Posttransplantation complications of lower limb polytetrafluoroethylene grafts in children

Two children had polytetrafluoroethylene (PTFE) arteriovenous thigh grafts for hemodialysis access. In one patient, after renal transplantation, a steal syndrome, which prevented renal graft function, developed. The renal transplant functioned promptly when the vascular graft was ligated. In the second case, acute thrombosis of the PTFE graft resulted in transient hypertensive encephalopathy. PTFE thigh grafts, because of the diversion of a large percentage of cardiac output through them, may have dramatic and dangerous consequences in transplanted children.

[Continuous peritoneal dialysis in children]

Thirty-two uremic children were treated by chronic peritoneal dialysis (CPD) since February 1982. Fifteen chose chronic ambulatory peritoneal dialysis (CCPD) while the 17 others were treated by continuous cycle peritoneal dialysis (CCPD). To this day, 10 patients (31%) are alive with a functioning kidney transplant, 16 (50%) are still treated by CPD awaiting a transplant, 5 have died (16%) and one went back to hemodialysis (3%). Complication in ranking order were peritonitis, mechanical drainage problems of the catheter and hernias. Linear growth was from good to excellent in the majority of patients. Globally, CPD was found to be attractive mainly because it allows a good quality of life.

Binding of [3H]hemicholinium-3 to the high-affinity choline transporter in electric organ synaptosomal membranes

Sodium-dependent binding of [3H]hemicholinium-3 was observed to be 10-fold higher with presynaptic membranes from the electric organ than with electroplaque membranes and this binding site copurified with synaptosomal membranes. The KD for specific [3H]hemicholinium-3 binding was found to be 31 +/- 4 nM and the Bmax, 5.0 +/- 0.2 pmol/mg protein; a Ki of 16 nM was estimated for hemicholinium-3 as a competitive inhibitor of high-affinity choline transport in electric organ synaptosomes. Choline and choline analogues were equally potent as inhibitors of [3H]choline uptake and [3H]hemicholinium-3 binding. Tubocurarine and oxotremorine also inhibited uptake and binding, but carbachol was without effect in both tests. These findings suggest that [3H]hemicholinium binds to the high-affinity choline transporter present at the cholinergic nerve terminal membrane. A comparison of maximal velocities for choline transport and the maximal number of hemicholinium-3 binding sites indicated that the high-affinity choline transporter has an apparent turnover number of about 3s-1 at 20 degrees C under resting conditions. The high transport rates observed in electric organ synaptosomes are likely due to the high density of high-affinity choline transporters in this tissue, estimated on the basis of [3H]hemicholinium-3 binding to be of the order of 100/micron2 of synaptosomal membrane.

Hemolytic uremic syndrome: urate nephropathy superimposed on an acute glomerulopathy? An hypothesis

The oligo-anuria of the hemolytic uremic syndrome is attributed to the presence of a renal lesion which is predominantly glomerulopathic but which may have a vasculopathic component of varying severity. Fourteen children, four of whom had anuric, four oliguric and six non oliguric acute renal failure were treated with intravenous fluids and high dose intravenous furosemide therapy. Polyuria was induced in all, obviating the need for dialysis. We hypothesize that oligo-anuria in this syndrome may be due to the previously recognized hyperuricemia causing a urate nephropathy superimposed on the glomerulopathy thus explaining its possible amenability to fluid and diuretic therapy.

NIH conference. Cystinosis: progress in a prototypic disease

OBJECTIVE

To review the history, basic defect, pathogenesis, clinical manifestations, diagnosis, and treatment of nephropathic cystinosis.

DESIGN

Lysosomal membrane transport studies, clinical reports, and a historically controlled 7-year trial of oral cysteamine therapy.

SETTING

University centers in the United States and Canada.

PATIENTS

One hundred forty-eight children, aged 0 to 12, with nephropathic cystinosis before renal transplant, who had renal tubular Fanconi syndrome, failure to grow, corneal cystine crystals, and elevated leukocyte cystine; 34 patients, aged 9 to 29, after transplant, some with visual impairment, corneal erosions, pancreatic dysfunction, or neurologic deterioration.

