the routine follow-up examination post-Ltx. The urine was screened for BKV and JCV DNA by using PCR in each case. A plasma analysis by PCR was also done if more than 100 000 DNA copies/mL urine were detected. BKV or JCV viruria was found in 19% (n = 19) of our patients. All patients were free of clinical signs of viral infection, PML, or nephropathy. GFR was normal in 97% of patients and we found no statistical difference of kidney function between patients with and without BKV/JCV viruria. The extent of immunosuppressive therapy had no influence on the polyomavirus viruria. Overall, we found a higher prevalence of polyomavirus viruria in our pediatric liver transplant recipients than reported in adult patients.     

BK polyomavirus infection in pediatric heart transplant recipients: a prospective study

BKV infection and nephropathy complicate pediatric HTx, but the incidence and time course of the disease are unknown. We assessed the incidence of BKV infection and its association with kidney dysfunction in pediatric HTx recipients. A single center prospective study compared pediatric (<18 years) HTx recipients, with and without BKV infection, who received an allograft between September 2013 and December 2014. Screening of urine for BKV was performed prior to transplant, and at week 1, and at months 3, 6, 9, 12, and 15 months post‐transplantation. Serum for BKV DNA was assayed if BK viruria was present. Statistics included Fisher's exact test and Student's t test. Twelve patients were enrolled. Two patients were removed per parent request. Two (20%) had BK viruria and one (10%) had BK viremia. No patients developed BKVN. BK viruria was present within 2 months following transplantation. There were no identifiable risk factors for BKV infection and no statistically significant difference in renal function between the groups; however, there was a trend toward worsening renal function in those with BKV infection. BKV infection can occur early following heart transplantation. Screening for BK viruria should be considered in HTx recipients.     

Post-transplantation lymphoproliferative disorder in pediatric kidney-transplant recipients - A national study

Cleper R, Ben Shalom E, Landau D, Weissman I, Krause I, Konen O, Rahamimov R, Mor E, Bar‐Nathan N, Frishberg Y, Davidovits M. Post‐transplantation lymphoproliferative disorder in pediatric kidney‐transplant recipients – A national study. Abstract: PTLD is the most common malignancy in pediatric kidney‐transplant recipients. We examined the prevalence, clinical features, and outcome of PTLD in Israel. Twelve (4.4%) of 272 pediatric (<19 yr) kidney‐transplant recipients retrieved from a search of the NIKTR for 1991–2008 had acquired PTLD at a median of 3.2 yr post‐transplantation. PTLD‐affected patients were younger at transplantation (4.2 vs. 12.5 yr, p = 0.02), had a higher rate of OKT3 therapy for acute rejection (25% vs. 4%, p = 0.015), and 5/12 were EBV‐seropositive at transplantation. Graft dysfunction was the presenting sign in six (50%). PTLD was predominantly abdominal (83%) and B‐cell type (67%); T‐cell PTLD occurred exclusively in EBV‐seropositive patients. Treatment consisted of immunosuppression cessation (6/12, 50%), antiviral agents (7/12, 58%), anti‐CD20 monoclonal antibodies (4/12, 33%), and chemotherapy (6/12, 50%). Survival was 100% in the EBV‐naïve patients and 40% in the EBV‐seropositive patients. Graft loss occurred in three of eight survivors (37.5%). PTLD‐associated mortality risk was older age: 11.2 vs. 3.4 yr, longer dialysis: 15 vs. 6.5 months, T‐cell type disease (75%), later PTLD onset: 6.35 vs. 1.9 yr post‐transplantation and era of transplantation (43% mortality before vs. 20% after 2001). Pretransplantation EBV‐seronegative status might confer a survival benefit with early detected PTLD. EBV‐seropositive patients are at risk for aggressive late‐onset lethal PTLD.     

Cost‐efficient screening for BK virus in pediatric kidney transplantation: A single‐center experience and review of the literature

Laskin BL and Goebel J. Cost‐efficient screening for BK virus in pediatric kidney transplantation: A single‐center experience and review of the literature.
Pediatr Transplantation 2010: 14:589–595. © 2010 John Wiley & Sons A/S. Abstract: BKVNP is an increasingly recognized cause of graft dysfunction and loss in kidney transplant recipients. Protocols for BKV screening and for the diagnosis of BKVNP are still evolving. PCR‐based BKV detection became available at our institution in 2007, when we began using it according to published guidelines. We subsequently reviewed our experience with urine and plasma BKV PCR testing in our pediatric kidney transplant recipient population. We found rates of viruria, viremia, and BKVNP that were similar to the published literature. We also conducted a cost analysis suggesting that urine PCR testing, as used by us, is not cost efficient in the detection of BKV. We conclude that plasma only‐based PCR testing for BKV may be sufficient in most clinical settings.     

