COVID-19 in pediatric kidney transplantation: The Improving Renal Outcomes Collaborative

There are limited data on the impact of COVID-19 in children with a kidney transplant (KT). We conducted a prospective cohort study through the Improving Renal Outcomes Collaborative (IROC) to collect clinical outcome data about COVID-19 in pediatric KT patients. Twenty-two IROC centers that care for 2732 patients submitted testing and outcomes data for 281 patients tested for SARS-CoV-2 by PCR. Testing indications included symptoms and/or potential exposures to COVID-19 (N = 134, 47.7%) and/or testing per hospital policy (N = 154, 54.8%). Overall, 24 (8.5%) patients tested positive, of which 15 (63%) were symptomatic. Of the COVID-19-positive patients, 16 were managed as outpatients, six received non-ICU inpatient care and two were admitted to the ICU. There were no episodes of respiratory failure, allograft loss, or death associated with COVID-19. To estimate incidence, subanalysis was performed for 13 centers that care for 1686 patients that submitted all negative and positive COVID-19 results. Of the 229 tested patients at these 13 centers, 10 (5 asymptomatic) patients tested positive, yielding an overall incidence of 0.6% and an incidence among tested patients of 4.4%. Pediatric KT patients in the United States had a low estimated incidence of COVID-19 disease and excellent short-term outcomes.     

Rapid response to rituximab in a pediatric liver transplant recipient with post-transplant lymphoproliferative disease and maintenance with sirolimus monotherapy

A 12-yr-old girl with end-stage renal disease secondary to primary hyperoxaluria type I received a living related (left lateral segment) liver transplant from her brother as the first step of a staged liver and kidney transplant. Renal transplantation was planned for a later date from the same donor. Nine weeks after transplantation she developed polymorphic PTLD of the tonsils and adenoids. Initial treatment with surgical resection and withdrawal of immunosuppression was insufficient as she developed recurrence of the PTLD lesion 1 wk after surgical resection and reduction of immunsuppression. Treatment with the chimeric monoclonal anti CD20 antibody, rituximab (Mabthera, Hoffman-La Roche AG, Grenzach-Whylen, Germany), resulted in quick response and complete recovery from PTLD within 2 wk, with no recurrence up to 8 months after treatment. Rejection prophylaxis was successfully achieved with Sirolimus (Rapamune, Wyeth Pharmaceuticals Inc., Philadelphia, PA, USA) monotherapy, with no episodes of acute rejection.     

Immediate post-transplant nephrosis in a patient with congenital nephrotic syndrome

A 19-month-old girl with congenital nephrotic syndrome of the Finnish type underwent a living-related renal transplant; 24 h after transplantation she became massively nephrotic. She did not respond to steroids, plasmapheresis, and high-dose cyclosporine. A month later, a renal biopsy showed only glomerular foot process effacement. She was treated with high-dose methylprednisolone pulses and oral cyclophosphamide. She rapidly went into complete remission with no further relapses. Graft function has been stable 2 years after transplantation. Received: 24 June 1999 / Revised: 21 February 2001 / Accepted: 23 February 2001     

Ventriculoperitoneal shunts in children on peritoneal dialysis: a survey of the International Pediatric Peritoneal Dialysis Network

Objective

The aim of this study was to inform best evidence-based practice by collating and disseminating the experiences of members of the International Pediatric Peritoneal Dialysis Network with children having concurrent ventriculoperitoneal shunts (VPS) and peritoneal dialysis catheters (PDC).

Methods

An online questionnaire was created and distributed to all 135 centers participating in the International Pediatric Peritoneal Dialysis Network; the overall response rate was 56 %.

