1
|
Wei J, Showen A, Bicki A, Lin F, McCulloch CE, Ku E, Hampson LA. Kidney transplant access for children and young adults with congenital anomalies of the kidney and urinary tract. Int Urol Nephrol 2023; 55:1531-1538. [PMID: 36626082 PMCID: PMC10185613 DOI: 10.1007/s11255-022-03459-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 12/27/2022] [Indexed: 01/11/2023]
Abstract
PURPOSE Although congenital anomalies of the kidney and urinary tract (CAKUT) are among the leading causes of end-stage kidney disease (ESKD) in children and young adults, kidney transplantation access for this population has not been well studied in the US. We compared transplantation access in the US based on whether the etiology of kidney disease was secondary to CAKUT, and additionally by CAKUT subgroups (anatomic vs. inherited causes of CAKUT). METHODS Using the United States Renal Data System, we conducted a retrospective cohort study of 80,531 children and young adults who started dialysis between 1995 and 2015. We used adjusted Cox models to examine the association between etiology of kidney disease (CAKUT vs. non-CAKUT, anatomic vs. inherited) and receipt of kidney transplantation, and secondarily, receipt of a living vs. deceased donor kidney transplant. RESULTS Overall, we found an increased likelihood of kidney transplantation access for participants with CAKUT compared to those without CAKUT (HR 1.23; 95% CI 1.20-1.27). Among the subset of individuals with CAKUT as the attributed cause of ESKD, we found a lower likelihood of kidney transplantation in those with anatomic causes of CAKUT compared to those with inherited causes of CAKUT (adjusted HR 0.85; 0.81-0.90). CONCLUSION There are notable disparities in kidney transplantation rates among CAKUT subgroups. Those with anatomic causes of CAKUT started on dialysis have significantly reduced access to kidney transplantations compared to individuals with inherited causes of CAKUT who were initiated on dialysis. Further studies are needed to understand barriers to transplantation access in this population.
Collapse
Affiliation(s)
- Jenny Wei
- Department of Medicine, Kaiser Permanente San Francisco, San Francisco, USA
| | - Amy Showen
- Department of Urology, University of California San Francisco, San Francisco, USA
| | - Alexandra Bicki
- Division of Pediatric Nephrology, Department of Pediatrics, University of California San Francisco, San Francisco, USA
| | - Feng Lin
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, USA
| | - Charles E McCulloch
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, USA
| | - Elaine Ku
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, USA.
- Divisions of Nephrology and Pediatric Nephrology, Department of Epidemiology and Biostatistics, Department of Medicine and Pediatrics, University of California San Francisco, 500 Parnassus Avenue, MBU-E 404, Box 0532, San Francisco, CA, 94143-0532, USA.
| | - Lindsay A Hampson
- Department of Urology, University of California San Francisco, San Francisco, USA
| |
Collapse
|
2
|
Exeni AM, Falke GF, Montal S, Rigali MP, Cisnero DR, Berberian L, Marchionatti S, Heredia S, Allegrotti HE, Torres SF, Russo RD, Rozanec J. Pediatric KT in children up to 15 kg: A single-center experience. Pediatr Transplant 2021; 25:e14102. [PMID: 34309990 DOI: 10.1111/petr.14102] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Revised: 06/29/2021] [Accepted: 07/13/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND KT is the preferred treatment for ESRD in pediatrics. However, it may be challenging in those weighing ≤15 kg with potential complications that impact on morbidity and graft loss. METHODS This retrospective review reports our experience in KT in children, weighing ≤15 kg, and the strategies to reduce morbidity and mortality. RESULTS All patients were on RRT prior to KT. Patients reached ESRD mainly due to urologic malformations (54.54%). LD was performed in 82% of patients. The recipient's median age was 2.83 years, and median weight 12.280 kg. Male sex was predominant (73%). All patients required transfusions of PRBCs. There was a high requirement for ventilated support in patients post-KT with no relation to weight, amount of resuscitation used intra-operatively or ml/kg of PRBCs. One patient presented with stenosis of the native renal artery. No patients presented DGF, graft thrombosis, or surgical complications. No association was found between cold ischemia and eGFR at 1 year (p = .12). In univariate analysis, eGFR at 1 year is related to AR. eGFR at 3 years is related to the number of UTI. Median follow-up was 1363 days. Patient and graft survival were 100%. CONCLUSIONS KT in children ≤15 kg can be challenging and requires a meticulous perioperative management and surgical expertise. Patient and graft survival are excellent with low rate of complications.
