Hypertension following renal transplantation in children

The files of 334 consecutive cadaver kidney (CK) and of 27 living related (LR) transplantations (T) in children and adolescents performed from 1973 to 1984 have been reviewed. Following cadaver transplantation, 52 patients (15%) never had hypertension (HT), 41 patients (12%) had only initial HT up to 6 months after transplantation and 18 other patients (5%) exhibited transient HT episodes while on high-dose steroid therapy. Finally, 209 patients (62%) had HT for periods longer than 6 months and 16 patients (5%) until death or graft failure within the first 3 months. Chronic graft rejection was the major cause of HT, but other factors either isolated or in association were also present. Renal artery stenosis (RAS) was diagnosed in 43 cases (13%) 2–17 months post-transplantation; 10 of these were operated upon (5 successfully) and 9 underwent transluminal angioplasty with a single success. Nine cases of RAS resolved spontaneously. HT was attributed to the host kidney in 10 cases (3%) and to recurrence of primary renal disease in 9 (3%). HT observed after CKT was sometimes severe and difficult to control. Acute complications from HT were recorded in 35 cases, with 6 deaths and 2 severe neurological sequelae. Among 25 LRT, 11 cases (40%) had no HT 13 (48%) had HT for longer than 6 months. In this group, no case of RAS was observed and only one complication (without sequelae) was noted. In conclusion, HT is a frequent and sometimes severe complication post-transplantation in children and adolescents.     

Symptomatic disc herniation and serum lipid levels

Insufficient blood supply to the intervertebral disc (IVD) has been proposed to play a role as causative factor in IVD degeneration. There is an association between IVD diseases and increased risk of dying of ischaemic heart disease. Obesity and tobacco are potential risk factors for degenerative IVD disease. High blood cholesterol and triglycerides serum levels are risk factors for atherosclerosis, and could be responsible for a decreased in the blood supply to the already poor vascularized IVD. We performed a frequency-matched case–control study to determine the serum levels of patients with symptomatic herniated lumbar disc. We examined the fasting serum lipid levels in 384 subjects who were operated at our institution. Group 1 included 169 consecutive patients (115 men and 54 women; mean age: 59.1 years, range 29–85) who underwent surgery for symptomatic disc herniation. Group 2 (control group) included 169 patients (115 men and 54 women; mean age: 61 years, range 26–86) who underwent arthroscopic meniscectomy for a meniscal tear in the same period. These patients were frequency-matched by age (within 3 years) and gender with patients of Group 1. Sera were extracted from blood samples and the concentrations of total cholesterol (TC) and triglycerides (TG) were determined. When comparing the two groups, patients with symptomatic herniated lumbar disc showed statistically significant higher triglyceride concentration (P = 0.02) and total cholesterol concentration (P = 0.01). Serum lipid levels may be a risk factor for IVD pathology. An enhanced understanding of these factors holds the promise of new approaches to the prevention and management of IVD pathology.     

Non-compliance following renal transplantation in children and adolescents

Reported frequencies of non-compliance in children with end-stage renal disease range from 8% to 70% with a mean around 40%. Sequelae amount to momentous emotional and financial burdens, including the loss of 7% of transplanted organs. Reasons for non-compliance have too often been attributed selectively to the patients (e.g., emotional, mental, social, or communication problems). Compared with general compliance research, this selective attribution appears to be too simplistic. Selective attribution neglects the patients’ experiences within the context of disease and treatment and prevents open communication about non-compliance. Research on personal reasons for non-compliance is scarce. In psychological interviews, a third of our 85 patients with end-stage renal disease (34 boys, 51 girls, mean age 12.7 years, range 7.4–19.3 years) communicated psychologically meaningful reasons for non-compliance, frequently related to interrelational and systemic treatment conditions. Patients indirectly asked for more communication about their subjective reasons for non-compliance. Received July 10, 1997; received in revised form and accepted April 30, 1998     