The potential of steroids and xenobiotic receptor polymorphisms in forecasting cyclosporine pharmacokinetic variability in young kidney transplant recipients

Ferraresso M, Turolo S, Belinghieri M, Tirelli AS, Grillo P, Groppali E, Edefonti A, Ghio L. The potential of steroids and xenobiotic receptor polymorphisms in forecasting cyclosporine pharmacokinetic variability in young kidney transplant recipients. Abstract: The steroids and xenobiotics receptor (SXR) up‐regulates the expression and the synthesis of key enzymes in CyA metabolism. In this study, we examined the possible interactions between CyA exposure and SXR polymorphisms during the first year after renal transplantation. The study involved 66 pediatric renal transplant recipients (25 women and 41 men, mean age 13.9 ± 7.4 yr). All patients were genotyped for two sequence variations in the NR1I2 gene: g.‐205_‐200delGAGAAG and 7635 A>G. CyA trough levels and CyA weight‐adjusted daily dose were recorded at 30, 90, 180, and 360 days after transplantation and compared between the different genotypes. A third newly discovered SXR polymorphism was characterized and also included in the study. CyA trough levels and CyA weight‐adjusted daily dose were comparable on four time points throughout the first year post‐transplant in all three groups. GEE showed a significant reduction in weight‐adjusted CyA daily dose in patients carrying the deletion of 6 bp in SXR with a significant group‐by‐time effect that persisted also when analysis was corrected for age, prednisone dose, and acute rejection episodes. In our group of patients, only the g.‐205_‐200delGAGAAG SXR polymorphism was able to influence the metabolism of CyA continuously, during the first year after transplantation.     

The impact of recipient BKV shedding before transplant on BKV viruria,DNAemia, and nephropathy post‐transplant: A prospective study

We previously demonstrated that detectable BKV replication in donor urine pretransplant was significantly associated with post‐transplant recipient BKV viremia. In this 4‐year prospective study, we assessed whether recipient BKV replication pretransplant was associated with post‐transplant viremia/BKV nephropathy. We studied 220 primary adult and pediatric organ transplant recipients for 490 person‐years and 2100 clinical visits. BKV viruria was detectable in 28 (16%), 26 adults and two children; and viremia in none pretransplant. Post‐transplant viruria occurred in all recipients with pretransplant BKV viruria, significantly more than in recipients without pretransplant viruria on univariate (P<.005) and multivariate analysis including type of organ transplanted and immunosuppression type (P .008). Time to post‐transplant viruria was significantly shorter in recipients with pretransplant viruria (P .01). By univariate and multivariate analysis, BKV viruria in recipients pretransplant did not impact post‐transplant BKV viremia (P=.97 and .97, respectively) even when stratified by type of organ transplant (kidney P=.6; liver P=.5). The peak serum and urine BKV PCR post‐transplant were not significantly different in patients with pretransplant BKV viruria and no one developed BK nephropathy. In conclusion, recipient BKV viruria prior to transplant predicts post‐transplant viruria but not viremia or BKV nephropathy.     

BK virus nephropathy in a pediatric autologous stem-cell transplant recipient

BK virus (BKV) is an increasingly identified cause of pathology in immunocompromised transplant recipients. BKV is a well-known cause of graft dysfunction following renal transplantation and has also been reported in the native kidneys of other solid organ recipients. Less commonly, BKV nephropathy occurs in allogeneic stem-cell transplant (SCT) recipients. We now describe the first reported case of BKV nephropathy after pediatric autologous SCT.     

BK virus-associated hemorrhagic cystitis in a pediatric lung transplant recipient

Abstract:  BKV was first postulated to be a potential pathogen in 1971 when it was isolated in the urine of a renal transplant recipient. The pathology of BKV is generally confined to the urinary tract. In renal transplant recipients, BKV has been associated with hemorrhagic cystitis, urethral stenosis, and interstitial nephritis. Reports of BKV infection in lung transplant recipients are limited to a few case reports in adult patients. A recent report revealed that up to 32% of adult lung transplant recipients may shed BKV in their urine without symptoms or renal dysfunction. To our knowledge, there are no published reports of pediatric lung transplant recipients with BKV-associated hematuria. We hereby report a case of BKV-induced hemorrhagic cystitis in a pediatric lung transplant recipient.     