Collapse
Affiliation(s)
| | | | - Silvina Montal
- Surgery, Hospital Universitario Austral, Pilar, Argentina
| | | | | | - Leandro Berberian
- Pediatric Surgery and Urology, Hospital Universitario Austral, Pilar, Argentina
| | - Sofia Marchionatti
- Pediatric Surgery and Urology, Hospital Universitario Austral, Pilar, Argentina
| | - Soledad Heredia
- Pediatric Surgery and Urology, Hospital Universitario Austral, Pilar, Argentina
| | | | | | | | - José Rozanec
- Urology, Hospital Universitario Austral, Pilar, Argentina
| |
Collapse
|
3
|
Ghidini F, De Corti F, Fascetti Leon F, Vidal E, Rancan A, Parolin M, Zadra N, Grazzini M, Maria Antoniello L, Ganarin A, Maita S, Tognon C, Mognato G, Castagnetti M, Benetti E, Gamba P, Dall'Igna P. Extraperitoneal kidney transplantation: a comparison between children weighting ≤15 kg and >15 kg. Experience of a single institution. Transpl Int 2021; 34:2394-2402. [PMID: 34411366 PMCID: PMC9292289 DOI: 10.1111/tri.14015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 08/05/2021] [Accepted: 08/15/2021] [Indexed: 12/20/2022]
Abstract
Extraperitoneal approach is sometimes recommended for kidney transplantation (KT) in children weighting <15 kg. We hypothesized that this approach might be as successful as in patients with normal weight. Data of all consecutive KTs performed between 2013 and 2019 were retrospectively reviewed. Early outcomes and surgical complications were compared between children weighing ≤15 kg (low‐weight (LW) group) and those weighing >15 kg (Normal‐weight (NW) group). All the 108 KTs were performed through an extraperitoneal approach. The LW group included 31 patients (mean age 3.5 ± 1.4 years), whose mean weight was 11.1 ± 2.0 kg. In the LW group,—a primary graft nonfunction (PNGF) occurred in one patient (3.2%), surgical complications occurred in nine (29%), with four venous thrombosis. In the NW group, PNGF occurred in one case (1.3%), delayed graft function (DGF) in eight (10%), surgical complications in 11 (14%) with only one case of venous thrombosis. In both groups, no need for patch during wound closure and no wound dehiscence were reported. The extraperitoneal approach can be effectively used in LW children. No differences were observed in the overall complication rate (P = 0.10), except for the occurrence of venous thrombosis (P = 0.02). This might be related to patients’ characteristics of the LW group.
Collapse
Affiliation(s)
- Filippo Ghidini
- Pediatric Urology, Department of Women's and Children's Health, University of Padua, Padua, Italy.,Pediatric Surgery, Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Federica De Corti
- Pediatric Surgery, Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Francesco Fascetti Leon
- Pediatric Surgery, Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Enrico Vidal
- Department of Medical and Biological Sciences, University of Udine, Udine, Italy
| | - Alessandra Rancan
- Pediatric Surgery, Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Mattia Parolin
- Pediatric Nephrology, Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Nicola Zadra
- Department of Anesthesia and Intensive Care, Padua University Hospital, Padua, Italy
| | - Maurizia Grazzini
- Department of Anesthesia and Intensive Care, Padua University Hospital, Padua, Italy
| | - Luca Maria Antoniello
- Pediatric Surgery, Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Alba Ganarin
- Pediatric Surgery, Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Sonia Maita
- Pediatric Surgery, Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Costanza Tognon
- Department of Anesthesia and Intensive Care, Padua University Hospital, Padua, Italy
| | - Guendalina Mognato
- Pediatric Surgery, Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Marco Castagnetti
- Pediatric Urology, Department of Women's and Children's Health, University of Padua, Padua, Italy.,Department of Surgery, Oncology, and Gastroenterology, University of Padova, Padova, Italy
| | - Elisa Benetti
- Pediatric Nephrology, Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Piergiorgio Gamba
- Pediatric Surgery, Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Patrizia Dall'Igna
- Pediatric Surgery, Department of Emergencies and Organ Transplantation, University of Bari, Bari, Italy
| |
Collapse
|
4
|
Kim JK, Chua ME, Teoh CW, Lee MJ, Kesavan A, Hebert D, Lorenzo AJ, Farhat WA, Koyle MA. Assessment of prophylactic heparin infusion as a safe preventative measure for thrombotic complications in pediatric kidney transplant recipients weighing <20 kg. Pediatr Transplant 2019; 23:e13512. [PMID: 31169341 DOI: 10.1111/petr.13512] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 03/20/2019] [Accepted: 05/12/2019] [Indexed: 11/28/2022]
Abstract