Assessment of bone mass following renal transplantation in children

Throughout childhood and adolescence, skeletal growth results in site-specific increases in trabecular and cortical dimensions and density. Childhood osteoporosis can be defined as a skeletal disorder characterized by compromised bone strength predisposing to an increased risk of fracture. Pediatric renal transplant recipients have multiple risk factors for impaired bone density and bone strength, including pre-existing renal osteodystrophy, delayed growth and development, malnutrition, decreased weight-bearing activity, inflammation, and immunosuppressive therapies. Dual energy X-ray absorptiometry (DXA) is the most-common method for the assessment of skeletal status in children and adults. However, DXA has many important limitations that are unique to the assessment of bone health in children. Furthermore, DXA is limited in its ability to distinguish between the distinct, and sometimes opposing, effects of renal disease on cortical and trabecular bone. This review summarizes these limitations and the difficulties in assessing and interpreting bone measures in pediatric transplantation are highlighted in a review of select studies. Alternative strategies are presented for clinical and research applications.This work was presented in part at the IPNA Seventh Symposium on Growth and Development in Children with Chronic Kidney Disease: The Molecular Basis of Skeletal Growth, 1–3 April 2004, Heidelberg. Germany     

Opportunistic infections in children following renal transplantation

Opportunistic infections following renal transplantation in children are a major cause of severe morbidity and mortality. These infections account for the majority of early post renal-transplant deaths in children. General risk factors which affect the incidence and severity of these infections include: transmission of the infectious agent by the donor organ; history of immunity in the recipient prior to transplantation; type and amount of immunosuppression including treatment for rejection episodes; availability of specific treatment for the infection. Children are at particular risk because of the lack of exposure to certain pathogens prior to transplantation. There have been recent advances in the prevention and treatment of important infections which occur in children following transplantation, including varicella,Pneumocystis carinii pneumonia (PCP) and cytomegalovirus (CMV) disease. Varicella is treatable with acyclovir, often without decreasing immunosuppression and placing the graft at risk. Prophylaxis against PCP may be achieved by provision of alternate-day trimethoprim sulpha, but clear guidelines for determining who should be treated are lacking. Treatment of this disease with high-dose trimethoprim sulfa or pentamidine is usually successful. CMV disease is frequently severe, especially when the donor is seropositive and the recipient seronegative. In these situations, prophylactic CMV immunoglobulin reduces the morbidity and the mortality of the disease and prophylactic oral acyclovir may decrease its incidence. Treatment of severe CMV disease with gancyclovir is promising.     

西罗莫司对肝移植术后肾功能和血脂的影响

目的探讨原发性肝细胞癌（肝癌）肝移植患者术后使用西罗莫司（sirolimus）对肾功能和血脂的影响。方法 56例肝癌肝移植患者分为两组。研究组（33例）采用西罗莫司＋小剂量他克莫司（FK506）＋肾上腺皮质激素（激素）方案,对照组（23例）采用FK506＋激素方案。动态监测两组患者术前,术后1、3、6、9、12个月的血清肌酐（Scr）、血清总胆固醇、甘油三酯及高密度脂蛋白的变化情况,分别行组内不同时点比较和同时点组间比较。结果术前两组患者的Scr水平差异无统计学意义（P〉0.05）,术后9个月时的Scr比较差异有统计学意义（P〈0.05）,研究组的Scr水平低于对照组,且研究组术后Scr呈先升高再降低的变化趋势,对照组Scr呈缓慢上升的趋势。术前两组患者的血脂水平相当（P〉0.05）。两组患者术后1个月的甘油三酯水平,术后6个月时的总胆固醇水平和高密度脂蛋白水平比较差异有统计学意义（P〈0.05）,研究组均高于对照组。两组患者未发现与高脂血症相关的心脑血管疾病。结论西罗莫司是一种低肾毒性的免疫抑制剂,与小剂量的FK506合用时可以减少FK506的肾毒性。西罗莫司的主要的不良反应是高脂血症。     

