Rejection Profile of Recent Pediatric Renal Transplant Recipients Compared with Historical Controls: a Report of the North American Pediatric Renal Transplant Cooperative Study (NAPRTCS)

Historically, higher acute rejection rates, earlier first rejection, and an inability to reverse the rejection characterize pediatric renal transplantation. In recent years, short-term (1-year) graft survival of pediatric renal transplants has steadily improved. To test the hypothesis that these improvements were mediated by changes in acute rejection, we considered the rejection profile of patients who received a renal allograft between 1987 and 1989 (cohort A) and compared it with recipients transplanted between 1997 and 1999 (Cohort B). Cohort A comprised 1469 transplants and cohort B comprised 1189 transplants. Restricting the data to the first year of follow-up, rejection ratios were 1.6 and 0.7, respectively (p < 0.001). Sixty per cent of the later cohort (B) were rejection free at 1 year, compared with 29% for the earlier cohort (A) (p < 0.001). Controlling for donor source, the rejection reversal rate for the later cohort was significantly better than that of the early cohort (p < 0.001). Cumulative distribution of times to first rejection was significantly better for cohort B (p < 0.001). One-year graft survival for cohort B at 94% was significantly better than 80% for cohort A (p < 0.001). We conclude that the improved short-term graft survival is mediated by improvements in the rejection profile in more recently transplanted patients and that this may translate into a better half-life for pediatric renal transplant recipients who received an allograft in the years 1997-99.     

Development of a hand-held computer platform for real-time behavioral assessment of physicians and nurses

We developed a hand-held data collection tool to facilitate real-time collection of data on the factors that affect hospital staff performance. To assure high-yield of data from busy clinicians, the design objectives included low response burden, the ability to collect complex real-time data in dynamic work environments, and automated data integration. Iterative user-centered design of custom interfaces resulted in a dynamic intuitive platform where branching logic was applied to present a series of survey questions dependent on the participant’s responses. Over a 12-month period, 304 inpatient physicians and nurses completed (with minimal initial training) a total of 11,381 survey responses. For randomly timed repeated survey prompts, complete (73%) or partial (12%) responses were obtained in a median time of 96 s.     

Renal transplantation from elderly living donors

A worldwide shortage of cadaveric donors has led to the increased utilization of elderly living donors, with controversial results. In an attempt to assess the effect of donor age on graft survival and subsequent renal function, we analyzed our clinical results in 276 consecutive recipients of living related renal transplants spanning both the cyclosporine and the azathioprine eras, of whom a total of 44 recipients received kidneys from donors over 55 years old. All recipients were otherwise similar in age, race, haplotype mismatch, number of retransplants, and number of pretransplant transfusions, apart from an increased number of diabetics among the CsA-treated recipients of elderly kidneys (38% vs. 14%). The cumulative patient and graft survival rates at 1 and 5 years were independent of donor age whether CsA or AZA was utilized. Nor was the incidence of rejection or infection significantly different in the older donor group when compared with the younger cohort. Short-term and intermediate-term renal function, as assessed by serum creatinine, was however poorer but stable in the older donor group when compared with the younger one. The mean serum creatinine levels at 1 year in the CsA- and AZA-treated recipients of kidneys from older donors were 2.4 and 2.0 mg/dl, respectively, compared with 1.6 and 1.4 mg/dl, respectively, when the donor age was less than 55 years (P less than 0.001). Since renal function at the end of the first posttransplant year is considered a determinant of long-term graft survival, this is a cause for concern, but in view of the universal shortage of organs and the negligible morbidity to donors, renal transplantation from elderly living donors remains an acceptable practice.     

Predictors of eventual end stage renal disease in children with posterior urethral valves

We reviewed the long-term outcome of 25 boys born with posterior urethral valves who were followed longitudinally. Patient age at diagnosis varied from 7 months intrauterine to 7 years postnatal, and the mean duration of followup was 9 years. Of the children 40 per cent had retardation of growth by the end of the followup period and 44 per cent had end stage renal disease. Of the various factors delay in diagnosis and the association of persistent vesicoureteral reflux seem to predict eventual end stage status. In 18 of 25 children the diagnosis of posterior urethral valves was made before they were 2 years old. Only 5 of these children have reached end stage disease status. In comparison, of 7 children whose diagnosis was delayed beyond 2 years 6 have end stage disease (p less than 0.01). Similarly, 7 of 9 children with persistent reflux had end stage disease compared to 4 of 16 who did not have persistent reflux (p less than 0.01). Since end stage renal disease status was reached at widely varying intervals a prolonged followup of children with this anomaly is necessary.     