INTERVENTION

Before transplant, replacement of renal losses, and treatment with oral cysteamine (55 mg/kg body weight.d for 1 to 6 years) and topical cysteamine eyedrops (0.1%, 1 drop/h while awake, for 6 months). After transplant, oral cysteamine and symptomatic treatment of late complications.

MEASUREMENTS AND MAIN RESULTS

Untreated patients reached renal failure at age 10. Oral cysteamine lowered leukocyte cystine over 80%, and in patients before transplant, improved growth and preserved renal function (mean creatinine clearance [+/- SE], 0.64 +/- 0.04 mL/s.1.73 m2 [38.5 +/- 2.5 mL/min.1.73 m2] in the cysteamine group compared with 0.50 +/- 0.03 mL/s.1.73 m2 [29.7 +/- 2.0 mL/min.1.73 m2] in controls; 95% CI for the difference, 1.8 to 15.8). Cysteamine eyedrops cleared the corneal crystals of two children less than 2 years old.

CONCLUSIONS

Cystinosis is a lysosomal storage disease due to impaired transport of cystine out of lysosomes. In young children, growth can be improved and renal deterioration delayed or prevented by oral cysteamine. Nonrenal complications after transplant might be prevented with long-term oral cysteamine.

Post-rejection ureteral obstruction owing to ureteral adherence to graft inferior pole

We describe 2 renal transplant patients with increasing plasma creatinine levels after resolution of acute rejection episodes. Antegrade pyelography demonstrated adherence of the ureter to the inferior pole of the kidney with partial obstruction in both cases, which was confirmed at operation.

Variable expression of autosomal recessive polycystic kidney disease and congenital hepatic fibrosis within a family

Blyth and Ockenden [1971] assigned patients with autosomal recessive polycystic kidney disease (ARPCKD) to 4 discrete groups (perinatal, neonatal, infantile, juvenile) on the basis of the age of presentation. They and others speculated that at least 4 genes were responsible for what they considered to be closely related, but different conditions. These views have gained wide but not universal acceptance. Some workers have insisted that the perinatal and neonatal "forms" of ARPCKD differ fundamentally from the juvenile "form." However, others have proposed that ARPCKD-CHF (congenital hepatic fibrosis) and CHF-ARPCKD are manifestations of the same disease with variation of expression in a kindred. We report on a patient who presented at birth (1979) with ARPCKD and respiratory distress. He died at 18 hr. An older sib presented at 16 yr in 1984. She had no symptoms, but her mother wanted reassurance that the daughter did not have a condition similar to that of the deceased sib. Blood pressure was 120/80 mm Hg and there was hepatosplenomegaly. A diagnosis of renal tubular ectasia and CHF was made by ultrasonography, radiologic studies, and a liver biopsy. The evidence from families such as this favors the concept that ARPCKD and CHF presenting as Blyth and Ockenden's perinatal form, and CHF and renal tubular ectasia as their juvenile form, are manifestations of the same genetic disorder, and that the different manifestations are more likely variations in expression than the results of different mutant genes. The manifestations in this family add weight to the growing body of evidence that intrafamilial variability may occur, not only in autosomal dominant conditions, but also in autosomal recessive disorders.

Renal complications of acquired immunodeficiency syndrome in children

A low incidence of renal disease was noted in a retrospective analysis of pediatric patients with acquired immunodeficiency syndrome. Episodes of acute renal failure were attributable to dehydration or nephrotoxicity. One patient, however, had nephrosis with focal glomerular sclerosis. Focal sclerosis involving 10% to 20% of glomeruli was evident in autopsy tissue from three patients.

Pancreatic endocrine insufficiency in posttransplant cystinosis

Nephropathic cystinosis causes renal death by approximately age 10 years. With increased life span due to kidney transplantation, ten to 25 years of cystine accumulation has resulted in pancreatic complications in individuals with cystinosis. We noted severe hyperglycemia in five posttransplant patients, three of whom remained insulin-dependent diabetics several years after transplant. The clinical findings were not consistent with steroid-dependent or insulin-resistant diabetes. Pancreatic cystine deposition was detected histologically and biochemically on post-mortem examination of two other patients. We conclude that hyperglycemia may be anticipated in the immediate posttransplant period in cystinotic patients and that some patients will require insulin therapy years later. The use of cystine-depleting agents should be considered in posttransplant cystinosis as an attempt to prevent potential damage to the pancreas and other organs from cystine deposition.