The initiation of erythropoiesis following renal transplantation

Erythropoiesis has been examined in relation to kidney function in 38 patients during the 3-month period following successful renal transplantation, using serial determinations of erythropoietin, haemoglobin, and creatinine. Two peaks of serum erythropoietin were observed: an early peak that occurred within 2 days of transplantation and was observed in ten patients, and a late one between 8 and 30 days, observed in 28 patients. The early peak did not produce an increase in haemoglobin and occurred only in the presence of delayed onset of graft excretory function when serum creatinine was greater than 1000 mumols/l. The ineffectiveness of the early peak may be due to the uraemic environment, which is probably a sequel of the tubular damage associated with postoperative acute tubular necrosis. The late peak followed a decrease in serum creatinine to less than 200 mumols/l and was associated with an increase in haemoglobin of 3-4 g/dl during the next 2-6 weeks.     

Left ventricular mass and heart sympathetic activity after renal transplantation in children and young adults

Recent studies considered that an increase in sympathetic activity (SA) may be responsible for left ventricular hypertrophy (LVH). Before and after renal transplantation (RT), we evaluated changes on left ventricular mass (LVM) and SA in 40 end-stage renal disease patients between 8 and 35 years old. Hypertension (95.0% vs. 71.0%; p=0.005), use of combined antihypertensive drugs (57.5% vs. 30.0%; p=0.01), and LVH (77.5% vs. 52.5%; p=0.01) significantly decreased after RT whereas low-to-high frequency ratio (LF/HF), which represents SA, increased (3.1 vs. 5.3; p=0.0001). However, LVM regressors (with decrease on LVM index more than 20%) showed a trend of lower change on LF/HF ratio (1.6 vs. 2.4; p= 0.09) than nonregressors. Living-donor graft, baseline LVM, use of antihypertensive drugs, lower change on LF/HF ratio, and lower systolic blood pressure levels were associated with LVM regression in the simple correlation analysis. However, in the logistic regression analysis, only baseline LVM and donor type remained in the model (R²=0.35; p=0.0003). Thus, LVH decreased after RT and was related to baseline LVM and living-donor type. However, it is possible that the higher persistence of LVH after RT could be explained at least in part by increase in heart sympathetic activity and use of immunosuppressors.     

亲属活体肾移植64例临床分析

观察亲属供肾肾移植的临床效果.方法 对64例亲属供肾肾移植的临床资料进行总结分析.结果所有供者无手术并发症,术后5~12 d内出院,术后1周血清肌酐(Scr)(91±25)μmol/L,术后2周供者肾功能恢复到术前水平.受者术后1周平均Scr 142 μmol/L.术后发生急性排斥反应的8例,给予甲泼尼龙及抗胸腺细胞球蛋白(ATG)冲击治疗后逆转.移植肾功能正常者55 例,移植肾失功行规律血液透析3例,死于肺部感染2例,死于结核性脑膜炎1例,死于心力衰竭1例,死于移植后肝衰竭1例,因经济原因不规则服药发生慢性排斥反应死亡1例.结论 亲属活体供肾对供者来说短期内肾功能及日常生活无明显影响,短期内是安全、有效、可行的,并且在一定程度上缓解了肾源紧缺问题.     

Persistent secondary hyperparathyroidism after renal transplantation in children

Secondary hyperparathyroidism (HPTH) is a frequent complication of chronic kidney disease (CKD). Renal transplantation corrects the biochemical abnormalities that cause HPTH; however, HPTH persists in some patients. The factors that contribute to the persistence of HPTH after transplantation in children are poorly understood. We examined 57 children who underwent renal transplantation and determined whether baseline clinical and biochemical parameters could predict the persistence of HPTH at 1 year post-transplantation, using multivariate logistic regression. At the time of transplantation, serum parathyroid hormone (PTH) levels were >300 pg/ml in 60%, 150–300 pg/ml in 17%, and <150 pg/ml in 23% of recipients. HPTH (PTH >73 pg/ml) persisted in 78% of patients at 6 months and in 56% at 1 year after transplant. Older age at transplantation was the strongest predictor of HPTH at 1 year (OR=1.17, P<0.05). After adjustment for age, other baseline clinical or laboratory parameters were not predictive of HPTH at 1 year. The relationship between older age and persistent HPTH may be explained by longer duration of CKD. Given the potential morbidities associated with persistent HPTH, the role of interventions that would prevent or reverse persistent HPTH post-transplantation requires further investigation.     