Outcome of renal transplantation in children: a multi-center national report from Iran

The outcome of pediatric renal transplantation was previously reported by a single-center study at the year 2006. Therefore, we aimed to evaluate and report the characteristics and outcome of renal pediatric renal transplantation in a multi-center nationwide study. In this nationwide report, medical records of 907 children (≤18yr) with renal transplantation in eight major pediatric transplant centers of Iran were recorded. These 907 patients received a total of 922 transplants. All children who failed to follow-up were excluded. Rather than baseline characteristics, graft and patient outcomes were considered for survival analysis. For further analysis, they were divided into two groups: patients who had graft survival time more than 10yr (n=91) and the ones with graft survival time of equal or less than 10yr (n=831). Of 922 recipients, 515 (55.8%) were boys and 407 (44.2%) were girls with the mean age of 13.10 (s.d.=3.54) yr. DGF and AR were occurred in 10% and 39.5% of the transplanted children, respectively. Transplantation year, dialyzing status before transplantation, DGF, and AR were significant enough to predict graft survival in cox regression model (overall model: p<0.001). Nowadays, there is a successful live donor pediatric renal transplantation in Iran. Graft survival has improved in our recipients and now the graft survival rates are near to international standards.     

Outcome after renal transplantation in children: results of follow-up by nephrologists in a primary referral center

Pediatric patients who receive a kidney transplant require extended follow-up to monitor graft function and for management of complications. Because of convenience, most patients are sent back to the nephrologists who referred them for transplantation (the primary nephrologist) for long-term care. As a consequence, many pediatric nephrologists who provide this extended care are not associated with a transplant center. It is not known if this arrangement yields satisfactory outcomes for children and adolescents who receive a kidney transplant. The objective was to determine if clinical outcomes are satisfactory in pediatric renal transplant recipients who were followed up by their primary nephrologists after the procedure. A chart review was carried out on all renal transplant recipients seen in the renal clinic at Schneider Children's Hospital (SCH) from 1982 to 2001. Patients were eligible if they were followed up by the primary referring nephrologists at SCH for a minimum of 6 months after transplantation. Relevant demographic and clinical outcome data were compiled. Twenty-eight patients who received a total of 33 renal allografts [living related donors (LRD) 15 and cadaveric donors (CD) 18] were seen during the study period. The transplantations in 19 children (68%) were carried out at Montefiore Hospital (Bronx, NY, USA), while the rest were performed at other centers. There were three (11%) deaths, two LRD patients and one CD patient. The group of 25 surviving patients consisted of 17 males and eight females, age range 4-28 yr (mean 17.2 yr). The mean duration of renal allograft survival was 6.3 +/- 5.3 yr and the mean duration of follow-up was 6.1 +/- 5.3 yr. The most recent serum creatinine ranged from 0.5 to 3.8 mg/dL with a mean of 1.3 +/- 0.8 mg/dL. There were several complications including acute rejection, renal artery stenosis, and hydronephrosis in the allograft. The team of primary referring nephrologists successfully treated all of these except the child with hydronephrosis. The primary nephrologist who refers pediatric patients to a tertiary care transplant center can accomplish long-term follow-up of renal transplant recipients after discharge from the transplant center. The clinical outcomes are acceptable and compare favorably with the results described in the literature that have been achieved in patients followed up at transplant centers. Problems rarely developed that required referral back to the transplant center for management. This approach to care is recommended because it is more likely to foster compliance by both patients and parents.     

Rapid steroid discontinuation for pediatric renal transplantation: a single center experience

To determine the outcomes of pediatric renal transplant recipients who received immunosuppression consisting of early withdrawal of corticosteroids at a single Northern California center. Protocols using minimal steroid exposure have been recently reported in adult transplant recipients with successful results. We examined the outcomes of pediatric renal transplant recipients who were managed at our center using a protocol with very early discontinuation of steroids after renal transplantation. We retrospectively studied the medical records of all renal transplant recipients followed at the Children's Hospital at the University of California, Davis Medical Center from 01/2004 to 12/2005. All patients were less than 18 yr of age at the time of transplantation. The immunosuppressive protocol included three tapering daily doses of methylprednisolone, together with five doses of thymoglobulin followed by maintenance therapy with tacrolimus and MMF. Eight patients with equal numbers of males and females were transplanted during this time period. There were equal numbers of Caucasians, African-Americans, Hispanics, and Asians. A total of 37.5% (3/8) of the subjects received preemptive transplantation, 25% (2/8) received peritoneal, and 37.5% (3/8) received hemodialysis before transplantation. The median (range) age at transplantation was 12.3 (3.1-16.0) year with a follow-up of 1.7 (0.9-2.8) year. At one yr post-transplantation, 57% (4/7) of patients still required anti-hypertensives. Three children required erythropoietin supplementation after transplantation. The mean delta height standard deviation score at 12 months was 0.20 +/- 0.56. There were no episodes of clinical acute rejection. One patient switched from tacrolimus to sirolimus due to biopsy-proven CAN. No patient became diabetic or required hypoglycemic agents. Surveillance biopsies showed no subclinical acute rejection in any patient. Steroid-free immunosuppression is safe in children after renal transplantation. Larger number of patients and longer follow-up are required to further confirm the effectiveness and safety of immunosuppression with rapid steroid discontinuation.     

