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Claro AR, Oliveira AR, Durão F, Reis PC, Sandes AR, Pereira C, Esteves da Silva J. Growth after pediatric kidney transplantation: a 25-year study in a pediatric kidney transplant center. J Pediatr Endocrinol Metab 2024; 37:425-433. [PMID: 38630308 DOI: 10.1515/jpem-2023-0524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Accepted: 03/13/2024] [Indexed: 05/05/2024]
Abstract
OBJECTIVES Growth failure is one of the major complications of pediatric chronic kidney disease. Even after a kidney transplant (KT), up to 50 % of patients fail to achieve the expected final height. This study aimed to assess longitudinal growth after KT and identify factors influencing it. METHODS A retrospective observational study was performed. We reviewed the clinical records of all patients who underwent KT for 25 years in a single center (n=149) and performed telephone interviews. Height-for-age and body mass index (BMI)-for-age were examined at KT, 3 months, 6 months, 1 year, and 5 years post-transplant and at the transition to adult care. We evaluated target height, disease duration before KT, need and type of dialysis, recombinant human growth hormone pretransplant use, nutritional support, glomerular filtration rate (GFR), and cumulative corticosteroid dose. RESULTS At transplant, the average height z-score was -1.38, and height z-scores showed catch-up growth at 6 months (z-score -1.26, p=0.006), 1 year (z-score -1.15, p<0.001), 5 years after KT (z-score -1.08, p<0.001), and on transition to adult care (z-score -1.22, p=0.012). Regarding BMI z-scores, a significant increase was also detected at all time points (p<0.001). After KT, GFR was significantly associated with height z-score (p=0.006) and BMI z-score (p=0.006). The height in transition to adult care was -1.28 SD compared to the target height. CONCLUSIONS Despite the encouraging results regarding catch-up growth after KT in this cohort, results remain far from optimum, with a lower-than-expected height at the time of transition.
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Affiliation(s)
- Ana Raquel Claro
- Departamento de Pediatria, 218728 Hospital de Santa Maria - Centro Hospitalar Universitário de Lisboa Norte, EPE , Lisboa, Portugal
| | - Ana Rita Oliveira
- Serviço de Pneumologia, 218728 Hospital de Santa Maria - Centro Hospitalar Universitário de Lisboa Norte, EPE , Lisboa, Portugal
| | - Filipa Durão
- Departamento de Pediatria, Unidade de Nefrologia e Transplantação Renal Pediátrica, 218728 Hospital de Santa Maria - Centro Hospitalar Universitário de Lisboa Norte, EPE , Lisboa, Portugal
- Clínica Universitária de Pediatria, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
| | - Patrícia Costa Reis
- Departamento de Pediatria, Unidade de Nefrologia e Transplantação Renal Pediátrica, 218728 Hospital de Santa Maria - Centro Hospitalar Universitário de Lisboa Norte, EPE , Lisboa, Portugal
- Clínica Universitária de Pediatria, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
| | - Ana Rita Sandes
- Departamento de Pediatria, Unidade de Nefrologia e Transplantação Renal Pediátrica, 218728 Hospital de Santa Maria - Centro Hospitalar Universitário de Lisboa Norte, EPE , Lisboa, Portugal
- Clínica Universitária de Pediatria, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
| | - Carla Pereira
- Departamento de Pediatria, Unidade de Endocrinologia Pediátrica, 218728 Hospital de Santa Maria - Centro Hospitalar Universitário de Lisboa Norte, EPE , Lisboa, Portugal
| | - José Esteves da Silva
- Departamento de Pediatria, Unidade de Nefrologia e Transplantação Renal Pediátrica, 218728 Hospital de Santa Maria - Centro Hospitalar Universitário de Lisboa Norte, EPE , Lisboa, Portugal
- Clínica Universitária de Pediatria, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
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Ng NSL, Gajendran S, Plant N, Shenoy M. Evaluation of height centile growth patterns compared with parental-adjusted target height following kidney transplantation. Pediatr Transplant 2023; 27:e14508. [PMID: 36919675 DOI: 10.1111/petr.14508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 02/02/2023] [Accepted: 02/24/2023] [Indexed: 03/16/2023]
Abstract
BACKGROUND Early steroid withdrawal (ESW) improves growth following kidney transplant (KT). It is not known whether these children achieve target height within mid-parental height range post-KT. METHODS Retrospective analysis of growth patterns of KT recipients following ESW in our center between 2009 and 2020 had minimum follow-up period of 12 months. RESULTS Forty-eight (female 29.2%) KT recipients, median age 5.3 years at first KT, were included. At KT, 29 (60.4%) recipients had normal height (SDS≥-1.88) and in 23 (47.9%), the height was within their target height (parental-adjusted height SDS within ±1.55). The proportion of children achieving normal height at 1-, 2-, 3-, and 5-years post-KT (median 5.5 years) were 75%, 83.3%, 86.5%, and 88% respectively. The proportion of children achieving target height measured at the same intervals was 68.8%, 73.8%, 73%, and 80%, respectively. Children <6 years were most growth impaired at KT but were most likely to achieve target height within first-year post-KT (72%; p = .023). All 19 children with short stature at KT received dialysis. Three children received growth hormone post-KT. Children who did not achieve target height post-KT (n = 14), five had eGFR <60 mL/min/1.73 m2 , and eight were on corticosteroid therapy at latest follow-up. CONCLUSIONS Although vast majority of children achieved normal height post-KT following ESW during the first 5 years post-KT, 20% of these children had not achieved their target height post-KT.
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Affiliation(s)
- Natasha Su Lynn Ng
- Department of Paediatric Nephrology, Royal Manchester Children's Hospital, Manchester, UK
| | - Sellathurai Gajendran
- Department of Paediatric Nephrology, Royal Manchester Children's Hospital, Manchester, UK
| | - Nicholas Plant
- Department of Paediatric Nephrology, Royal Manchester Children's Hospital, Manchester, UK
| | - Mohan Shenoy
- Department of Paediatric Nephrology, Royal Manchester Children's Hospital, Manchester, UK
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3
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Early corticosteroid withdrawal is associated with improved adult height in pediatric kidney transplant recipients. Pediatr Nephrol 2023; 38:279-289. [PMID: 35482097 DOI: 10.1007/s00467-022-05581-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 04/06/2022] [Accepted: 04/07/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND Catch-up growth after pediatric kidney transplantation (kTx) is usually insufficient to reach normal adult height. We aimed to analyze the effect of pre-transplant recombinant human growth hormone (rhGH) and corticosteroid withdrawal on linear growth in the first year after kidney transplantation and identify factors associated with final height (FH). METHODS Patients who underwent kTx between 1996 and 2018 at below 18 years old in five Belgian and Dutch centers were included. We analyzed the differences between height Z-scores at kTx and 1 year post-transplant (Δ height Z-score) in children with and without corticosteroids at 1 year (CS + /CS -) and with and without rhGH treatment before kTx (rhGH + /rhGH -). Univariable and multivariable linear regression analysis was applied to identify factors associated with height Z-score at 1 year post-kTx, Δ height Z-score, and FH Z-score. RESULTS A total of 177 patients were included, with median age 9.3 years at kTx. Median height Z-scores pre-kTx and 1 year later in the CS - /rhGH - , CS + /rhGH - , CS - /rhGH + , and CS + /rhGH + groups were - 1.42/ - 0.80, - 0.90/ - 0.62, - 1.35/ - 1.20, and - 1.30/ - 1.60 (p = 0.001). CS use 1 year post-kTx was the only factor associated with Δ height (p = 0.003) on multivariable analysis. CS use at 1 year was the only variable associated with FH (p = 0.014) in children with pre-transplant height Z-score below - 1 (n = 52). CONCLUSIONS Increase in height Z-score in the first year post-kTx was highest in the CS - /rhGH - group and lowest in the CS + /rhGH + group. The use of corticosteroids at 1 year post-kTx is associated with catch-up growth and in children with pre-transplant height Z-score below - 1 also with final height. A higher resolution version of the Graphical abstract is available as Supplementary information.
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4
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Kizilbash SJ, Jensen CJ, Kouri AM, Balani SS, Chavers B. Steroid avoidance/withdrawal and maintenance immunosuppression in pediatric kidney transplantation. Pediatr Transplant 2022; 26:e14189. [PMID: 34786800 DOI: 10.1111/petr.14189] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 09/30/2021] [Accepted: 10/06/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Corticosteroids have been an integral part of maintenance immunosuppression for pediatric kidney transplantation. However, prolonged steroid therapy is associated with significant toxicities resulting in several SW/avoidance strategies in recent years. METHOD/OBJECTIVE This comprehensive review aims to discuss steroid-related toxicities and the safety, efficacy, and benefit of steroid avoidance/withdrawal immunosuppression in pediatric kidney transplant recipients. RESULTS Initial studies of SW/avoidance conducted in the setting of CSA and AZA showed an increased incidence of AR but no increase in graft loss or mortality with SW/avoidance maintenance immunosuppression. Studies performed under modern immunosuppression (induction therapy, Tac, and MMF) show no significant increase in AR or graft loss with SW/avoidance immunosuppression. Furthermore, SW/avoidance immunosuppression is associated with significant improvement in growth, BMI, BP control, and lipid profile in pediatric kidney transplant recipients. Despite these data, SW/avoidance remains controversial, and only 40% of pediatric kidney transplant recipients in the United States are currently on SW/avoidance maintenance immunosuppression. CONCLUSION SW/avoidance maintenance immunosuppression is safe and associated with fewer side effects compared with steroid-inclusive maintenance immunosuppression in pediatric kidney transplant recipients.