Polycythemia in pediatric renal transplantation

Post-transplant polycythemia is not uncommon in adult patients and is usually transient, responding to phlebotomy. Five pediatric patients developed erythrocytosis post-transplantation. Three patients had end-stage renal disease due to cystinosis, one had reflux glomerulopathy and one had focal glomerular sclerosis. The probable causes of the polycythemia were graft arterial stenosis in three patients. In one, polycythemia occurred with nephrosis. Polycythemia with hypertension may indicate the presence of arterial stenosis in children post-transplantation.

Relevance of constipation to enuresis, urinary tract infection and reflux. A review

Little attention has been afforded the relevance of constipation to urinary symptoms. Problems of definition and measurement have contributed to this problem. A review of the literature suggests that rectal dilatation may influence the function of the urinary tract leading to urinary tract infection and enuresis. Our studies indicate that constipation may, by causing uninhibited bladder contractions, cause urinary tract infection, enuresis and vesicoureteral reflux.

Constipation associated with vesicoureteral reflux

Seventeen children who had vesicoureteral reflux underwent urodynamic and rectal manometric studies. All had uninhibited bladder contractions. All had rectal dilatation confirming the presence of constipation by rectal balloon manometry. The recurrent association of constipation with ureteral reflux suggests the possibility of a nonfortuitous association.

Lack of antiglomerular basement membrane antibody binding to alveolar membranes after hydrocarbon exposure in rats

A causal relationship has been proposed for the development of Goodpasture's syndrome and hydrocarbon (gasoline) exposure in man. Infusion of antiglomerular basement membrane antibody into rats subjected to gasoline inhalation did not result in linear binding to alveolar basement membranes suggesting that the endothelial barriers remained intact despite administration of near lethal doses of gasoline.

Constipation a commonly unrecognized cause of enuresis

Constipation was confirmed by history, rectal examination, and rectal manometric studies in 22 of 25 children with enuresis. Treatment of constipation resulted in resolution of enuresis. Uninhibited bladder contractions, observed in enuretic constipated children, were also noted in children with constipation alone, suggesting that constipation is a commonly unrecognized etiologic factor in enuresis.

Hirschsprung's disease and urinary tract infection: unrecognized association

Constipation is associated with and may be an etiologic factor in recurrent urinary tract infection (UTI) in girls. To determine if an increased incidence of urinary infection occurs in constipating illness, we retrospectively analyzed UTI incidence in 146 patients with Hirschsprung's disease. An increased incidence pre- and postoperatively was noted.

Renal anomalies and agenesis associated with total intestinal aganglionosis

Four patients with total aganglionosis of the intestine had renal abnormalities. Two patients had cortical subcapsular cysts, one had unilateral renal agenesis and one other had unilateral renal dysplasia. The consistency of renal anomalies with total aganglionosis suggests the presence of a common genetic origin.

Femoral neuropathy after renal transplantation

We report 2 cases of cadaveric renal transplantation in which the grafts were placed in the right iliac fossa. Postoperatively, both patients complained of ipsilateral thigh weakness. Electromyography and nerve conduction studies indicated femoral nerve neuropathy. Muscle weakness gradually resolved. Difficulty was encountered in placing both grafts, and each kidney and limb were subjected to prolonged ischemia. We suggest that the femoral neuropathy was ischemic in origin.

Medullary sponge kidney in childhood

Medullary sponge kidney is reported in six children aged 2-18 years. One child was asymptomatic; the others had hematuria or a urine-concentrating defect. Renal function and size were otherwise normal, as was liver function. The diagnosis was made at excretory urography according to criteria established in adults. Sonography revealed hyperechogenic pyramids, at first at the periphery, later generalized. Computed tomography proved this to be calcium. Medullary sponge kidney is rare but exists in children. Sonography is very sensitive to the pyramidal nephrocalcinosis that complicates this disease and explains the frequent presenting symptom of hematuria in these children.