De novo hemolytic uremic syndrome following renal transplantation

We report a case of complete recovery of renal function in a patient with de novo hemolytic uremic syndrome (HUS) following renal transplantation. This 3-year-old girl had none of the factors known to contribute to the development of HUS in transplant recipients. This case illustrates the usefulness of renal biopsy in the accurate diagnosis and management of dysfunction in the allograft following renal transplantation.     

Hypothalamic-pituitary thyroid abnormalities in children after renal transplantation

Patients with a successful renal transplant may have abnormalities in thyroid function. We evaluated serum thyroid hormone levels, serum thyrotropin (TSH) response to thyrotropin-releasing hormone (TRH), and the circadian pattern of serum TSH in 18 children aged 6.6 – 19.4 years (median 12.6 years), 4.0 ± 2.9 years after renal transplantation. In 14 children, immunosuppressive therapy included methylprednisone [mean (± SD) 0.17 ± 0.05 mg/kg per day], while in 11 it included deflazacort (0.32 ± 0.1 mg/kg per day). Seven children were studied twice, under methylprednisone and again while on deflazacort therapy. Mean total and free thyroxine (T₄) values were significantly below the mean control levels (total T₄ 108.5 ± 21.5 vs. 118.7 ± 22.1 nmol/l, P <0.05 and free T₄ 14.4 ± 4.0 vs. 18 ± 4.9 pmol/l, P <0.001). Morning basal TSH levels were within the normal range. The mean TSH increment after TRH was 4.4 ± 3.5 mU/l, significantly lower than that of controls (10.8 ± 4.26, P <0.001). Of 7 patients on methylprednisone, 4 had nocturnal TSH surges below the normal range (95% confidence limits 47% – 300%); this occurred in 3 of 8 patients on deflazacort therapy. The TSH response to TRH was correlated with deflazacort dose. Patients on methylprednisone and deflazacort therapy had similar thyroid alterations. Our findings support the hypothesis that after renal transplantation some children have hypothalamic-pituitary thyroid abnormalities in which glucocorticoids may play a significant role. Received August 11, 1995; received in revised form and accepted December 6, 1995     

Natural history and etiology of hyperuricemia following pediatric renal transplantation

A retrospective review was conducted to determine the incidence, etiology, natural history and complications of hyperuricemia after pediatric renal transplantation. Of 81 active transplant recipients aged 10.1±4.8 (mean±SD) years being followed by St. Christoper's Hospital for Children, 57 (70%) were males and 59 (73%) Caucasian. Their immunosuppression consisted of azathioprine, cyclosporine A and prednisone. Mean serum uric acid concentrations peaked at 6 months post transplantation (6.2±2.6 mg/dl), when 39% of the patients had hyperuricemia and 60% were receiving diuretics, and decreased thereafter. At 30 months, 23% of the patients had hyperuricemia and 17% required diuretics. When we compared 42 normouricemic (group A) with 24 hyperuricemic (group B) patients at 18 months post transplantation, we found that patients in group B were older (11.6±4.2 vs. 8.6±5.2 years,P=0.01), had worse renal function (77±25 vs. 96±36 ml/min per 1.73 m²,P=0.03) and required diuretics more frequently (63% vs. 21%,P=0.001), but had identical blood levels of cyclosporine A (82±28 vs. 84±35 ng/ml,P=0.78). A family history of gout did not affect the prevalence of hyperuricemia after transplantation. Asymptomatic hyperuricemia is common following pediatric renal transplantation and is more likely attributable to reduced renal function and diuretic therapy than to the known hyperuricemic effect of cyclosporine A. Of these variables, only diuretic therapy is readily controllable and should be closely regulated following pediatric renal transplantation.     