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Affiliation(s)
- Sarah J Kizilbash
- Pediatric Nephrology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Chelsey J Jensen
- Solid Organ Transplant, University of Minnesota, Minneapolis, Minnesota, USA
| | - Anne M Kouri
- Pediatric Nephrology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Shanthi S Balani
- Pediatric Nephrology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Blanche Chavers
- Pediatric Nephrology, University of Minnesota, Minneapolis, Minnesota, USA
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Gajardo M, Delucchi A, Pérez D, Cancino JM, Gálvez C, Ledezma X, Ceballos ML, Lillo AM, Cano F, Guerrero JL, Rojo A, Azócar M, González G, Pinilla C, Correa R, Toro L. Long-term outcome of early steroid withdrawal in pediatric renal transplantation. Pediatr Transplant 2021; 25:e14096. [PMID: 34327777 DOI: 10.1111/petr.14096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 06/15/2021] [Accepted: 07/08/2021] [Indexed: 01/29/2023]
Abstract
BACKGROUND Steroid use in renal transplant is related to multiple adverse effects. Long-term effects of early withdrawal steroids in pediatric renal transplant were assessed. METHODS Renal transplant children with low immunological risk treated on basiliximab, tacrolimus, and mycophenolate with steroid withdrawal or steroid control were evaluated between 2003 and 2019. Clinical variables, treatment adherence, acute rejection, graft loss, and death were analyzed through hazard ratios, and Kaplan-Meier and multivariate analyses. RESULTS The study included 152 patients, 71.1% steroid withdrawal, mean follow-up 8.5 years, 64.5% structural abnormalities, and 81.6% deceased donor. At 12 years of transplant, event-free survival analysis for graft loss or death showed no significant difference between steroid withdrawal and control steroid treatment (85.9% vs. 80.4%, p = .36) nor in acute rejection at 10 years (18.5% vs. 20.5%, p = .78) or in donor-specific antibody appearance (19.6% vs. 21.4%, p = .98). Delta height Z-score was increased in the steroid withdrawal group (p < .01). The main predictor of graft loss or death was non-adherence to treatment (p = .001; OR: 17.5 [3.3-90.9]). CONCLUSIONS Steroid withdrawal therapy was effective and safe for low-risk pediatric renal transplant in long-term evaluation. Non-adherence was the main predictor of graft loss or death.
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Affiliation(s)
- Macarena Gajardo
- Division of Nephrology, Hospital Luis Calvo Mackenna, Santiago, Chile.,University of Chile, Santiago, Chile.,Division of Nephrology, Hospital Roberto del Río, Santiago, Chile
| | - Angela Delucchi
- Division of Nephrology, Hospital Luis Calvo Mackenna, Santiago, Chile.,University of Chile, Santiago, Chile.,Division of Nephrology, Clínica Alemana, Santiago, Chile
| | - Diego Pérez
- Department of Pediatric, Hospital Luis Calvo Mackenna, Santiago, Chile
| | - José M Cancino
- Division of Nephrology, Hospital del Salvador, Santiago, Chile
| | - Carla Gálvez
- Division of Nephrology, Hospital Luis Calvo Mackenna, Santiago, Chile
| | - Ximena Ledezma
- Division of Nephrology, Hospital Luis Calvo Mackenna, Santiago, Chile
| | - María L Ceballos
- Division of Nephrology, Hospital Luis Calvo Mackenna, Santiago, Chile.,University of Chile, Santiago, Chile
| | - Ana M Lillo
- Division of Nephrology, Hospital Luis Calvo Mackenna, Santiago, Chile
| | - Francisco Cano
- Division of Nephrology, Hospital Luis Calvo Mackenna, Santiago, Chile.,University of Chile, Santiago, Chile
| | - José L Guerrero
- Division of Nephrology, Hospital Luis Calvo Mackenna, Santiago, Chile
| | - Angélica Rojo
- Division of Nephrology, Hospital Luis Calvo Mackenna, Santiago, Chile
| | - Marta Azócar
- Division of Nephrology, Hospital Luis Calvo Mackenna, Santiago, Chile.,University of Chile, Santiago, Chile
| | - Gloria González
- Renal transplant program, Hospital Luis Calvo Mackenna, Santiago, Chile
| | - Cesar Pinilla
- Renal transplant program, Hospital Luis Calvo Mackenna, Santiago, Chile
| | - Ramón Correa
- Renal transplant program, Hospital Luis Calvo Mackenna, Santiago, Chile
| | - Luis Toro
- Division of Nephrology, Department of Medicine, Hospital Clinico Universidad de Chile, Santiago, Chile.,Centro de Investigación Clínica Avanzada, Hospital Clinico Universidad de Chile, Santiago, Chile.,Critical Care Center, Clínica Las Condes, Santiago, Chile
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6
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Balani SS, Jensen CJ, Kouri AM, Kizilbash SJ. Induction and maintenance immunosuppression in pediatric kidney transplantation-Advances and controversies. Pediatr Transplant 2021; 25:e14077. [PMID: 34216190 DOI: 10.1111/petr.14077] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 05/04/2021] [Accepted: 05/26/2021] [Indexed: 12/16/2022]
Abstract
Advances in immunosuppression have improved graft survival in pediatric kidney transplant recipients; however, treatment-related toxicities need to be balanced against the possibility of graft rejection. Several immunosuppressive agents are available for use in transplant recipients; however, the optimal combinations of agents remain unclear, resulting in variations in institutional protocols. Lymphocyte-depleting antibodies, specifically ATG, are the most common induction agent used for pediatric kidney transplantation in the US. Basiliximab may be used for induction in immunologically low-risk children; however, pediatric data are scarce. CNIs and antiproliferative agents (mostly Tac and mycophenolate in recent years) constitute the backbone of maintenance immunosuppression. Steroid-avoidance maintenance regimens remain controversial. Belatacept and mTOR inhibitors are used in children under specific circumstances such as non-adherence or CNI toxicity. This article reviews the indications, mechanism of action, efficacy, dosing, and side effect profiles of various immunosuppressive agents available for pediatric kidney transplantation.
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Affiliation(s)
- Shanthi S Balani
- Pediatric Nephrology, University of Minnesota, Minneapolis, MN, USA
| | - Chelsey J Jensen
- Solid Organ Transplant, University of Minnesota, Minneapolis, MN, USA
| | - Anne M Kouri
- Pediatric Nephrology, University of Minnesota, Minneapolis, MN, USA
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7
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CMV, EBV, JCV and BKV infection and outcome following kidney transplantation in children initiated on a corticosteroid-minimisation immunosuppressive regimen. Pediatr Nephrol 2021; 36:3229-3240. [PMID: 33825043 DOI: 10.1007/s00467-021-05047-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 03/02/2021] [Accepted: 03/05/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Modern immunosuppressive regimens in paediatric kidney transplant recipients have contributed to improved long-term allograft survival, but at the expense of an increased incidence of viral infections. Here, we describe, for the first time, the incidence, risk factors and clinical outcome of CMV, EBV, BKV and JCV viraemia in a cohort of paediatric allograft recipients treated with a corticosteroid-minimisation immunosuppressive regimen (CMR). METHODS We retrospectively analysed 98 children treated with a CMR (basiliximab induction, corticosteroids until day 4, long-term tacrolimus and mycophenolate mofetil), who received a kidney transplant in our centre between 2009 and 2019. RESULTS Over the first 4 years post-transplant, the incidences of viraemia were as follows: CMV, 25.5%; EBV, 52.0%; JCV, 16.3%; BKV, 26.5%. Younger children at time of transplant were more likely to develop EBV and BKV viraemia. EBV viraemia was also associated with a regimen involving corticosteroids, but lacking MMF. Recipient CMV serology predicted the development of EBV, BKV and CMV viraemia. Fifty-six percent of CMV viraemia episodes in high-risk patients occurred whilst the graft recipients were still receiving anti-viral prophylaxis or within 3 months of cessation. There was no difference in graft function at latest follow-up between those with and without viraemia. CONCLUSIONS Judicious monitoring of viraemia, coupled with timely clinical intervention, can result in similar long-term outcomes for graft recipients compared to controls. The high incidence of CMV viraemia observed within a short period of cessation of anti-viral prophylaxis supports an extension of the length of prophylactic treatment in high-risk allograft recipients.