Correlation of fetal heart rate monitoring and acid-base status with periventricular/intraventricular hemorrhage in the low birthweight neonate

We investigated the correlation of fetal heart rate patterns and fetal acid-base findings with the occurrence of early periventricular/intraventricular hemorrhage and variants. Ninety-five consecutive singleton neonates with birthweights less than or equal to 2000 gm were investigated. One-third of them showed early periventricular/intraventricular hemorrhage or variants. Fetal heart rate scores and umbilical arterial/venous acid-base status showed no correlation with results of scanning. The implications of these findings are discussed.     

Pre-transplant blood transfusion and renal allograft outcome: a report of the North American Pediatric Renal Transplant Cooperative Study

Data from the North American Pediatric Renal Transplant Cooperative Study were analyzed to determine the effect of pre-transplant blood transfusions on graft survival and acute rejection for pediatric renal transplant recipients. Between January 1, 1987 and November 11, 1995, 4015 renal transplants in children <18 years of age (2007 living donor, 2008 cadaver) were registered in the study. Recipients were grouped by number of pre-transplant blood transfusions (0, n=1171; 1-5, n=1796; >5, n=1048). The risks of graft failure and acute rejection were related to number of pre-transplant transfusions by proportional hazards regression analysis. Models were adjusted for recipient age, sex, race, induction therapy, prior dialysis, prior transplant, HLA-DR mismatching, and transplant year. Additionally, the living donor (LD) model was adjusted for the use of donor-specific blood transfusion, and the cadaver donor (CAD) model was adjusted for donor age and cold storage time. The risk of graft failure was increased in LD (p<0.001) and CAD (p=0.001) recipients who received >5 pre-transplant transfusions. There was no significant difference in the causes of graft loss between groups. The risk of a first acute rejection decreased in LD recipients who received 1-5 blood transfusions compared with 0 (p=0.04) or >5 (p=0.003) and in CAD recipients who received 1-5 compared with 0 (p=0.05). We conclude that multiple (>5) pre-transplant blood transfusions are a risk factor for graft failure in pediatric recipients and should be avoided. However, limited blood transfusions (1-5) are associated with a decreased risk of acute rejection. Our data show that for pediatric recipients the number of pre-transplant blood transfusions is an important factor in transplant outcome.     

Renal transplantation in children from 1987-1996: the 1996 Annual Report of the North American Pediatric Renal Transplant Cooperative Study

The 1996 Annual Report of the North American Pediatric Renal Transplant Cooperative Study (NAPRTCS) summarizes data voluntarily collected from 130 centers on 4329 children and adolescent patients who received renal transplants on or after January 1, 1987. This report updates information on transplants; data on dialysis and chronic renal insufficiency have, for the first time, been reported separately (in submission). The NAPRTCS registry shows that the majority of pediatric renal transplants are performed in children above 6 years of age (73%). The most frequent diagnoses include obstructive uropathy (16%), aplastic/hypoplastic/dysplastic kidneys (16%), and focal segmental glomerulosclerosis (12%). Pre-emptive transplantation was performed in 24% of patients. Triple drug maintenance therapy with prednisone, cyclosporine and azathioprine was used by >70% of all transplant recipients throughout 7 years of follow-up. Fifty-six per cent of transplant recipients were rehospitalized during months 1-5 (51% live donor (LD), 62% cadaver donor (CD)), with rejection and infection as the main causes. In the period 30-35 months post-transplant, 19-22% of patients (163 LD, 185 CD) were rehospitalized. The median time to the first rejection was 46 days for CD transplants and 377 days for LD grafts (p<.001). Six-year graft survival rates were 73% and 56% for LD grafts and CD grafts, respectively (p<.001). The overall growth deficit was constant over a period of 60 months. However, children transplanted under 5 years of age reduce their height deficit by about one-third compared to an increase in height deficit of up to 22% for older children. The NAPRTCS data analysis also demonstrates a delay in first rejection episodes in LD compared to CD transplants, and a steady improvement in CD graft survival over the past 5 years in pediatric transplant recipients.