肾移植术后肺部感染状态下免疫抑制剂的调整

目的 探讨肾移植术后肺部感染患者免疫抑制剂的应用与预后的关系.方法 对肾移植术后合并肺部感染的98例患者临床资料进行回顾性分析.将患者分为维持应用免疫抑制剂组(维持剂量组,45例)与免疫抑制剂减量或停用组(调整剂量组,53例).按与感染相关的器官衰竭估计评分(SOFA)标准,在肾移植术后肺部感染较重(SOFA≥12分)和感染较轻(SOFA＜12分)的情况下,分别分析两组患者的死亡率、感染恢复时间和排斥反应发生率的差异.结果 当SOFA≥12分时,调整剂量组死亡率和感染恢复时间明显低于维持剂量组(P＜0.05),而排斥反应发生率在两组之间的差异则无统计学意义(P＞0.05);当SOFA＜12分时,死亡率和感染恢复时间在两组之间差异无统计学意义(P＞0.05),但调整剂量组患者排斥反应发生率明显高于维持剂量组(P＜0.05).结论 在肾移植术后肺部感染较重(SOFA≥12分)时,减量和停用免疫抑制剂有利于降低患者的死亡率和缩短抗感染疗程;但感染较轻(SOFA＜12分)时,建议维持免疫抑制剂原剂量不变.     

Benign intracranial hypertension in children following renal transplantation

Benign intracranial hypertension (BIH) is a condition characterized by headache, papilledema, and a raised cerebrospinal fluid pressure with normal cranial imaging. It is uncommon in childhood. Previously, there have been reports that children with chronic impairment of renal function may be at greater risk of developing BIH. This study involved retrospective case note analysis of children undergoing renal transplantation over the last 11 years at our institution. Nine children developed BIH after renal transplantation. The prevalence of the condition in our series was 4.4%. Several etiologically relevant risk factors were identified, including medication (nitrofurantoin, minocycline) and excess weight gain. Our results suggest that BIH may be a more frequent complication of the post-operative care of pediatric renal transplant recipients than previously thought. We hope to alert pediatric nephrologists that examination of the fundus for papilledema in all renal transplant patients complaining of headache is essential. If the diagnosis of BIH is delayed, irretrievable visual loss may not be avoided.     

肾移植患者胆固醇酯转运蛋白基因多态性与脂代谢的关系

目的 探讨肾移植患者胆固醇酯转运蛋白(CETP)基因多态性与脂代谢的关系。方法 生物化学方法检测肾移植患者移植前及移植后6～8个月时的血脂水平；多聚酶链反应-限制性片断长度(PCR-RFLP)方法检测CETP内含子1TaqⅠB与内含子8MSPⅠ位点基因多态性。结果肾移植患者移植前甘油三脂(TG)水平显著高于正常对照组，血清总胆固醇(TC)、高密度脂蛋白胆固醇(HDLC)、低密度脂蛋白胆固醇(LDLC)、脂蛋白(a)[Lp(a)]水平均显著低于正常对照组；移植后TC、TG、HDLC、LDLC、载脂蛋白(ApoB、ApoE)水平均显著高于对照组及移植前水平。肾移植患者CETP TaqⅠB与MSPⅠ位点基因型及等位基因频率的发生率与正常对照组差异无显著性。CETP TaqⅠB基因型为B1/B1的肾移植患者，移植前TG、ApoB水平显著增高，HDLC水平显著降低，移植后表现为TG水平显著增高。肾移植患者CETPMSPI位点不同的基因型间血脂水平差异无显著性。结论肾移植患者易发生高脂血症。CETP内含子TaqⅠB位点基因多态性可显著性影响肾移植患者TG水平，基因型为B1/B1的患者易发生高甘油三酯血症。     