Small-sized kidney recipients (<20 kg) are at high risk of allograft vessel thrombosis. HP has been used to mitigate this risk but may infer an increase in bleeding risks. Therefore, we aim to determine whether HP is a safe means to prevent thrombosis in small kidney transplant patients by comparing those who have received HP and those who have NHP. A retrospective review of patients < 20 kg who underwent kidney transplant in our institution from 2000 to 2015 was performed. At our institution, unfractionated heparin 10 units/kg/hour is used as HP since 2009. Patients at increased risk of thrombosis (previous thrombosis, thrombophilia, nephrotic syndrome) and bleeding (therapeutic doses of heparin, diagnosis of coagulopathy) were excluded. Fifty-six patients were identified (HP n = 46; NHP n = 10). Baseline demographics were similar between HP and NHP. There was no statistical difference in frequency of transfusions, surgical re-exploration, or thrombotic events between HP and NHP. The HP group was more likely to have drop in Hb > 20 g/L (67.4% vs 30.0%, P = 0.038), and those who had drop in Hb > 20 g/L were more likely to also require pRBC transfusions (63.0% vs 20.0%, P = 0.017). Within the HP group, those who had bleeding complications had similar Hb levels as those who did not at baseline and post-transplant. Outcomes in the HP and NHP groups were no different with respect to thrombosis or significant bleeding complications requiring pRBC transfusions or surgical intervention. Future prospective studies are required to investigate the balance of preventing thrombosis and risks of pRBC transfusions for small-sized kidney recipients.
Collapse
Affiliation(s)
- Jin K Kim
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of Urology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Michael E Chua
- Division of Urology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Chia Wei Teoh
- Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Min Joon Lee
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of Urology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Amre Kesavan
- Division of Urology, The Hospital for Sick Children, Toronto, Ontario, Canada.,School of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Diane Hebert
- Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Armando J Lorenzo
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Walid A Farhat
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Martin A Koyle
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
5
|
Intra-abdominal Complications After Pediatric Kidney Transplantation: Incidence and Risk Factors. Transplantation 2019; 103:1234-1239. [DOI: 10.1097/tp.0000000000002420] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
6
|
Outcome of kidney transplantation from young pediatric donors (aged less than 6 years) to young size-matched recipients. J Pediatr Urol 2019; 15:213-220. [PMID: 31005637 DOI: 10.1016/j.jpurol.2019.03.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 01/10/2019] [Accepted: 03/20/2019] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Pediatric donation is underutilized because of presumed increased risk of vascular thrombosis (VT) and graft loss. Using young pediatric donors (YPDs) for young pediatric recipients (YPRs) is suggested to be even at greater risk and therefore precluded in many centers. The aim of this study was to analyze the outcome of kidney transplantation (KT) from YPD to age-matched YPR. PATIENT AND METHODS A retrospective study of 118 pediatric KT performed between January 2007-July 2017. The authors identified KT with YPD (considered as those aged <6 years) and age-matched YPR. Organ allocation was performed based on the best paired size (YPR for YPR). Data were collected regarding donor and recipient characteristics, surgical and urological complications, graft loss, and outcomes. RESULTS Forty cases of YPD to age-matched YPR were identified (33.89% of the cohort). Mean recipient and donor age were 2.9 years (SD 1.68) and 2.24 years (SD 1.5), respectively. Mean recipient and donor weight were 12.7 kg (SD 4.1) and 13.7 kg (SD 4.15), respectively. Thirty of those young recipients (75%) weighed <15 kg. The most frequent primary renal disease was the congenital nephrotic syndrome. Nine out of 40 patients (22.5%) had received a previous KT before. Three received a combined liver-KT. Eight (20%) were classified as high immunological risk and 19 (47.5%) as high thrombotic risk. All allografts were implanted extraperitoneally and anastomosed to the iliac vessels. Major complications requiring reintervention occurred in seven patients (17.5%): three VT, three bleeding episodes, and one ureteral necrosis. Remarkably, only one surgical complication (VT) resulted in graft loss. Regarding long-term urological complications, four patients (10%) all with obstructive uropathy-developed vesicoureteral reflux to the graft. Actuarial graft survival at 1,5, and 10 years in the YPD to age-matched YPR cohort was 83% -78% -78%, respectively. Mean follow-up was 3.6 years (SD 3.2) (r = 7-10). Over time, eight patients lost their graft, not related to surgical factors in seven out of eight cases. CONCLUSION The authors suggest that KT using YPD for age-match YPR yields good results in expert centers, even in high-risk patients and is associated with good graft survival. In this series, surgical complications were rarely related to graft loss.