Outcomes of kidney transplantation in children with nephronophthisis: An analysis of the North American Pediatric Renal Trials and Collaborative Studies (NAPRTCS) Registry

Abstract: NPHP is an autosomal recessive chronic tubulointerstitial nephropathy that progresses to ESRD. In the 2006 NAPRTCS report, NPHP was the primary diagnosis in 2.8% of all renal transplant patients. At our pediatric center, that covers a population in which the NPHP1 gene is prevalent, 24% of transplant recipients had a primary diagnosis of NPHP. Since no previous literature reports have documented kidney transplant outcomes in patients with NPHP, a review of the 2006 NAPRTCS database was performed. The results of this review illustrate that patients with NPHP as their underlying kidney disease have a significantly better overall graft survival when compared with all other patients registered in the NAPRTCS database. Sub‐analysis demonstrated that this benefit is statistically significant only for LD kidney transplant recipients. CrCl was better in NPHP at all time points from transplant up to five‐yr follow‐up. Moreover, in NPHP LD transplant recipients the decline of CrCl over five yr was slower compared with non‐NPHP LD transplant recipients. Rates of thrombosis, acute, and chronic rejection as well as causes of graft failure were similar in NPHP patients and all other patients. This review demonstrates that NPHP transplant recipients have excellent outcomes that are shown to be better compared with the general pediatric transplant population.     

New approaches to the autosomal recessive polycystic kidney disease patient with dual kidney–liver complications

Improved neonatal medical care and renal replacement technology have improved the long‐term survival of patients with ARPKD. Ten‐yr survival of those surviving the first year of life is reported to be 82% and is continuing to improve further. However, despite increases in overall survival and improved treatment of systemic hypertension and other complications of their renal disease, nearly 50% of survivors will develop ESRD within the first decade of life. In addition to renal pathology, patients with ARPKD develop ductal plate malformations with cystic dilation of intra‐ and extrahepatic bile ducts resulting in CHF and Caroli syndrome. Many patients with CHF will develop portal hypertension with resulting esophageal varices, splenomegaly, hypersplenism, protein losing enteropathy, and gastrointestinal bleeding. Management of portal hypertension may require EBL of esophageal varices or porto‐systemic shunting. Complications of hepatic involvement can include ascending cholangitis, cholestasis with malabsorption of fat‐soluble vitamins, and rarely benign or malignant liver tumors. Patients with ARPKD who eventually reach ESRD, and ultimately require kidney transplantation, present a unique set of complications related to their underlying hepato‐biliary disease. In this review, we focus on new approaches to these challenging patients, including the indications for liver transplantation in ARPKD patients with severe chronic kidney disease awaiting kidney transplant. While survival in patients with ARPKD and isolated kidney transplant is comparable to that of age‐matched pediatric patients who have received kidney transplants due to other primary renal diseases, 64–80% of the mortality occurring in ARPKD kidney transplant patients is attributed to cholangitis/sepsis, which is related to their hepato‐biliary disease. Recent data demonstrate that surgical mortality among pediatric liver transplant recipients is decreased to <10% at one yr. The immunosuppressive regimen used for kidney transplant recipients is adequate for most liver transplant recipients. We therefore suggest that in a select group of ARPKD patients with recurrent cholangitis or complications of portal hypertension, combined liver–kidney transplant is a viable option. Although further study is necessary to confirm our approach, we believe that combined liver–kidney transplantation can potentially decrease overall mortality and morbidity in carefully selected ARPKD patients with ESRD and clinically significant CHF.     