Bladder dysfunction in children and adolescents after renal transplantation

The underlying mechanisms of urinary-tract infections (UTI) in renal transplant recipients are still not fully understood. In otherwise healthy children, bladder dysfunction increases the susceptibility to UTI. The aim of this study was to evaluate lower-urinary-tract function in children and adolescents after renal transplantation. Sixty-eight recipients of renal transplants, 5–20 years of age and 1–15 years after transplantation, were evaluated for their bladder function with a questionnaire, uroflowmetry and bladder ultrasound, and for renal function (glomerular filtration rate) by measuring clearance of inulin or iohexol. Forty-nine patients (72%) had some type of abnormality of bladder function. Abnormal bladder capacity was found in 26%, abnormal urinary flow in 50% and residual urine in 32% of the patients. There was no significant difference in bladder or renal function in children with urinary-tract malformations compared with those with normal urinary tract. Furthermore, there was no significant difference in renal function in patients with bladder dysfunction compared with those without. The incidence of bladder dysfunction is high in children and adolescents after renal transplantation, but the clinical significance of this finding and whether there is a correlation between bladder dysfunction and UTI in these patients need to be clarified further.     

肾移植后重症肺炎38例临床分析

目的 分析总结38例肾移植术后肺炎重症患者临床特点及救治措施.方法 选择38例2006年至2011年在郑州大学第一附属医院呼吸暨重症监护室收治的肾移植术后肺部感染患者的临床资料进行回顾性分析.结果 38例患者治愈30例,死亡8例.结论 肺炎肾移植患者应用免疫抑制剂的严重并发症,全面综合治疗是救治成功的关键.     

肝移植术后早期急性肾功能衰竭5例临床分析

目的总结肝移植术后早期急性肾功能衰竭的防治经验。方法回顾性分析5例肝移植受者术后早期发生急性肾功能衰竭临床资料,手术方式为改良背驮式肝移植术,其中4例术前即合并肾功能不全。结果5例术后早期急性肾功能衰竭患者3例通过调整免疫抑制方案和改善肾脏灌注及利尿治疗肾功能恢复;2例给予连续性肾脏替代治疗后肾功能恢复。结论肝移植术后免疫抑制剂的个体化应用,积极改善肾脏灌注,必要时选择血液透析治疗,有助于防治肝移植术后早期急性肾功能衰竭。     

肾移植术后并发尿路上皮肿瘤(附25例报告)

目的 探讨肾移植术后并发尿路上皮肿瘤的临床特点及其诊治方法.方法 回顾性分析1998年～2006年间肾移植术后发生尿路上皮肿瘤的临床资料25例.就患者性别、移植时年龄、导致肾功能不全的原发病、移植后肿瘤发生的时间、临床症状、肿瘤发生部位及转归等项目进行临床分析.所有病例移植前均排除肿瘤.肿瘤均经影像学和膀胱镜等检查方法诊断.22例患者行手术治疗,术后所有患者免疫抑制剂用量减少1/3并辅以局部灌注化疗.结果 本组25例患者中男4例,女21例;移植时患者平均年龄55.1岁;原发病为慢性间质性肾炎的患者19例;术后发生肿瘤的时间距肾移植时间平均26个月;临床表现为肉眼血尿或镜下血尿25例,反复泌尿系感染10例,肾盂输尿管积水者12例;肿瘤为多发者22例;移植肾同侧有上尿路肿瘤者16例;3例行姑息性治疗的晚期肿瘤患者分别于发现肿瘤5个月、6个月及8个月后死亡,22例手术治疗患者已随访2～7年,18例肿瘤复发,再行手术治疗;所有患者在免疫抑制剂减量期间均未出现急性排斥,肾功能正常.结论 本组显示慢性间质性肾炎导致肾功能衰竭的肾移植患者和女性肾移植患者易发生移植后尿路上皮肿瘤;血尿、泌尿系感染和肾盂积水是常见的症状,多发性和易复发性是另一临床特点;移植肾同侧上尿路较对侧好发肿瘤.