Constipation: a cause of enuresis, urinary tract infection and vesico-ureteral reflux in children

The observation that constipation alone may induce uninhibited bladder contractions in children and is associated with recurrent urinary tract infection in childhood suggests an etiologic association. Rectal distension due to faecal retention in chronic functional constipation causes bladder distortion and may cause stimulation of detrusor stretch receptors resulting in detrusor peroneal dyssynergism. Distortion of the trigonal area may result in failure of ureteral valve competence and allow for vesico-ureteric reflux.

Reconstitution of carrier-mediated choline transport in proteoliposomes prepared from presynaptic membranes of Torpedo electric organ, and its internal and external ionic requirements

Proteoliposomes made by a butanol-sonication technique from electric organ presynaptic membranes showed choline transport activity. In contrast to intact nerve terminals, the uptake of choline was dissociated from its conversion to acetylcholine in this preparation. The kinetics of choline uptake by proteoliposomes was best described by two Michaelis-Menten components. At a low concentration of choline, uptake was inhibited by hemicholinium-3 and required external Na+ and, thus, closely resembled high-affinity choline uptake by intact cholinergic nerve terminals. Choline transport could be driven by the Na+ gradient and by the transmembrane potential (inside negative) but did not directly require ATP. External Cl-, but not a Cl- gradient, was needed for choline transport activity. It is suggested that internal K+ plays a role in the retention of choline inside the proteoliposome. Proteoliposomes should prove a useful tool for both biochemical and functional studies of the high-affinity choline carrier.

Mesangial IgA deposits with steroid responsive nephrotic syndrome: probable minimal lesion nephrosis

Two children presented with nephrotic syndrome. Renal biopsy demonstrated minimal lesion nephrosis with mesangial IgA deposits. Response to prednisone therapy was prompt in both cases. The clinical and histologic features of these and other reported cases suggested a diagnosis of minimal lesion nephrosis and not IgA nephropathy (Berger's disease).

Local renal graft irradiation in children

Between 1974-1979, 64 renal cadaveric transplants were performed in 54 pediatric recipients at our institution. Forty eight of these 64 transplants experienced at least one episode of acute rejection. These patients were divided in two equal groups including 24 transplants in 21 recipients, one group treated with chemical immunosuppression alone, the other group treated by chemical immunosuppression and radiotherapy. Kidney survival at 2 years was 54.1% (13/24) in the control group treated by chemical immunosuppression alone. In the group treated by radiotherapy and immunosuppression, kidney survival after 2 years gave a success rate of 45.8% (11/24). Thus, it would appear that addition of radiotherapy to standard immunosuppressive treatment exerted no beneficial long term effect in acutely rejected renal transplants. In view of the disappointing results obtained with radiotherapy, it is felt that this mode of treatment should be restricted to use in particular circumstances as a temporary means of immunosuppression where systemic immunosuppression is hazardous.

Constipation, bladder instability, urinary tract infection syndrome

Forty-seven children with recurrent urinary tract infection were noted to have large fecal reservoirs by rectal examination and rectal manometry. Constipation was accompanied in the majority by enuresis and/or encopresis. Urodynamic studies indicated uninhibited bladder contractions. Aggressive treatment of the constipation resulted in cessation of infection in 44 patients, enuresis in 22 of 32 patients and encopresis in 20 of 21 patients and an improvement in bladder function with cessation of all other forms of treatment.

Nephrosis with varicocele: probable renal vein thrombosis

A 3-year-old boy with relapsing nephrosis presented with a left sided varicocele. Echographic studies demonstrated enlargement of the left kidney, and there was delayed excretion on renal scintigraphy suggesting the presence of renal vein thrombosis. The varicocele resolved with remission of his nephrosis.

Wegener's granulomatosis in a 7 year old child

A 7 year old boy presented with a history of recurrent episodes of sinusitis and otitis. He developed paresis of the external muscle of his right eye with exophthalmos. A biopsy of his sinus mucosa demonstrated necrotizing granulomatous involvement of the membranes with the presence of multiple giant cells interspersed in zones of fibrosis. A diagnosis of Wegener's granulomatosis was entertained. However the absence of pulmonary and renal manifestations did not allow for a definitive diagnosis to be made. He later developed hematuria and a renal biopsy demonstrated a renal lesions consistent with Wegener's granulomatosis. He has responded well to Cyclophosphamide and Prednisone therapy.