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Dudley J, Christian M, Andrews A, Andrews N, Baker J, Boyle S, Convery M, Gamston F, Garcia M, Haq S, Hegde S, Holt R, Jones H, Khan S, McCaughan J, Milford D, Pickles C, Reynolds B, Sathyanarayana V, Stojanovic J, Tse Y, Wallace D, Walsh G, Ware N, Williams A, Yadav P, Marks S. Clinical practice guidelines standardisation of immunosuppressive and anti-infective drug regimens in UK paediatric renal transplantation: the harmonisation programme. BMC Nephrol 2021; 22:312. [PMID: 34530758 PMCID: PMC8447621 DOI: 10.1186/s12882-021-02460-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 06/25/2021] [Indexed: 12/04/2022] Open
Affiliation(s)
- Jan Dudley
- Consultant Paediatric Nephrologist, Bristol, UK.
| | | | | | | | | | | | - Mairead Convery
- Consultant Paediatric Nephrologist, Belfast, Northern Ireland
| | | | - Martin Garcia
- Specialist trainee in Paediatric Nephrology, Evelina, London, UK
| | - Shuman Haq
- Consultant Paediatric Nephrologist, Southampton, UK
| | | | - Richard Holt
- Consultant Paediatric Nephrologist, Liverpool, UK
| | - Helen Jones
- Consultant Paediatric Nephrologist, Evelina, London, UK
| | | | | | | | | | | | | | | | - Yincent Tse
- Consultant Paediatric Nephrologist, Newcastle, UK
| | - Dean Wallace
- Consultant Paediatric Nephrologist, Manchester, UK
| | | | - Nick Ware
- Consultant Paediatric Nephrologist, Evelina, London, UK
| | | | | | - Stephen Marks
- Consultant Paediatric Nephrologist, Great Ormond St, London, UK
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9
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McCaffrey J, Shenoy M. Acute rejection and growth outcomes in paediatric kidney allograft recipients treated with a corticosteroid minimisation immunosuppressive protocol. Pediatr Nephrol 2021; 36:2463-2472. [PMID: 33560455 DOI: 10.1007/s00467-021-04948-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 12/16/2020] [Accepted: 01/12/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Corticosteroid minimisation immunosuppressive protocols (CMP) for children are an approach to safely reduce unwanted medication side effects associated with long-term exposure following kidney transplantation. Here, we provide data regarding the incidence of acute rejection and growth over an extended follow-up in children receiving the CMP used in our centre. METHODS We retrospectively analysed all children treated with a CMP who received a kidney transplant and had follow-up care in our centre between 2009 and 2019. Data were compared to 5 control groups from recent studies. RESULTS Ninety-nine kidney allograft recipients were included in the study (mean follow-up 4.4 years). There was no difference in the cumulative frequency of acute rejection in CMP-treated graft recipients compared to controls. Graft function at latest follow-up was significantly lower in graft recipients experiencing acute rejection compared to those without acute rejection (53.7 mL/min/1.73 m2 vs. 66.8 mL/min/1.73 m2, p = 0.021). Children experiencing >1 acute rejection episode had a greatly elevated risk of graft failure (p = 0.0009, OR 68.25). At latest follow-up, 64/90 (71.1%) graft recipients had a normal height, and younger graft recipients demonstrated greater catch up growth than older children. CMP-treated graft recipients showed a reduced rate of height deficit (28.9% vs. 55.1%, p = 0.0025), less obesity (12.2% vs. 23.9%, p = 0.031), and reduced rates of hypertension (35.4% vs. 68.2%, p< 0.0001). CONCLUSIONS Children treated with a CMP show greater height attainment, lower frequency of obesity, and reduced rates of hypertension, without an increased risk of acute rejection. Graphical abstract.
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Affiliation(s)
- James McCaffrey
- Department of Histopathology, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK
| | - Mohan Shenoy
- Department of Paediatric Nephrology, Royal Manchester Children's Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.
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10
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Bonthuis M, Harambat J, Jager KJ, Vidal E. Growth in children on kidney replacement therapy: a review of data from patient registries. Pediatr Nephrol 2021; 36:2563-2574. [PMID: 34143298 PMCID: PMC8260545 DOI: 10.1007/s00467-021-05099-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 04/27/2021] [Indexed: 12/12/2022]
Abstract
Growth retardation is a major complication in children with chronic kidney disease (CKD) and on kidney replacement therapy (KRT). Conversely, better growth in childhood CKD is associated with an improvement in several hard morbidity-mortality endpoints. Data from pediatric international registries has demonstrated that improvements in the overall conservative management of CKD, the search for optimal dialysis, and advances in immunosuppression and kidney transplant techniques have led to a significant improvement of final height over time. Infancy still remains a critical period for adequate linear growth, and the loss of stature during the first years of life influences final height. Preliminary new original data from the European Society for Paediatric Nephrology/European Renal Association-European Dialysis and Transplant Association (ESPN/ERA-EDTA) Registry confirm an association between the final height and the height attained at 2 years in children on KRT.
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Affiliation(s)
- Marjolein Bonthuis
- ESPN/ERA-EDTA Registry, Department of Medical Informatics, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, J1B-108.1, P.O. Box 22700, 1100 DE, Amsterdam, The Netherlands.
| | - Jérôme Harambat
- Department of Pediatrics, Bordeaux University Hospital, Bordeaux Population Health Research Center UMR 1219, University of Bordeaux, Bordeaux, France
| | - Kitty J Jager
- ESPN/ERA-EDTA Registry, Department of Medical Informatics, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, J1B-108.1, P.O. Box 22700, 1100 DE, Amsterdam, The Netherlands
| | - Enrico Vidal
- Division of Pediatrics, Department of Medicine, University of Udine, Udine, Italy
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11
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Aref A, Sharma A, Halawa A. Does steroid-free immunosuppression improve the outcome in kidney transplant recipients compared to conventional protocols? World J Transplant 2021; 11:99-113. [PMID: 33954088 PMCID: PMC8058645 DOI: 10.5500/wjt.v11.i4.99] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 01/22/2021] [Accepted: 03/19/2021] [Indexed: 02/06/2023] Open
Abstract
Steroids continue to be the cornerstone of immune suppression since the early days of organ transplantation. Steroids are key component of induction protocols, maintenance therapy and in the treatment of various forms of rejection. Prolonged steroid use resulted in significant side effects on almost all the body organs owing to the presence of steroid receptors in most of the mammalian cells. Kidney allograft recipients had to accept the short and long term complications of steroids because of lack of effective alternatives. This situation changed with the intro-duction of newer and more effective immune suppression agents with a relatively more acceptable side effect profile. As a result, the clinicians have been contemplating if it is the time to abandon the unquestionable reliance on maintenance steroids in modern transplantation practice. This review aims to evaluate the safety and efficacy of various steroid-minimization approaches (steroid avoidance, early steroid withdrawal, and late steroid withdrawal) in kidney transplant recipients. A meticulous electronic search was conducted through the available data resources like SCOPUS, MEDLINE, and Liverpool University library e-resources. Relevant articles obtained through our search were included. A total number of 90 articles were eligible to be included in this review [34 randomised controlled trials (RCT) and 56 articles of other research modalities]. All articles were evaluating the safety and efficacy of various steroid-free approaches in comparison to maintenance steroids. We will cover only the RCT articles in this review. If used in right clinical context, steroid-free protocols proved to be comparable to steroid-based maintenance therapy. The appropriate approach should be tailored individually according to each recipient immuno-logical challenges and clinical condition.
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Affiliation(s)
- Ahmed Aref
- Department of Nephrology, Sur hospital, Sur 411, Oman
| | - Ajay Sharma
- Department of Transplantation, Royal Liverpool University Hospitals, Liverpool 111, United Kingdom
| | - Ahmed Halawa
- Department of Transplantation, Sheffield Teaching Hospitals, Sheffield S5 7AU, United Kingdom
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12
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Liverman R, Chandran MM, Crowther B. Considerations and controversies of pharmacologic management of the pediatric kidney transplant recipient. Pharmacotherapy 2021; 41:77-102. [PMID: 33151553 DOI: 10.1002/phar.2483] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 09/18/2020] [Accepted: 10/10/2020] [Indexed: 12/23/2022]
Abstract
Pediatric kidney transplantation has experienced considerable growth and improvement in patient and allograft outcomes over the past 20 years, in part due to advancements in immunosuppressive regimens and management. Despite this progress, care for this unique population can be challenging due to limited pediatric transplant data and trials, intricacies related to differences in children and adolescents compared with their adult counterparts, and limitations to long-term survival facing all solid organ transplant populations. Immunosuppression and infection prevention practices vary from one pediatric transplant center to another and clinical controversies exist surrounding treatment and dosing. This review aims to summarize key aspects of pharmacologic management in this population and present pertinent data that describe the influence of practice to serve as a resource for practitioners caring for this unique specialty patient population. Additionally, this review highlights select controversies that exist within pediatric kidney transplantation.
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Affiliation(s)
- Rochelle Liverman
- Department of Pharmacy, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Mary Moss Chandran
- Department of Pharmacy, Childeren's Hospital Colorado, Aurora, Colorado, USA
| | - Barrett Crowther
- Ambulatory Care Pharmacy Services, University of Colorado Hospital, Aurora, Colorado, USA
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13
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Grohs J, Rebling RM, Froede K, Hmeidi K, Pavičić L, Gellermann J, Müller D, Querfeld U, Haffner D, Živičnjak M. Determinants of growth after kidney transplantation in prepubertal children. Pediatr Nephrol 2021; 36:1871-1880. [PMID: 33620573 PMCID: PMC8172393 DOI: 10.1007/s00467-021-04922-2] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 11/23/2020] [Accepted: 01/05/2021] [Indexed: 01/23/2023]
Abstract
BACKGROUND Short stature is a frequent complication after pediatric kidney transplantation (KT). Whether the type of transplantation and prior treatment with recombinant human growth hormone (GH) affects post-transplant growth, is unclear. METHODS Body height, leg length, sitting height, and sitting height index (as a measure of body proportions) were prospectively investigated in 148 prepubertal patients enrolled in the CKD Growth and Development study with a median follow-up of 5.0 years. We used linear mixed-effects models to identify predictors for body dimensions. RESULTS Pre-transplant Z scores for height (- 2.18), sitting height (- 1.37), and leg length (- 2.30) were reduced, and sitting height index (1.59) was increased compared to healthy children, indicating disproportionate short stature. Catch-up growth in children aged less than 4 years was mainly due to stimulated trunk length, and in older children to improved leg length, resulting in normalization of body height and proportions before puberty in the majority of patients. Use of GH in the pre-transplant period, congenital CKD, birth parameters, parental height, time after KT, steroid exposure, and transplant function were significantly associated with growth outcome. Although, unadjusted growth data suggested superior post-transplant growth after (pre-emptive) living donor KT, this was no longer true after adjusting for the abovementioned confounders. CONCLUSIONS Catch-up growth after KT is mainly due to stimulated trunk growth in young children (< 4 years) and improved leg growth in older children. Beside transplant function, steroid exposure and use of GH in the pre-transplant period are the main potentially modifiable factors associated with better growth outcome.