Collapse
|
7
|
Vascular thrombosis in pediatric kidney transplantation: Graft survival is possible with adequate management. J Pediatr Urol 2018; 14:222-230. [PMID: 29588143 DOI: 10.1016/j.jpurol.2018.01.027] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Accepted: 01/19/2018] [Indexed: 01/14/2023]
Abstract
OBJECTIVE Vascular thrombosis (VT) in pediatric kidney transplantation (KT) is a dreaded event that leads to graft loss in almost 100% of cases. In recent years, VT has become the most common cause of early graft loss. The aim of this study was to analyze our experience in diagnosis and treatment of VT and the impact of a new management protocol on patient outcome. METHODS We conducted a retrospective study of 176 consecutive KT performed at our institution by the pediatric urology team between January 2000 and December 2015 and identified patients with VT. A protocol of prevention and early detection of VT was introduced in 2012. RESULTS Out of 176 KT, nine cases of VT were identified (5.1%). The mean recipient age was 5.1 years (SD 4.9 years) and mean weight was 22.28 kg (SD 15.6 kg). Diagnosis was intraoperative in two cases and within the first 24 h after surgery in the remaining seven. Immediate surgical exploration was performed after diagnosis in all. Of the five episodes that occurred before 2012, all developed complete graft ischemia requiring transplantectomy. However, in the four cases diagnosed after 2012, graft perfusion could be restored in three, and abdominal wall closure with a mesh and delayed sequentially closure under ultrasound guidance was performed. With a follow-up of 30, 25, and 20 months, the three recovered grafts are still functioning normally. CONCLUSIONS Increased awareness and the application of a protocol for prevention, detection and treatment of VT in pediatric KT can prevent graft loss. Immediate surgical intervention is mandatory after diagnosis. Avoiding compartment syndrome with delayed sequential closure may be useful to improve graft survival.
Collapse
|
8
|
ElSheemy MS, Ghoneima W, Aboulela W, Daw K, Shouman AM, Shoukry AI, Soaida S, Salah DM, Bazaraa H, Fadel FI, Hussein AA, Habib E, Saad IR, El Ghoneimy M, Morsi HA, Lotfi MA, Badawy H. Risk factors for urological complications following living donor renal transplantation in children. Pediatr Transplant 2018; 22. [PMID: 29082641 DOI: 10.1111/petr.13083] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/08/2017] [Indexed: 11/29/2022]
Abstract
The aim of this study was to detect possible risk factors for UC and UTI following pediatric renal Tx and effect of these complications on outcome. One hundred and eight children who underwent living donor Tx between 2009 and 2015 were retrospectively included. Extraperitoneal approach was used with stented tunneled extravesical procedure. Mean recipient age was 9.89 ± 3.46 years while mean weight was 25.22 ± 10.43 kg. Seventy-three (67.6%) recipients were boys while 92 (85.2%) were related to donors. Urological causes of ESRD were present in 33 (30.6%) recipients (14 [13%] posterior urethral valve, 16 [14.8%] VUR, and 3 [2.8%] neurogenic bladder). Augmentation ileocystoplasty was performed in 9 (8.3%) patients. Mean follow-up was 39.3 ± 17.33 months. UC were detected in 10 (9.3%) children (leakage 4 [3.7%], obstruction 3 [2.8%], and VUR 3 [2.8%]) while UTIs were reported in 40 (37%) children. After logistic regression analysis, UC were significantly higher in children with cystoplasty (44.4% vs 6.1%; P = .001). UTIs were significantly higher in girls (51.4% vs 30.1%; P = .001) and in children with urological causes of ESRD (51.5% vs 30.7%; P = .049). UC and UTI were not significantly associated with increased graft loss or mortality. UC were significantly higher in children with cystoplasty while UTIs were significantly higher in girls and children with urological causes of ESRD. Presence of UC did not affect the rate of graft loss or mortality due to its early detection and proper management.