Results

A total of 18 patients with a concurrent VPS and PDC were reported. The children were 0–12 (mean 6.8) years old at the time of placement of the second indwelling device (PDC or VPS). In 15 cases, the PDC was inserted post-VPS. On average, the two catheters were present concurrently for 23 (range 1–60) months. There were 20 episodes of peritonitis observed in 11 of the 18 patients during a period of 392 months at risk, which is a peritonitis rate of 1/19.6 months. Only one patient developed both a VPS infection and an episode of peritonitis, and these events were temporally unrelated. No episodes of an ascending shunt infection or meningitis occurred in association with any episode of peritonitis, and no other complications of catheter dysfunction were described.

Conclusions

The rate of peritonitis, the absence of any documented ascending or descending infections and the lack of catheter dysfunction during the period of observation suggests that the presence of, or need for, a VPS should not preclude PD as a safe option for children requiring renal replacement therapy.     

Intravenous immunoglobulin therapy in the treatment of BK viremia and nephropathy in pediatric renal transplant recipients

Anyaegbu EI, Almond PS, Milligan T, Allen WR, Gharaybeh S, Al‐Akash SI. Intravenous immunoglobulin therapy in the treatment of BK viremia and nephropathy in pediatric renal transplant recipients.
Pediatr Transplantation 2012: 16: E19–E24. © 2010 John Wiley & Sons A/S. Abstract: Polyoma BKVN is a significant cause of allograft dysfunction and loss in renal transplant recipients. Reduction in immunosuppression is accepted as first‐line therapy to decrease viral load and prevent allograft injury and dysfunction. We report our experience with persistent BKV after reduction in immunosuppression followed by successful clearance of BKV in three pediatric renal transplant recipients and histological resolution of BKVN in a fourth patient following therapy with IVIG. Once BKV was detected, immunosuppression was reduced and BKV was monitored until clearance was achieved. All four patients were given IVIG in a dose of 2 g/kg. Allograft function remained stable in all patients. Early routine screening for BKV allows early intervention to prevent the development of BKVN and permanent allograft damage. While immunosuppression reduction is a logical first‐line therapy, second‐line therapy is not well established. IVIG seems to be an effective treatment for persistent BKV after reduction in immunosuppression and for BKVN and can therefore be considered as a therapeutic option in these patients.     

An unusual case of pyelonephritis in a pediatric renal transplant recipient

Emphysematous (Gas-forming) pyelonephritis (EPN) is a rare and life-threatening infection of the renal parenchyma with or without involvement of the peri-renal tissues. Diagnosis of this condition is usually made on clinical and radiological grounds. Risk factors for this condition include diabetes mellitus, urinary tract obstruction, renal anomalies such as polycystic kidneys, stones, old age and others. Review of the literature did not reveal any reports of (EPN) in the pediatric age group especially in transplanted patients. We report the first case of EPN in a child, a 12-yr-old boy with a renal transplant, and discuss the various diagnostic and management issues of this particular case and EPN in general.     

Towards continuous improvement of endoscopy standards: validation of a colonoscopy assessment form

Aim The assessment of procedural colonoscopy skills is important and topical. The aim of this study was to develop and validate a competency‐based colonoscopy assessment form that would be easy to use, suitable for the assessment of junior and senior endoscopists and potentially a useful instrument to detect differences in performance standards following different training interventions. Method A standardized assessment form was developed incorporating a checklist with dichotomous yes/no responses and a global assessment section incorporating several different elements. This form was used prospectively to evaluate colonoscopy cases during the period of the study in several university teaching hospitals. Results were analysed using ANOVA with Bonferroni corrections for post hoc analysis. Results Eighty‐one procedures were assessed, performed by eight consultant and 19 trainee endoscopists. There were no serious errors. When divided into three groups based on previous experience (novice, intermediate and expert) the assessment form demonstrated statistically significant differences between all three groups (P < 0.05). When separate elements were taken into account, the global assessment section was a better discriminator of skill level than the checklist. Conclusion This form is a valid, easy‐to‐use assessment method. We intend to use it to assess the value of simulator training in trainee endoscopists. It also has the potential to be a useful training tool when feedback is given to the trainee.