Impact of liver transplantation on HRQOL in children less than 5 years old

Our primary goal was to assess health related quality of life (HRQOL) at transplantation and 1 yr after transplantation in pediatric liver transplant patients aged less than 5 years. We conducted a prospective longitudinal study of HRQOL in pediatric liver transplant recipients, aged less than 5 years to define the impact of liver transplantation on HRQOL and identify factors that predict HRQOL after transplantation. The infant toddler health status questionnaire (ITHQ) was completed at the time of listing for liver transplantation and at 6 and 12 months after liver transplantation. The primary outcome measures were the subscale scores that comprise ITHQ. The mean age (+/-s.e.m.) of the enrolled patients (n = 45) at transplantation was 1.4 (+/-1.2) yr. Thirty-eight (84%) of the enrolled patients completed the study. The highest mean baseline scores of 78.6 (+/-3.3) were for global mental health (GlobalMH). ITHQ subscale scores increased steadily after transplantation. The greatest increase was in the first 6 months after transplant. At 1 yr after transplantation, there were significant increases in all of the ITHQ subscale scores except for GlobalMH. ITHQ subscales were similar for patients who received LDLT compared with those who received cadaver donor liver transplantation (CDLT) at baseline and a year after transplant. Time elapsed as transplantation was a significant predictor of functional health in all of the models generated. Scores for general health (GH), global health (GGH), parental time-impact (PT) and parental time-emotion (PE) were higher for male children. Family cohesion (FC) improved with time elapsed since transplant and increased number of inpatient days. HRQOL improves after transplantation in all of our patients irrespective of the donor type. Functional health scores were higher in patients with normal serum bilirubin at 1 yr post-transplant. Assessment of HRQOL should be an integral part of care for liver transplant patients and their caregivers.     

Determinants of long-term survival of pediatric kidney grafts reported to the United Network for Organ Sharing kidney transplant registry

Pediatric 1-yr kidney graft survival rates have steadily improved in the US so that, by 1998, over 90% of hospital-discharged young recipients had survived the first year post-transplantation (Tx). However, 25% of the early surviving kidney grafts failed at 5 yr, yielding a projected half-life of 10 yr. Given a median age at transplant of 13 yr (range 0-20 yr), 50% of all current pediatric kidney recipients will need a second graft before the age of 25 years. We examined 8,422 pediatric renal transplants reported to the United Network for Organ Sharing (UNOS) Kidney Transplant Registry and, by using a log-linear multifactorial analysis, determined the relative influence of 26 major transplant factors on long-term graft survival. Results are reported as percentages of assignable variation (totaling 100% for all 26 factors combined) in pediatric outcomes beyond 1 yr and as adjusted graft survival rates. Transplant center, recipient race and age, transplant year, and panel-reactive antibody (PRA) had assignable variation percentages of 25, 24, 16, 12, and 4, respectively. When combined, they accounted for 81% of changes in long-term survival. Besides center effects, Blacks, teenagers, and transplants performed before 1994 exhibited significantly (p <0.0001) lower adjusted 5-yr graft survival rates as did the few sensitized (PRA>40%) pediatric patients (p = 0.02). Patients transplanted with a living donor kidney demonstrated a 5% point advantage at 5 yr post-Tx over cadaver donor kidneys (p = 0.001). Although the survival rate of pediatric kidney transplants has improved steadily, the long-term outcomes for teenagers and for Black recipients lag significantly behind those of younger patients and non-Blacks.     

Skin changes in pediatric transplant patients

The advent of organ transplantation identified a new group of diseases. Dermatologists are studying transplant-associated diseases along with the atypical behavior of already known dermatoses. Pediatric patients have been treated as an extension of adult population, but unique aspects of age required clarification. A prospective cohort was studied including patients from both genders up to 17 yr of age who were recipients of kidney, liver or BMT during 2003 in Porto Alegre, Brazil. Regular skin examinations were performed up to the sixth month after the procedure, and an analysis was determined by ID (i.e. = number of skin changes/number of patients-month x 100). Thirty-nine patients were examined: 20 were kidney transplant recipients; 11 were BMT recipients (10 autologous transplants and 1 allogeneic transplant); and 8 were liver transplant recipients. Skin changes result primarily from the use of medication (87.2). Individually, kidney transplant patients presented the highest ID of skin changes because of medications (104.1). BMT recipients presented the highest ID of alterations occurring on skin appendages (85.4) and liver transplant recipients had the highest ID of vascular changes (94.9). In conclusion, this study shows that cutaneous alterations in pediatric transplant recipients present some particularities not described in adult recipients, such as ichthyosiform xerosis in renal recipients and skin scaling with pellagroid appearance in bone marrow recipients. Also, dermatoses secondary to medication use were the main finding in pediatric population.