Collapse
Affiliation(s)
| | - Waleed Ghoneima
- Urology Department, Kasr Al-Ainy Hospital, Cairo University, Cairo, Egypt
| | - Waseem Aboulela
- Urology Department, Kasr Al-Ainy Hospital, Cairo University, Cairo, Egypt
| | - Kareem Daw
- Urology Department, Kasr Al-Ainy Hospital, Cairo University, Cairo, Egypt
| | - Ahmed M Shouman
- Urology Department, Kasr Al-Ainy Hospital, Cairo University, Cairo, Egypt
| | - Ahmed I Shoukry
- Urology Department, Kasr Al-Ainy Hospital, Cairo University, Cairo, Egypt
| | - Sherif Soaida
- Division of Pediatric Anesthesia, Kasr Al-Ainy Hospital, Cairo University, Cairo, Egypt
| | - Doaa M Salah
- Division of Pediatric Nephrology, Kasr Al-Ainy Hospital, Cairo University, Cairo, Egypt
| | - Hafez Bazaraa
- Division of Pediatric Nephrology, Kasr Al-Ainy Hospital, Cairo University, Cairo, Egypt
| | - Fatina I Fadel
- Division of Pediatric Nephrology, Kasr Al-Ainy Hospital, Cairo University, Cairo, Egypt
| | - Ahmed A Hussein
- Urology Department, Kasr Al-Ainy Hospital, Cairo University, Cairo, Egypt
| | - Enmar Habib
- Urology Department, Kasr Al-Ainy Hospital, Cairo University, Cairo, Egypt
| | - Ismail R Saad
- Urology Department, Kasr Al-Ainy Hospital, Cairo University, Cairo, Egypt
| | | | - Hany A Morsi
- Urology Department, Kasr Al-Ainy Hospital, Cairo University, Cairo, Egypt
| | - Mohammed A Lotfi
- Urology Department, Kasr Al-Ainy Hospital, Cairo University, Cairo, Egypt
| | - Hesham Badawy
- Urology Department, Kasr Al-Ainy Hospital, Cairo University, Cairo, Egypt
| |
Collapse
|
9
|
Misra P, Kirpalani A, Leung G, Vlachou PA, Lee JY, Jothy S, Zaltzman J, Yuen DA. The role of thrombectomy and diffusion-weighted imaging with MRI in post-transplant renal vein thrombosis: a case report. BMC Nephrol 2017; 18:224. [PMID: 28693502 PMCID: PMC5504730 DOI: 10.1186/s12882-017-0618-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 06/09/2017] [Indexed: 01/06/2023] Open
Abstract
Background Surgical thrombectomy in the context of acute renal vein thrombosis (RVT) post-transplantation has had limited success, with considerable variation in the surgical techniques used. Unfortunately, it is usually followed by allograft nephrectomy within a few days if rapid allograft recovery does not ensue. We report a case of acute RVT in which nephrectomy was not performed despite a prolonged requirement for dialysis post-thrombectomy, but with recovery of renal function 2 weeks later. We also report the findings of serial MRI with diffusion-weighted imaging (DW-MRI) throughout the patient’s recovery, which provided novel insights into allograft microvascular perfusion changes post-thrombectomy. Case presentation A 65-year old patient underwent living-unrelated kidney transplantation complicated by acute RVT. Surgical thrombectomy and irrigation led to a delayed, but significant, recovery of renal function. Serial non-contrast DW-MRI scanning was used to non-invasively assess microvascular renal blood flow post-operatively. Unlike standard Doppler ultrasonography, DW-MRI documented reduced microvascular perfusion initially, with gradual but incomplete recovery that mirrored the partial improvement in renal function. Conclusions Our findings suggest that surgical thrombectomy may be more effective than previously described if followed by careful patient observation. Moreover, diffusion-weighted MRI appears to provide important insights into the pathophysiology of delayed graft function and deserves further investigation.