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Affiliation(s)
- Julia Grohs
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Children’s Hospital, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Rainer-Maria Rebling
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Children’s Hospital, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Kerstin Froede
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Children’s Hospital, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Kristin Hmeidi
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Children’s Hospital, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany ,Department of Orthopedic Surgery, Vivantes Auguste-Viktoria-Hospital, Rubensstr. 125, 12157 Berlin, Germany
| | | | - Jutta Gellermann
- Department Department of Pediatrics, Division of Gastroenterology, Nephrology and Metabolic Diseases, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum, Augstenburger Platz 1, 13353 Berlin, Germany
| | - Dominik Müller
- Department Department of Pediatrics, Division of Gastroenterology, Nephrology and Metabolic Diseases, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum, Augstenburger Platz 1, 13353 Berlin, Germany
| | - Uwe Querfeld
- Department Department of Pediatrics, Division of Gastroenterology, Nephrology and Metabolic Diseases, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum, Augstenburger Platz 1, 13353 Berlin, Germany
| | - Dieter Haffner
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Children’s Hospital, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Miroslav Živičnjak
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Children's Hospital, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
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14
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Tönshoff B, Tedesco-Silva H, Ettenger R, Christian M, Bjerre A, Dello Strologo L, Marks SD, Pape L, Veldandi U, Lopez P, Cousin M, Pandey P, Meier M. Three-year outcomes from the CRADLE study in de novo pediatric kidney transplant recipients receiving everolimus with reduced tacrolimus and early steroid withdrawal. Am J Transplant 2021; 21:123-137. [PMID: 32406111 DOI: 10.1111/ajt.16005] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 04/27/2020] [Accepted: 04/30/2020] [Indexed: 01/25/2023]
Abstract
CRADLE was a 36-month multicenter study in pediatric (≥1 to <18 years) kidney transplant recipients randomized at 4 to 6 weeks posttransplant to receive everolimus + reduced-exposure tacrolimus (EVR + rTAC; n = 52) with corticosteroid withdrawal at 6-month posttransplant or continue mycophenolate mofetil + standard-exposure TAC (MMF + sTAC; n = 54) with corticosteroids. The incidence of composite efficacy failure (biopsy-proven acute rejection [BPAR], graft loss, or death) at month 36 was 9.8% vs 9.6% (difference: 0.2%; 80% confidence interval: -7.3 to 7.7) for EVR + rTAC and MMF + sTAC, respectively, which was driven by BPARs. Graft loss was low (2.1% vs 3.8%) with no deaths. Mean estimated glomerular filtration rate at month 36 was comparable between groups (68.1 vs 67.3 mL/min/1.73 m2 ). Mean changes (z-score) in height (0.72 vs 0.39; P = .158) and weight (0.61 vs 0.82; P = .453) from randomization to month 36 were comparable, whereas growth in prepubertal patients on EVR + rTAC was better (P = .050) vs MMF + sTAC. The overall incidence of adverse events (AEs) and serious AEs was comparable between groups. Rejection was the leading AE for study drug discontinuation in the EVR + rTAC group. In conclusion, though AE-related study drug discontinuation was higher, an EVR + rTAC regimen represents an alternative treatment option that enables withdrawal of steroids as well as reduction of CNIs for pediatric kidney transplant recipients. ClinicalTrials.gov: NCT01544491.
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Affiliation(s)
- Burkhard Tönshoff
- Department of Pediatrics I, University Children's Hospital Heidelberg, Heidelberg, Germany
| | | | - Robert Ettenger
- Division of Pediatric Nephrology, UCLA Mattel Children's Hospital, Los Angeles, California, USA
| | - Martin Christian
- Department of Pediatric Nephrology, Nottingham Children's Hospital, Nottingham, UK
| | - Anna Bjerre
- Division of Pediatric and Adolescent Medicine, Department of Pediatrics, Oslo University Hospital, Oslo, Norway
| | - Luca Dello Strologo
- Nephrology Unit, Department of Pediatrics, Institute for Scientific Research, Bambino Gesù Children's Hospital, Rome, Italy
| | - Stephen D Marks
- Department of Pediatric Nephrology, Great Ormond Street Hospital for Children, NHS Foundation Trust and University College London Great Ormond Street Institute of Child Health, NIHR Great Ormond Street Hospital Biomedical Research Centre, London, UK
| | - Lars Pape
- Department of Pediatric Nephrology, Hannover Medical School, Hannover, Germany
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15
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Pickles C, Kaur A, Wallace D, Brix C, Lennon R, Plant N, Shenoy M. Bilateral native nephrectomies for severe hypertension in children with stage 5 chronic kidney disease leads to improved BP control following transplantation. Pediatr Nephrol 2020; 35:2373-2376. [PMID: 32885281 PMCID: PMC7614297 DOI: 10.1007/s00467-020-04738-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 07/21/2020] [Accepted: 08/04/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Hypertension is a common problem in stage 5 chronic kidney disease (CKD 5) and following kidney transplantation (KT). There is limited data on the outcome of children with CKD 5 who undergo bilateral native nephrectomies (BNN) for the management of hypertension. METHOD Retrospective review of 134 children who underwent KT at a single centre over a 10-year period and had a minimum follow up period of 1 year. Children who had undergone BNN for hypertension prior to, and after, KT were identified and their outcome with regard to blood pressure (BP), anti-hypertensive medications and graft function was compared with that of the rest of the cohort. RESULTS Eleven children (8.2%) underwent BNN, including 2 performed after KT, due to poorly controlled BP despite a median of 3 anti-hypertensive medications. The median age at BNN was 7 years (range 0.5-17 years). All 9 children who underwent BNN prior to KT discontinued anti-hypertensive medication after a median of 6 months and remained normotensive post KT. After a median follow up of 5 years following KT, there was a trend towards lower prevalence of hypertension in children who underwent BNN compared with that of the rest of the cohort (9.1% vs 25%, p 0.23). None of the children who underwent BNN had any evidence of proteinuria, and the median eGFR was 74 ml/min/1.73 m 2 after KT. CONCLUSION BNN for severe hypertension in CKD 5 is associated with resolution of hypertension prior to KT. It is also associated with a trend towards lower prevalence of hypertension and good graft function following KT.
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Affiliation(s)
- Charles Pickles
- Department of Paediatric Nephrology, Royal Manchester Children's Hospital, Oxford Road, Manchester, M13 9WL, UK
| | - Amrit Kaur
- Department of Paediatric Nephrology, Royal Manchester Children's Hospital, Oxford Road, Manchester, M13 9WL, UK
| | - Dean Wallace
- Department of Paediatric Nephrology, Royal Manchester Children's Hospital, Oxford Road, Manchester, M13 9WL, UK
| | - Christian Brix
- Department of Paediatric Nephrology, Royal Manchester Children's Hospital, Oxford Road, Manchester, M13 9WL, UK
| | - Rachel Lennon
- Department of Paediatric Nephrology, Royal Manchester Children's Hospital, Oxford Road, Manchester, M13 9WL, UK.,Wellcome Centre for Cell-Matrix Research, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Nicholas Plant
- Department of Paediatric Nephrology, Royal Manchester Children's Hospital, Oxford Road, Manchester, M13 9WL, UK
| | - Mohan Shenoy
- Department of Paediatric Nephrology, Royal Manchester Children's Hospital, Oxford Road, Manchester, M13 9WL, UK.
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16
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Growth Patterns After Kidney Transplantation in European Children Over the Past 25 Years: An ESPN/ERA-EDTA Registry Study. Transplantation 2020; 104:137-144. [PMID: 30946218 DOI: 10.1097/tp.0000000000002726] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Improved management of growth impairment might have resulted in less growth retardation after pediatric kidney transplantation (KT) over time. We aimed to analyze recent longitudinal growth data after KT in comparison to previous eras, its determinants, and the association with transplant outcome in a large cohort of transplanted children using data from the European Society for Paediatric Nephrology/European Renal Association and European Dialysis and Transplant Association Registry. METHODS A total of 3492 patients transplanted before 18 years from 1990 to 2012 were included. Height SD scores (SDS) were calculated using recent national or European growth charts. We used generalized equation models to estimate the prevalence of growth deficit and linear mixed models to calculate adjusted mean height SDS. RESULTS Mean adjusted height post-KT was -1.77 SDS. Height SDS was within normal range in 55%, whereas 28% showed moderate, and 17% severe growth deficit. Girls were significantly shorter than boys, but catch-up growth by 5 years post-KT was observed in both boys and girls. Children <6 years were shortest at KT and showed the greatest increase in height, whereas there was no catch-up growth in children transplanted >12. CONCLUSIONS Catch-up growth post-KT remains limited, height SDS did not improve over time, resulting in short stature in nearly half of transplanted children in Europe.
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17
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Hirata Y, Sanada Y, Omameuda T, Katano T, Miyahara G, Yamada N, Okada N, Onishi Y, Sakuma Y, Sata N. Liver Transplant for Posthepatectomy Liver Failure in Hepatoblastoma. EXP CLIN TRANSPLANT 2020; 18:612-617. [PMID: 32799783 DOI: 10.6002/ect.2019.0323] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Predicting the risk of posthepatectomy liver failure is important when performing extended hepatectomy. However, there is no established method to evaluate liver function and improve preoperative liver function in pediatric patients. MATERIALS AND METHODS We show the clinical features of pediatric patients who underwent living donor liver transplant for posthepatectomy liver failure in hepatoblastoma. The subjects were 4 patients with hepatoblastoma who were classified as Pretreatment Extent of Disease III, 2 of whom had distal metastasis (chest wall and lung). RESULTS Hepatic right trisegmentectomy was performed in 3 patients and extended left hepatectomy in 1 patient. The median alpha-fetoprotein level at the diagnosis of hepatoblastoma was 986300 ng/mL (range, 22500-2726350 ng/mL), and the median alpha-fetoprotein level before hepatectomy was 8489 ng/mL (range, 23-22500 ng/mL). The remnant liver volume after hepatectomy was 33.3% (range, 20% to 34.9%). Four patients had cholangitis after hepatectomy and progressed to posthepatectomy liver failure. The peak serum total bilirubin after hepatectomy was 11.4 mg/dL (range, 8.7-14.6 mg/dL). Living donor liver transplant was performed for these 4 patients with posthepatectomy liver failure, and they did not have a recurrence. CONCLUSIONS When the predictive remnant liver volume by computed tomography-volumetry before extended hepatectomy for patients with hepatoblastoma is less than 40%, the possibility of posthepatectomy liver failure should be recognized.
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Affiliation(s)
- Yuta Hirata
- >From the Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Shimotsuke City, Tochigi, Japan
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18
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19
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Tönshoff B. Immunosuppressive therapy post-transplantation in children: what the clinician needs to know. Expert Rev Clin Immunol 2020; 16:139-154. [DOI: 10.1080/1744666x.2020.1714437] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Burkhard Tönshoff
- Department of Pediatrics I, University Children’s Hospital, Heidelberg, Germany
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20
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Haffner D. Strategies for Optimizing Growth in Children With Chronic Kidney Disease. Front Pediatr 2020; 8:399. [PMID: 32850527 PMCID: PMC7406572 DOI: 10.3389/fped.2020.00399] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 06/10/2020] [Indexed: 01/30/2023] Open
Abstract
Growth failure is a hallmark in children with chronic kidney disease (CKD). Therefore, early diagnosis and adequate management of growth failure is of utmost importance in these patients. The risk of severe growth retardation is the higher the younger the child is, which places an additional burden on patients and their families and hampers the psychosocial integration of these children. Careful monitoring of growth, and effective interventions are mandatory to prevent and treat growth failure in children with CKD at all ages and all stages of kidney failure. Early intervention is critical, as all therapeutic interventions are much more effective if they are started prior to the initiation of dialysis. Prevention and treatment of growth failure focuses on: (i) preservation of renal function, e.g., normalization of blood pressure and proteinuria by use of inhibitors of the renin-angiotensin aldosterone system, (ii) adequate energy intake, including tube feeding or gastrostomy in case of persisting malnutrition, (iii) substitution of water and electrolytes, especially in children with renal malformation, (iv) correction of metabolic acidosis, (v) control of parathyroid hormone levels within the CKD-dependent target range, (vi) use of recombinant human growth hormone in cases of persistent growth failure, and, (vii) early/preemptive kidney transplantation using steroid-minimizing immunosuppressive protocols in children with end-stage CKD. This review discusses these measures based on recent guidelines.
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Affiliation(s)
- Dieter Haffner
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School Children's Hospital, Hanover, Germany
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21
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Lopez-Gonzalez M, Munoz M, Perez-Beltran V, Cruz A, Gander R, Ariceta G. Linear Growth in Pediatric Kidney Transplant Population. Front Pediatr 2020; 8:569616. [PMID: 33364221 PMCID: PMC7752780 DOI: 10.3389/fped.2020.569616] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 10/26/2020] [Indexed: 11/13/2022] Open
Abstract
Introduction: Growth retardation is one of the main complications of chronic kidney disease (CKD) in children and induces a negative impact on quality of life. Materials and Methods: Retrospective analysis of all consecutive patients younger than 18 years old who received a first KT in our center between 2008 and 2018. Results: 95 first KT recipients, median age at KT of 7.83 years. At the time of KT, 65.52% of males and 54.05% females showed normal height. After transplantation, linear growth improved from -1.53 at transplant to -1.37 SDS height at the last visit. We detected a different linear growth pattern according to patient age at KT. Children younger than 3 years old exhibited the most significant growth retardation at baseline and the greatest linear growth over time (-2.29 vs. -1.82 SDS height), whereas catch-up was not observed in older patients. Multivariate analysis showed that use of corticosteroids was negatively related to SDS height at 1 year after transplantation and final SDS height only was positively associated with SDS height at KT. 44.2 and 22.1% patients received rhGH treatment before and after KT. 71.88% patients reached adulthood with normal final height. Conclusions: In our study, pediatric KT recipients exhibited a normal height in more than half of cases at KT and in more than two thirds at the final adult height. Only children younger than 6 years old presented a relevant growth catch-up after KT. Treatment with rhGH was used before and after KT with significant improvement in height.
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Affiliation(s)
| | - Marina Munoz
- Department of Pediatric Nephrology, University Hospital Vall d'Hebron, Barcelona, Spain
| | - Victor Perez-Beltran
- Department of Pediatric Nephrology, University Hospital Vall d'Hebron, Barcelona, Spain
| | - Alejandro Cruz
- Department of Pediatric Nephrology, University Hospital Vall d'Hebron, Barcelona, Spain
| | - Romy Gander
- Pediatric Urology and Renal Transplant Unit, Department of Pediatric Surgery, University Hospital Vall d'Hebron, Barcelona, Spain
| | - Gema Ariceta
- Department of Pediatric Nephrology, University Hospital Vall d'Hebron, Barcelona, Spain.,Department of Pediatrics, University Autonomous of Barcelona, Barcelona, Spain
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22
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Vock DM, Matas AJ. Rapid discontinuation of prednisone in kidney transplant recipients from at-risk subgroups: an OPTN/SRTR analysis. Transpl Int 2019; 33:181-201. [PMID: 31557340 DOI: 10.1111/tri.13530] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 07/30/2019] [Accepted: 09/19/2019] [Indexed: 12/23/2022]
Abstract
Although rapid discontinuation of prednisone (RDP) after kidney transplantation has been successful in low-risk recipients, there is concern about RDP use in recipients at increased risk for rejection or recurrent disease. Using SRTR, we compared outcomes for RDP versus maintenance prednisone-treated recipients for all adult 1st and 2nd transplants (n = 169 479) and the following 1st transplant subgroups: African American (AA); highly sensitized; those with a potentially recurrent disease; and pediatric recipients. For all adult 1st LD and DD transplants, RDP was associated with better patient and graft survival. For all LD subgroups, RDP and maintenance prednisone were associated with similar patient, graft, and death-censored (DC) graft survival. For 1st transplant DD subgroups, RDP was associated with better patient survival in AA, those with potentially recurrent disease, and pediatric recipients; graft survival with RDP was better in AAs. For adult 2nd DD transplants, RDP was associated with worse DC-graft survival. Importantly, for all differences, the effect size was small. With the exception of 2nd DD transplants, RDP protocols can be used without decreasing patient or graft survival for subgroups of 1st DD and LD kidney transplant recipients and for 2nd LD transplant recipients, at increased risk of rejection or recurrent disease.
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Affiliation(s)
- David M Vock
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Arthur J Matas
- Division of Transplantation, Department of Surgery, Medical School, University of Minnesota, Minneapolis, MN, USA
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23
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Vondrak K, Parisi F, Dhawan A, Grenda R, Webb NJA, Marks SD, Debray D, Holt RCL, Lachaux A, Kelly D, Kazeem G, Undre N. Efficacy and safety of tacrolimus in de novo pediatric transplant recipients randomized to receive immediate- or prolonged-release tacrolimus. Clin Transplant 2019; 33:e13698. [PMID: 31436896 PMCID: PMC6900073 DOI: 10.1111/ctr.13698] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 08/06/2019] [Accepted: 08/19/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS This multicenter trial compared immediate-release tacrolimus (IR-T) vs prolonged-release tacrolimus (PR-T) in de novo kidney, liver, and heart transplant recipients aged <16 years. Each formulation had similar pharmacokinetic (PK) profiles. Follow-up efficacy and safety results are reported herein. MATERIALS AND METHODS Patients, randomized 1:1, received once-daily, PR-T or twice-daily, IR-T within 4 days of surgery. After a 4-week PK assessment, patients continued randomized treatment for 48 additional weeks. At Year 1, efficacy assessments included the number of clinical acute rejections, biopsy-confirmed acute rejection (BCAR) episodes (including severity), patient and graft survival, and efficacy failure (composite of death, graft loss, BCAR, or unknown outcome). Adverse events were assessed throughout. RESULTS The study included 44 children. At Year 1, mean ± standard deviation tacrolimus trough levels were 6.6 ± 2.2 and 5.4 ± 1.6 ng/mL, and there were 2 and 7 acute rejection episodes in the PR-T and IR-T groups, respectively. No cases of graft loss or death were reported during the study. The overall efficacy failure rate was 18.2% (PR-T n = 1; IR-T n = 7). CONCLUSIONS In pediatric de novo solid organ recipients, the low incidence of BCAR and low efficacy failure rate suggest that PR-T-based immunosuppression is effective and well tolerated to 1-year post-transplantation.