Collapse
Affiliation(s)
- Paraish Misra
- Division of Nephrology, St. Michael's Hospital, University of Toronto, Toronto, ON, M5B 1W8, Canada
| | - Anish Kirpalani
- Department of Medical Imaging, St. Michael's Hospital, University of Toronto, 30 Bond Street, 3 Cardinal Carter South, Toronto, ON, M5B 1W8, Canada.,Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Rm 509, 5th Floor, 209 Victoria Street, Toronto, ON, M5B 1T8, Canada
| | - General Leung
- Department of Medical Imaging, St. Michael's Hospital, University of Toronto, 30 Bond Street, 3 Cardinal Carter South, Toronto, ON, M5B 1W8, Canada.,Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Rm 509, 5th Floor, 209 Victoria Street, Toronto, ON, M5B 1T8, Canada
| | - Paraskevi A Vlachou
- Department of Medical Imaging, St. Michael's Hospital, University of Toronto, 30 Bond Street, 3 Cardinal Carter South, Toronto, ON, M5B 1W8, Canada
| | - Jason Y Lee
- Division of Urology, Department of Surgery, St. Michael's Hospital, University of Toronto, 61 Queen Street East Suite 2-012, Toronto, ON, M5C 2T2, Canada
| | - Serge Jothy
- Department of Laboratory Medicine, St. Michael's Hospital, 30 Bond Street, Room 2-015 CC Wing, Toronto, ON, M5B 1W8, Canada.,Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Rm 509, 5th Floor, 209 Victoria Street, Toronto, ON, M5B 1T8, Canada
| | - Jeffrey Zaltzman
- Division of Nephrology, St. Michael's Hospital, University of Toronto, Toronto, ON, M5B 1W8, Canada.,Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Rm 509, 5th Floor, 209 Victoria Street, Toronto, ON, M5B 1T8, Canada
| | - Darren A Yuen
- Division of Nephrology, St. Michael's Hospital, University of Toronto, Toronto, ON, M5B 1W8, Canada. .,Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Rm 509, 5th Floor, 209 Victoria Street, Toronto, ON, M5B 1T8, Canada.
| |
Collapse
|
10
|
Saad IR, Habib E, ElSheemy MS, Abdel-Hakim M, Sheba M, Mosleh A, Salah DM, Bazaraa H, Fadel FI, Morsi HA, Badawy H. Outcomes of living donor renal transplantation in children with lower urinary tract dysfunction: a comparative retrospective study. BJU Int 2015; 118:320-6. [PMID: 26434410 DOI: 10.1111/bju.13347] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To compare outcomes of renal transplantation (RTx) in children with end-stage renal disease (ESRD) resulting from lower urinary tract dysfunction (LUTD) vs other causes. PATIENTS AND METHODS A database of children (<18 years old) who underwent RTx between May 2008 and April 2012 was reviewed. Patients were divided into those with LUTD (group A, n = 29) and those with other causes of ESRD (group B, n = 74). RTx was performed after achieving low intravesical pressure (<30 cmH2 O) with adequate bladder capacity and drainage. The groups were compared using Student's t-test, Mann-Whitney, chi-squared or exact tests. Graft survival rates (GSRs) were evaluated using Kaplan-Meier curves and the log-rank test. RESULTS The mean ± sd (range) age of the study cohort was 5.05 ± 12.4 (2.2-18) years. Causes of LUTD were posterior urethral valve (PUV; 41.4%), vesico-ureteric reflux (VUR; 37.9%), neurogenic bladder (10.3%), prune belly syndrome (3.4%), obstructive megaureter (3.4%) and urethral stricture disease (3.4%). There was no significant difference in age, dialysis duration or donor type. In group A, 25 of the 29 patients (86.2%) underwent ≥1 surgery to optimize the urinary tract for allograft. Pretransplant nephrectomy was performed in 15 of the 29 patients (51.7%), PUV ablation in nine patients (31%) and ileocystoplasty in four patients (13.7%). The mean ± sd follow-up was 4.52 ± 1.55 and 4.07 ± 1.27 years in groups A and B, respectively. There was no significant difference in creatinine and eGFR between the groups at different points of follow-up. The GSRs at the end of the study were 93.1 and 91.1% in groups A and B, respectively (P = 1.00). According to Kaplan-Meier survival curves, there was no significant difference in the GSR between the groups using the log-rank test (P = 0.503). No graft was lost as a result of urological complications. In group B, one child died from septicaemia. The rate of urinary tract infections was 24 and 12% in groups A and B, respectively, but was not significant. No significant difference was found between the groups with regard to the incidence of post-transplantation hydronephrosis. Of the 22 patients who had hydronephrosis after transplantation, three were complicated by UTI. Injection of bulking agents was required in two patients for treatment of grade 3 VUR. In the third patient, augmentation cystoplasty was needed. CONCLUSION Acceptable graft function, survival and UTI rates can be achieved in children with ESRD attributable to LUTD. Thorough assessment and optimization of LUT, together with close follow-up, are key for successful RTx.