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Affiliation(s)
| | | | | | - Ryszard Grenda
- The Children's Memorial Health Institute, Warsaw, Poland
| | | | - Stephen D Marks
- Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | | | | | - Alain Lachaux
- Université Lyon 1 et Hospices Civils de Lyon, Lyon, France
| | - Deirdre Kelly
- Birmingham Women's & Children's Hospital, Birmingham, UK
| | - Gbenga Kazeem
- Astellas Pharma Europe Ltd, Chertsey, UK.,BENKAZ Consulting Ltd, Cambridge, UK
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24
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Steroid withdrawal improves blood pressure control and nocturnal dipping in pediatric renal transplant recipients: analysis of a prospective, randomized, controlled trial. Pediatr Nephrol 2019; 34:341-348. [PMID: 30178240 DOI: 10.1007/s00467-018-4069-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 08/13/2018] [Accepted: 08/13/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Variable effects of steroid minimization strategies on blood pressure in pediatric renal transplant recipients have been reported, but data on the effect of steroid withdrawal on ambulatory blood pressure and circadian blood pressure rhythm have not been published so far. METHODS In a prospective, randomized, multicenter study on steroid withdrawal in pediatric renal transplant recipients (n = 42) on cyclosporine, mycophenolate mofetil, and methylprednisolone, we performed a substudy in 28 patients, aged 11.2 ± 3.8 years, for whom ambulatory blood pressure monitoring (ABPM) data were available. RESULTS In the steroid-withdrawal group, the percentage of patients with arterial hypertension, defined as systolic and/or diastolic blood pressure values recorded by ABPM > 1.64 SDS and/or antihypertensive medication, at month 15 was significantly lower (35.7%, p = 0.002) than in controls (92.9%). The need of antihypertensive medication dropped significantly by 61.2% (p < 0.000 vs. control), while in controls, it even rose by 69.3%. One year after steroid withdrawal, no patient exhibited hypertensive blood pressure values above the 95th percentile, compared to 35.7% at baseline (p = 0.014) and to 14.3% of control (p = 0.142). The beneficial impact of steroid withdrawal was especially pronounced for nocturnal blood pressure, leading to a recovered circadian rhythm in 71.4% of patients vs. 14.3% at baseline (p = 0.002), while the percentage of controls with an abnormal circadian rhythm (35.7%) did not change. CONCLUSIONS Steroid withdrawal in pediatric renal transplant recipients with well-preserved allograft function is associated with less arterial hypertension recorded by ABPM and recovery of circadian blood pressure rhythm by restoration of nocturnal blood pressure dipping.
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25
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Abstract
The goal of immunosuppressive therapy post-transplantation in pediatric renal transplant recipients is to prevent acute and chronic rejection while minimizing drug side effects. Most therapies alter immune response mechanisms but are not immunologically specific, and a careful balance is required to find the dose that prevents rejection of the graft while minimizing the risks of overimmunosuppression leading to infection and cancer. While this chapter because of space constraints focuses on immunosuppressive therapy in pediatric renal transplant recipients, many aspects can be applied on pediatric recipients of other solid organ transplants such as the liver and heart. The major maintenance immunosuppressive agents currently used in various combination regimens are tacrolimus, cyclosporine, mycophenolate mofetil, azathioprine, everolimus, sirolimus, and glucocorticoids (steroids). Although data from adult renal transplantation trials are used to help guide management decisions in pediatric patients, immunosuppressive therapy in pediatric renal transplant recipients often must be modified because of the unique dosage requirements and clinical effects of these agents in children, including their impact on growth and development. The optimal immunosuppressive therapy post-transplant is not established. The goal remains to find the best combination of immunosuppressive agents that optimizes allograft survival by preventing acute rejection while limiting drug toxicities.
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26
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Lancia P, Aurich B, Ha P, Maisin A, Baudouin V, Jacqz-Aigrain E. Adverse Events under Tacrolimus and Cyclosporine in the First 3 Years Post-Renal Transplantation in Children. Clin Drug Investig 2018; 38:157-171. [PMID: 29236209 DOI: 10.1007/s40261-017-0594-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Progress in immunosuppression has reduced acute rejection, graft loss and mortality after renal transplantation. Adverse drug reactions are well described in adults but few data are available in children. Our objectives were to analyse the adverse events reported in the first 3 years post-transplantation in children receiving tacrolimus or cyclosporine-based immunosuppression and compare them with the information of the Summary of Product Characteristics. METHODS This retrospective study included all children who underwent a renal transplant at Hospital Robert Debré between 2002 and 2015. Initial immunosuppression was based on induction, calcineurin inhibitor, mycophenolate mofetil and corticosteroids. Adverse events were collected from medical records and coded using the Medical Dictionary for Regulatory Activities and the implications of tacrolimus and cyclosporine analysed. Statistical analyses were performed using SAS 9.4. RESULTS One hundred and twenty-five children were included. During the observation period [2.7 years (0.6-4.3)], 105 patients received tacrolimus and 39 received cyclosporine. The incidence rate for gastrointestinal disorders was 0.128 and 0.056 by patient-years of exposure (p < 0.05), under tacrolimus and cyclosporine schedules. For neutropenia, it was 0.064 and 0.014 (p < 0.05). The frequencies of toxic nephropathy and gastrointestinal pain were higher than those in the Summary of Product Characteristics of tacrolimus (> 20%) and cyclosporine (> 10%). Cosmetic events for cyclosporine and neutropenia for tacrolimus were frequently observed (18 and 14.3%, respectively), although uncommon in the Summary of Product Characteristics. CONCLUSIONS The exposure-adjusted incidence rate of gastrointestinal disorders and neutropenia was higher in children under the tacrolimus schedule. Our findings contribute to the evaluation of the benefit-risk balance of immunosuppressive therapy following paediatric renal transplantation.
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Affiliation(s)
- Pauline Lancia
- Department of Paediatric Pharmacology and Pharmacogenetics, Hospital Robert Debré, APHP, 48 Boulevard Sérurier, 75019, Paris, France
| | - Beate Aurich
- Department of Paediatric Pharmacology and Pharmacogenetics, Hospital Robert Debré, APHP, 48 Boulevard Sérurier, 75019, Paris, France
| | - Phuong Ha
- Department of Paediatric Pharmacology and Pharmacogenetics, Hospital Robert Debré, APHP, 48 Boulevard Sérurier, 75019, Paris, France
| | - Anne Maisin
- Department of Paediatric Nephrology, Hospital Robert Debré, APHP, 48 Boulevard Sérurier, 75019, Paris, France
| | - Véronique Baudouin
- Department of Paediatric Nephrology, Hospital Robert Debré, APHP, 48 Boulevard Sérurier, 75019, Paris, France
| | - Evelyne Jacqz-Aigrain
- Department of Paediatric Pharmacology and Pharmacogenetics, Hospital Robert Debré, APHP, 48 Boulevard Sérurier, 75019, Paris, France. .,Clinical Investigation Center CIC1426, INSERM, Paris, France. .,Paris Diderot University, Sorbonne Paris Cité, Paris, France.
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Nehus EJ, Liu C, Lu B, Macaluso M, Kim MO. Graft survival of pediatric kidney transplant recipients selected for de novo steroid avoidance-a propensity score-matched study. Nephrol Dial Transplant 2018; 32:1424-1431. [PMID: 28810723 DOI: 10.1093/ndt/gfx193] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 04/20/2017] [Indexed: 01/19/2023] Open
Abstract
Background Steroid-avoidance protocols have gained popularity in pediatric kidney transplant recipients at low immunologic risk. The long-term safety of steroid avoidance in children with immunologic risk factors remains unknown. Methods Pediatric kidney transplant recipients from 2004 to 2014 in the Organ Procurement and Transplantation Network database who received tacrolimus and mycophenolate immunosuppression were investigated. Propensity score matching was used to compare graft survival in 1624 children who received steroid avoidance with 1624 children who received steroid-based immunosuppression. The effect of steroid avoidance on graft failure among immunologic risk strata was estimated using Cox proportional hazards regression in this propensity score-matched cohort. Results It was observed that 5-year graft survival was mildly improved in children receiving steroid avoidance (84.8% versus 81.2%, P = 0.03). This improvement in graft survival occurred in the first 2 years following transplant, when the hazard ratio (HR) for allograft failure in children receiving steroid avoidance was 0.62 [95% confidence interval (CI) 0.45-0.86]. In contrast, steroid avoidance was not associated with improved allograft survival during Years 2-10 following transplant (HR = 0.93; 95% CI 0.75-1.15). During this time period, HRs (95% CIs) for allograft failure within immunologic risk strata were not significantly different from the null value of 1: repeat kidney transplants, 1.84 (0.84-4.05); African-Americans, 1.02 (0.67-1.56); sensitized recipients, 1.24 (0.63-2.43); recipients of deceased donor kidneys, 1.02 (0.79-1.32); recipients of completely human leukocyte antigen-mismatched kidneys, 0.80 (0.47-1.37); and recipients with pretransplant glomerular disease, 0.94 (0.71-1.23). Conclusions In pediatric kidney transplant recipients receiving tacrolimus- and mycophenolate-based immunosuppression, steroid avoidance can be safely practiced in children with immunologic risk factors.
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Affiliation(s)
- Edward J Nehus
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Chunyan Liu
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Bo Lu
- Division of Biostatistics, The Ohio State University, Columbus, OH, USA
| | - Maurizio Macaluso
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.,Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Mi-Ok Kim
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
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Single-Nucleotide Polymorphism of CYP3A5 Impacts the Exposure to Tacrolimus in Pediatric Renal Transplant Recipients: A Pharmacogenetic Substudy of the TWIST Trial. Ther Drug Monit 2017; 39:21-28. [PMID: 28030534 DOI: 10.1097/ftd.0000000000000361] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The pharmacokinetics of tacrolimus (TAC) and mycophenolic acid (MPA) are highly variable. An impact of single-nucleotide polymorphisms (SNPs) of the genes coding for enzymes and transporters involved in the pharmacokinetics of TAC and/or MPA is intuitively conceivable. Accordingly, we sought to analyze the influence of different SNPs on TAC and MPA exposure in pediatric renal transplant recipients. METHODS A subpopulation of 37 patients (median age: 12.8 years, range 2.2-18.3 years) participating in the TWIST study was included in the analysis of SNPs of CYP3A5, ABCB1 (MDR1), ABCG2, SLCO1B3 (coding for OATP2), ABCC2 (coding for cMOAT), and UGT1/2. TAC trough concentrations and abbreviated area under the concentration-time curves (AUC) of MPA were measured on days 7, 28, 91, and 183 after transplant. Both of these were adjusted to the respective dose the patient received. RESULTS The allele frequencies of analyzed SNP's were comparable to those reported previously for white populations. Dose-adjusted trough concentrations of TAC were approximately 60% lower in patients with the CYP3A5*1/*3 allele as compared with the CYP3A5*3/*3 allele (P = 0.004). Steroid-free patients in CYP3A5*3/*3 and CYP3A5*1/*3 carrier subgroups had comparable dose-adjusted TAC concentrations to the subgroup on steroids (P = 0.13). Patients younger than 10 years had a significantly lower median dose-adjusted TAC C0 concentration than patients older than 10 years; this age effect was comparable in heterozygous and homozygous CYP3A5 carriers as well as in patients on and off steroid medication. As for MPA, the genetic variability of transporters or enzymes had no impact on dose-adjusted MPA-AUC due to the low allele frequencies. Patients off steroids had a higher dose-adjusted MPA-AUC (0.18 mg·h/L per mg/m, 0.012-0.27) compared with patients on steroids (0.12 mg·h·L·mg, 0.09-0.19; P = 0.04). CONCLUSIONS Genetic variability of CYP3A5 has an impact on TAC metabolism in pediatric renal transplant recipients, contributing partly to the variability of TAC exposure. Therefore, adjusting initial TAC dosing to the genotype of CYP3A5 might be of clinical benefit.
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Haffner D, Zivicnjak M. Pubertal development in children with chronic kidney disease. Pediatr Nephrol 2017; 32:949-964. [PMID: 27464647 DOI: 10.1007/s00467-016-3432-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 05/22/2016] [Accepted: 05/23/2016] [Indexed: 11/24/2022]
Abstract
Impairment of pubertal growth and sexual maturation resulting in reduced adult height is an significant complication in children suffering from chronic kidney disease (CKD). Delayed puberty and reduced pubertal growth are most pronounced in children with pre-existing severe stunting before puberty, requiring long-term dialysis treatment, and in transplanted children with poor graft function and high glucocorticoid exposure. In pre-dialysis patients, therapeutic measures to improve pubertal growth are limited and mainly based on the preservation of renal function and the use of growth hormone treatment. In patients with end-stage CKD, early kidney transplantation with steroid withdrawal within 6 months of renal transplantation allows for normal pubertal development in the majority of patients. This review focuses on the underlying pathophysiology and strategies for improving height and development in these patients.
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Affiliation(s)
- Dieter Haffner
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany.
| | - Miroslav Zivicnjak
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany
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Hodson EM, Craig JC. How randomised trials have improved the care of children with kidney disease. Pediatr Nephrol 2016; 31:2191-2200. [PMID: 27488519 DOI: 10.1007/s00467-016-3455-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Revised: 06/24/2016] [Accepted: 06/27/2016] [Indexed: 10/21/2022]
Abstract
Randomised controlled trials (RCTs) provide the most reliable way to evaluate the benefits and harms of interventions. Participants are divided into groups using methods that balance the characteristics (both known and unknown) of the participants between treatment groups; thus, differences in outcomes are due to the interventions administered. From Cochrane Kidney and Transplant's Specialised Register, a comprehensive registry of trials in kidney disease, we identified 482 trials involving children. The vast majority concerned urinary tract infection (UTI; 134) and nephrotic syndrome (136). Most were small, with a median enrolment of 46 children, with only 26 trials enrolling 200 or more participants, and of these, 18 involved children with UTI. We discuss a number of important advances in the care of children with UTI with or without vesico-ureteric reflux, nephrotic syndrome, chronic kidney disease (CKD) and kidney transplantation that have been driven largely by trials in these conditions.
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Affiliation(s)
- Elisabeth M Hodson
- Centre for Kidney Research, The Children's Hospital at Westmead, Locked Bag 4001, Westmead, Sydney, NSW, 2145, Australia. .,Sydney School of Public Health, University of Sydney, Sydney, Australia.
| | - Jonathan C Craig
- Centre for Kidney Research, The Children's Hospital at Westmead, Locked Bag 4001, Westmead, Sydney, NSW, 2145, Australia.,Sydney School of Public Health, University of Sydney, Sydney, Australia
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Martial LC, Verstegen RHJ, Cornelissen EAM, Aarnoutse RE, Schreuder MF, Brüggemann RJM. A preliminary study searching for the right dose of tacrolimus in very young (≤4 years) renal transplant patients. ACTA ACUST UNITED AC 2016; 68:1366-1372. [PMID: 27669677 DOI: 10.1111/jphp.12639] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Accepted: 08/24/2016] [Indexed: 12/22/2022]
Abstract
OBJECTIVES The Radboudumc Amalia Children's hospital in the Netherlands has a programme for renal transplantation in children aged ≤4 years. Children receive chronic corticosteroid sparing immunosuppressive therapy that consists of tacrolimus and mycophenolate mofetil. This work aimed to describe the PK of tacrolimus in children ≤4 years with renal transplants. METHODS Paediatric renal transplant patients aged ≤4 years were included in this analysis. A PK curve of tacrolimus recorded ≤3 weeks after transplantation has been standard of care in our institution and aided in adjusting the dose in each patient to attain a target AUC0-12h of 210 μg h/l early after transplantation. KEY FINDINGS Eight patients were included. The first two patients received an initial twice-daily regimen and the subsequent six patients a three-times daily regimen. Median dose-corrected AUCtau was 63 μg h/l. AUC target attainment was 37.5%. Of the remaining patients, two had an AUC very close to (around 10% below) the target. CONCLUSIONS Large interindividual variability of tacrolimus was observed and showed suboptimal AUC target attainment. In this population, an even more aggressive approach of higher doses (e.g. 0.4 mg/kg per day) and more early AUC determination should be considered. This should be evaluated prospectively in a larger group of patients.
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Affiliation(s)
- Lisa C Martial
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands. .,Radboud Institute for Health Sciences, Nijmegen, The Netherlands.