Collapse
Affiliation(s)
- Ismail R Saad
- Department of Urology, Kasr Al-Ainy Hospitals, Cairo University, Cairo, Egypt
| | - Enmar Habib
- Department of Urology, Kasr Al-Ainy Hospitals, Cairo University, Cairo, Egypt
| | - Mohammed S ElSheemy
- Department of Urology, Kasr Al-Ainy Hospitals, Cairo University, Cairo, Egypt
| | - Mahmoud Abdel-Hakim
- Department of Urology, Kasr Al-Ainy Hospitals, Cairo University, Cairo, Egypt
| | - Mostafa Sheba
- Department of Urology, Kasr Al-Ainy Hospitals, Cairo University, Cairo, Egypt
| | - Aziz Mosleh
- Department of Urology, Kasr Al-Ainy Hospitals, Cairo University, Cairo, Egypt
| | - Doaa M Salah
- Division of Pediatric Nephrology, Kasr Al-Ainy Hospitals, Cairo University, Cairo, Egypt
| | - Hafez Bazaraa
- Division of Pediatric Nephrology, Kasr Al-Ainy Hospitals, Cairo University, Cairo, Egypt
| | - Fatina I Fadel
- Division of Pediatric Nephrology, Kasr Al-Ainy Hospitals, Cairo University, Cairo, Egypt
| | - Hany A Morsi
- Department of Urology, Kasr Al-Ainy Hospitals, Cairo University, Cairo, Egypt
| | - Hesham Badawy
- Department of Urology, Kasr Al-Ainy Hospitals, Cairo University, Cairo, Egypt
| |
Collapse
|
11
|
Renal transplantation in children weighing <15 kg: does concomitant lower urinary tract dysfunction influence the outcome? Pediatr Nephrol 2015; 30:1337-42. [PMID: 25601707 DOI: 10.1007/s00467-015-3047-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Revised: 01/02/2015] [Accepted: 01/05/2015] [Indexed: 10/24/2022]
Abstract
BACKGROUND We reviewed our experience with renal transplantation (RTx) in children weighing <15 kg to determine if the presence of lower urinary tract dysfunction (LUTD) influenced the outcome. METHODS Between 1987 and 2012, 68 RTx were performed in patients weighing less than 15 kg, including 17 with associated LUTD and 51 without. We detailed the lower urinary tract management in these patients, and compared graft survival rates and estimated clearance 12 and 60 months after RTx between groups. RESULTS None of the patients without LUTD required any lower urinary tract surgery vs 8 out of 17 (47 %) with LUTD (p = 0.0001). The latter included a temporary incontinent urinary diversion in 5 cases (29 %), namely 2 vesicostomies and 3 cutaneous ureterostomies. After comparable follow-ups, there was no difference in patient survival, graft survival, and glomerular filtration rates between groups. CONCLUSIONS Provided that there is appropriate bladder management, a concomitant LUTD does not adversely influence the outcome of RTx in patients weighing less than 15 kg. However, 50 % of our patients required lower urinary tract reconstruction and, in 30 %, a temporary incontinent urinary diversion was placed at RTx, since lower urinary tract function could not be assessed reliably, the patient was not collaborative enough to be involved in a voiding program, and/or the RTx was prioritized.
Collapse
|
12
|
Abstract
Due to progressive advances in surgical techniques, immunosuppressive therapies, and supportive care, outcomes from both solid organ transplantation and hematopoietic stem cell transplantation continue to improve. Thrombosis remains a challenging management issue in this context, with implications for both graft survival and long-term quality of life. Unfortunately, there remains a general paucity of pediatric-specific data regarding thrombosis incidence, risk stratification, and the safety or efficacy of preventative strategies with which to guide treatment algorithms. This review summarizes the available evidence and rationale underlying the spectrum of current practices aimed at preventing thrombosis in the transplant recipient, with a particular focus on risk factors, pathophysiology, and described antithrombotic regimens.
Collapse
Affiliation(s)
- J D Robertson
- Haematology Service, Division of Medicine, Lady Cilento Children's Hospital, Brisbane, Qld, Australia
| |
Collapse
|