| | - Ruud H J Verstegen
- Department of Paediatric Nephrology, Radboudumc Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Elisabeth A M Cornelissen
- Department of Paediatric Nephrology, Radboudumc Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Rob E Aarnoutse
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands.,Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Michiel F Schreuder
- Department of Paediatric Nephrology, Radboudumc Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Roger J M Brüggemann
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands.,Radboud Institute for Health Sciences, Nijmegen, The Netherlands
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Haller MC, Royuela A, Nagler EV, Pascual J, Webster AC. Steroid avoidance or withdrawal for kidney transplant recipients. Cochrane Database Syst Rev 2016; 2016:CD005632. [PMID: 27546100 PMCID: PMC8520739 DOI: 10.1002/14651858.cd005632.pub3] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Steroid-sparing strategies have been attempted in recent decades to avoid morbidity from long-term steroid intake among kidney transplant recipients. Previous systematic reviews of steroid withdrawal after kidney transplantation have shown a significant increase in acute rejection. There are various protocols to withdraw steroids after kidney transplantation and their possible benefits or harms are subject to systematic review. This is an update of a review first published in 2009. OBJECTIVES To evaluate the benefits and harms of steroid withdrawal or avoidance for kidney transplant recipients. SEARCH METHODS We searched the Cochrane Kidney and Transplant Specialised Register to 15 February 2016 through contact with the Information Specialist using search terms relevant to this review. SELECTION CRITERIA All randomised and quasi-randomised controlled trials (RCTs) in which steroids were avoided or withdrawn at any time point after kidney transplantation were included. DATA COLLECTION AND ANALYSIS Assessment of risk of bias and data extraction was performed by two authors independently and disagreement resolved by discussion. Statistical analyses were performed using the random-effects model and dichotomous outcomes were reported as relative risk (RR) and continuous outcomes as mean difference (MD) with 95% confidence intervals. MAIN RESULTS We included 48 studies (224 reports) that involved 7803 randomised participants. Of these, three studies were conducted in children (346 participants). The 2009 review included 30 studies (94 reports, 5949 participants). Risk of bias was assessed as low for sequence generation in 19 studies and allocation concealment in 14 studies. Incomplete outcome data were adequately addressed in 22 studies and 37 were free of selective reporting.The 48 included studies evaluated three different comparisons: steroid avoidance or withdrawal compared with steroid maintenance, and steroid avoidance compared with steroid withdrawal. For the adult studies there was no significant difference in patient mortality either in studies comparing steroid withdrawal versus steroid maintenance (10 studies, 1913 participants, death at one year post transplantation: RR 0.68, 95% CI 0.36 to 1.30) or in studies comparing steroid avoidance versus steroid maintenance (10 studies, 1462 participants, death at one year after transplantation: RR 0.96, 95% CI 0.52 to 1.80). Similarly no significant difference in graft loss was found comparing steroid withdrawal versus steroid maintenance (8 studies, 1817 participants, graft loss excluding death with functioning graft at one year after transplantation: RR 1.17, 95% CI 0.72 to 1.92) and comparing steroid avoidance versus steroid maintenance (7 studies, 1211 participants, graft loss excluding death with functioning graft at one year after transplantation: RR 1.09, 95% CI 0.64 to 1.86). The risk of acute rejection significantly increased in patients treated with steroids for less than 14 days after transplantation (7 studies, 835 participants: RR 1.58, 95% CI 1.08 to 2.30) and in patients who were withdrawn from steroids at a later time point after transplantation (10 studies, 1913 participants, RR 1.77, 95% CI 1.20 to 2.61). There was no evidence to suggest a difference in harmful events, such as infection and malignancy, in adult kidney transplant recipients. The effect of steroid withdrawal in children is unclear. AUTHORS' CONCLUSIONS This updated review increases the evidence that steroid avoidance and withdrawal after kidney transplantation significantly increase the risk of acute rejection. There was no evidence to suggest a difference in patient mortality or graft loss up to five year after transplantation, but long-term consequences of steroid avoidance and withdrawal remain unclear until today, because prospective long-term studies have not been conducted.
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Affiliation(s)
- Maria C Haller
- Medical University ViennaSection for Clinical Biometrics, Center for Medical Statistics, Informatics and Intelligent SystemsSpitalgasse 23ViennaAustriaA‐1090
- Krankenhaus Elisabethinen LinzDepartment for Internal Medicine III, Nephrology & Hypertension Diseases, Transplantation Medicine & RheumatologyFadingerstrasse 1LinzAustria4040
- Ghent University HospitalEuropean Renal Best Practice (ERBP), guidance issuing body of the European Renal Association – European Dialysis and Transplant Association (ERA‐EDTA), Methods Support TeamGhentBelgium
| | - Ana Royuela
- Hospital Ramon y CajalCIBER Epidemiologia y Salud Publica (CIBERESP)Ctra. Colmenar km, 9.1MadridSpain28047
- Instituto de Investigación Puerta de Hierro (IDIPHIM)Clinical Biostatistics UnitC/ Joaquín Rodrigo, 2Edif. Laboratorio. Planta 0.MajadahondaMadridSpain28222
| | - Evi V Nagler
- Ghent University HospitalEuropean Renal Best Practice (ERBP), guidance issuing body of the European Renal Association – European Dialysis and Transplant Association (ERA‐EDTA), Methods Support TeamGhentBelgium
- Ghent University HospitalRenal Division, Department of Internal MedicineDe Pintelaan 185GhentBelgium9000
| | - Julio Pascual
- Hospital del Mar‐IMIMDepartment of NephrologyPasseig Maritim 25‐29BarcelonaSpain08003
| | - Angela C Webster
- The University of SydneySydney School of Public HealthEdward Ford Building A27SydneyNSWAustralia2006
- The University of Sydney at WestmeadCentre for Transplant and Renal Research, Westmead Millennium InstituteWestmeadNSWAustralia2145
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
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Bamgbola O. Metabolic consequences of modern immunosuppressive agents in solid organ transplantation. Ther Adv Endocrinol Metab 2016; 7:110-27. [PMID: 27293540 PMCID: PMC4892400 DOI: 10.1177/2042018816641580] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Among other factors, sophistication of immunosuppressive (IS) regimen accounts for the remarkable success attained in the short- and medium-term solid organ transplant (SOT) survival. The use of steroids, mycophenolate mofetil and calcineurin inhibitors (CNI) have led to annual renal graft survival rates exceeding 90% in the last six decades. On the other hand, attrition rates of the allograft beyond the first year have remained unchanged. In addition, there is a persistent high cardiovascular (CV) mortality rate among transplant recipients with functioning grafts. These shortcomings are in part due to the metabolic effects of steroids, CNI and sirolimus (SRL), all of which are implicated in hypertension, new onset diabetes after transplant (NODAT), and dyslipidemia. In a bid to reduce the required amount of harmful maintenance agents, T-cell-depleting antibodies are increasingly used for induction therapy. The downsides to their use are greater incidence of opportunistic viral infections and malignancy. On the other hand, inadequate immunosuppression causes recurrent rejection episodes and therefore early-onset chronic allograft dysfunction. In addition to the adverse metabolic effects of the steroid rescue needed in these settings, the generated proinflammatory milieu may promote accelerated atherosclerotic disorders, thus setting up a vicious cycle. The recent availability of newer agent, belatacept holds a promise in reducing the incidence of metabolic disorders and hopefully its long-term CV consequences. Although therapeutic drug monitoring as applied to CNI may be helpful, pharmacodynamic tools are needed to promote a customized selection of IS agents that offer the most benefit to an individual without jeopardizing the allograft survival.
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Affiliation(s)
- Oluwatoyin Bamgbola
- State University of New York Downstate Medical Center, 450 Clarkson Avenue, Brooklyn, NY 11203-2098, USA
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Zhang H, Zheng Y, Liu L, Fu Q, Li J, Huang Q, Liu H, Deng R, Wang C. Steroid Avoidance or Withdrawal Regimens in Paediatric Kidney Transplantation: A Meta-Analysis of Randomised Controlled Trials. PLoS One 2016; 11:e0146523. [PMID: 26991793 PMCID: PMC4798578 DOI: 10.1371/journal.pone.0146523] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Accepted: 12/18/2015] [Indexed: 12/17/2022] Open
Abstract
Background We combined the outcomes of all randomised controlled trials to investigate the safety and efficacy of steroid avoidance or withdrawal (SAW) regimens in paediatric kidney transplantation compared with steroid-based (SB) regimens. Methods A systematic literature search of PubMed, Embase, Cochrane Library, the trials registry and BIOSIS previews was performed. A change in the height standardised Z-score from baseline (ΔHSDS) and acute rejection were the primary endpoints. Results Eight reports from 5 randomised controlled trials were included, with a total of 528 patients. Sufficient evidence of a significant increase in the ΔHSDS was observed in the SAW group (mean difference (MD) = 0.38, 95% confidence interval (CI) 0.07–0.68, P = 0.01), particularly within the first year post-withdrawal (MD = 0.22, 95% CI 0.10–0.35, P = 0.0003) and in the prepubertal recipients (MD = 0.60, 95% CI 0.21–0.98, P = 0.002). There was no significant difference in the risk of acute rejection between the groups (relative risk = 1.04, 95% CI 0.80–1.36, P = 0.77). Conclusions The SAW regimen is justified in select paediatric renal allograft recipients because it provides significant benefits in post-transplant growth within the first year post-withdrawal with minimal effects on the risk of acute rejection, graft function, and graft and patient survival within 3 years post-withdrawal. These select paediatric recipients should have the following characteristics: prepubertal; Caucasian; with primary disease not related to immunological factors; de novo kidney transplant recipient; with low panel reactive antibody.
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Affiliation(s)
- Huanxi Zhang
- Organ Transplant Center, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yitao Zheng
- Organ Transplant Center, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Longshan Liu
- Organ Transplant Center, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Qian Fu
- Organ Transplant Center, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jun Li
- Organ Transplant Center, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Qingshan Huang
- Medical Information Institute, Sun Yat-Sen University, Guangzhou, China
| | - Huijiao Liu
- Department of Neurology, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Ronghai Deng
- Organ Transplant Center, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- * E-mail: (CW); (RD)
| | - Changxi Wang
- Organ Transplant Center, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- * E-mail: (CW); (RD)
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Abstract
Renal transplantation in paediatric patients usually provides excellent short-term and medium-term results. Early diagnosis of chronic kidney disease and active therapy of end-stage renal disease before and after transplantation enables the majority of children to grow and develop normally. The adverse effects of immunosuppressive medication and reduced graft function might, however, hamper long-term outcomes in these patients and can lead to metabolic complications, cardiovascular disease, reduced bone health, and malignancies. The neurocognitive development and quality of life of paediatric transplant recipients largely depend on the primary diagnosis and on graft function. Poor adherence to immunosuppression is an important risk factor for graft loss in adolescents, and controlled transition to adult care is of utmost importance to ensure a continued normal life. In this Review, we discuss the outcomes and long-term effects of renal transplantation in paediatric recipients, including consequences on growth, development, bone, metabolic, and cardiovascular disorders. We discuss the key problems in the care of paediatric renal transplant recipients and the remaining challenges that should be the focus of future research.
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