Cardiovascular risk factors in children after kidney transplantation--from short-term to long-term follow-up

Adult and late adolescent complications of pediatric solid organ transplantation

BACKGROUND

There have been over 51 000 pediatric solid organ transplants since 1988 in the United States alone, leading to a growing population of long-term survivors who face complications of childhood organ failure and long-term immunosuppression.

AIMS

This is an educational review of existing literature.

RESULTS

Pediatric solid organ transplant recipients are at increased risk for risk for cardiovascular and kidney disease, skin cancers, and growth problems, though the severity of impact may vary by organ type. Pediatric recipients often are able to complete schooling, maintain a job, and form family and social networks in adulthood, though at somewhat lower rates than the general population, but face additional challenges related to neurocognitive deficits, mental health disorders, and discrimination.

CONCLUSIONS

Transplant centers and research programs should expand their focus to include long-term well-being. Increased collaboration between pediatric and adult transplant specialists will be necessary to better understand and manage long-term complications.

Physical activity and its impact on cardiovascular health in pediatric kidney transplant recipients

BACKGROUND

Cardiovascular (CV) morbidity after kidney transplantation (KTx) in childhood is of increasing importance. In light of a high prevalence of CV risk factors, protective measures such as physical activity (PA) come into focus. Our aim was to comprehensively assess PA in pediatric KTx recipients and evaluate its impact on CV health.

METHODS

Forty-eight patients were assessed for frequency, duration, intensity, and setting of PA using the "Motorik-Modul" PA questionnaire. Walking-based activity was measured by accelerometer in a subgroup (n = 23). CV risk factors and subclinical CV organ damage were determined. The impact of PA on CV parameters was analyzed using linear regression models.

RESULTS

Fifty-two percent of pediatric KTx recipients did not reach WHO recommended PA level; 54% did not engage in PA with vigorous intensity (VPA). Twenty-nine percent indicated an extremely inactive lifestyle (< 120 min/week of moderate to vigorous intensity PA, MVPA). Compared to the healthy German KiGGS cohort, KTx recipients specifically lacked engagement in sport activities (KTx: 129 min/week; 95%CI, 97-162 vs. KiGGS, 242 min/week; 95%CI, 230-253). VPA was associated with lower systolic blood pressure (p = 0.024) and resting heart rate (p = 0.005), MVPA with fewer components of the post-transplant metabolic syndrome (p = 0.037), and better left ventricular diastolic function (p = 0.006).

CONCLUSIONS

A considerable lack of PA, especially VPA, exists in young KTx recipients. PA was positively associated with important parameters of CV health. While long-term CV protection through PA seems promising in pediatric KTx recipients, specific educational approaches are most likely needed to increase patients' engagement in sport activities.

Lipid abnormalities in pediatric kidney transplant recipients on steroid withdrawal maintenance immunosuppression

BACKGROUND

Dyslipidemia is a modifiable risk factor for cardiovascular disease. The prevalence of dyslipidemia in pKTR (pediatric kidney transplant recipients) under modern immunosuppression remains unknown. We determined the prevalence, risk factors, co-morbidities, and treatment patterns of lipid abnormalities in pediatric kidney transplant recipients on steroid withdrawal immunosuppression.

METHODS

pKTR (age ≤ 21 years) at a single center on steroid withdrawal immunosuppression underwent lipid screening between January 1, 2020, and September 30, 2022. Continuous and categorical variables were compared using the Wilcoxon rank-sum and chi-square or Fisher's exact tests, respectively. The correlation between total cholesterol and BMI (body mass index) was assessed using Pearson's product-moment correlation, and predictors of lipid abnormalities were evaluated using the multivariable logistic regression.

RESULTS

A total of 96 patients were included, with a median post-transplant time of 2.5 years (IQR: 1.3-5.4). Of the total, 64.6% (n = 62) of patients had a fasting lipid abnormality. We found a significant linear correlation between total cholesterol and BMI (r = 0.38, p = 0.0022). After multivariable adjustment, every 1 ml/min/1.73 m2 increase in eGFR was associated with a 2% lower odds of a lipid abnormality (OR 0.979, p = 0.026). Obesity, hypertension, and left ventricular hypertrophy were similar between those with and without lipid abnormalities, while insulin-treated diabetes was more prevalent in recipients with lipid abnormalities (12.9% vs. 0%, p = 0.047). Only 36.5% of patients (n = 19) were referred to a dietician and/or lipid specialist; one received statin therapy.

CONCLUSIONS

Lipid abnormalities are highly prevalent in pKTR, but therapeutic intervention is infrequent. Calcineurin inhibition without corticosteroids may not be protective; however, higher eGFR is associated with a lower prevalence of lipid abnormalities. A higher resolution version of the Graphical abstract is available as Supplementary information.

Children Are Not Small Adults: Similarities and Differences in Renal Transplantation Between Adults and Pediatrics

Kidney transplantation is the treatment of choice for all patients with end-stage kidney disease, including pediatric patients. Graft survival in pediatrics was lagging behind adults, but now is comparable with the adult cohort. Although many of the protocols have been adopted from adults, there are issues unique to pediatrics that one should be aware of to take care of this population. These issues include recipient size consideration, increased incidence of viral infections, problems related to growth, common occurrence of underlying urological issues, and psychosocial issues. This article addresses the similarities and differences in renal transplantation, from preparing a patient for transplant, the transplant process, to post-transplant complications.

Cardiac Function in Children After Kidney Transplant

OBJECTIVES

Renal transplant improves echocardiographic markers of systolic and diastolic heart functions. The aim of this study was to evaluate the gradual changes in left and right ventricle functions in children and young adults before and after renal transplant.

MATERIALS AND METHODS

Thirty kidney recipients of median age 13 years (range, 5-19 years) were included the study. Tissue Dopplerimaging from the septal and lateral mitral annulus ofthe left ventricle and free wall of the right ventricle was performed. Right ventricle systolic excursion velocity and tricuspid annular plane systolic excursion were calculated. Systolic and diastolic heart functions-which gained just before transplant, were compared with posttransplant early- term (6 months to 1 year) and long-term (longer than 1 year) functions.

RESULTS

Twelve patients received deceased-donor and 18 patients received living donor renal transplant. Follow-up after transplant was 44 ± 23 months. Left ventricle ejection fractions were normal. The left ventricle, right ventricle, and interventricular septalTei indices were significantly higher before transplant.The posttransplantation early- and late-term results of left ventricle,right ventricle, and interventricular septal Tei indices were similar. Tricuspid annular plane systolic excursion levels were abnormal in 11 patients (36%), and right ventricle systolic excursion velocities were abnormal in 7 patients (23%) before transplant. All tricuspid annular plane systolic excursion levels and 94% ofright ventricle systolic excursion velocities were normal, but left ventricle Tei indices were higher in 8 (26%) and right ventricle Tei indices were higher in 14 patients (46%) at late-term follow-up.

CONCLUSIONS

The systolic and diastolic dysfunctions of both ventricles appear to be highly prevalent in pediatric renal transplant recipients, especially soon after transplant, and were shown to usually decrease with time. Improvements in right ventricle dysfunction are slower, even in optimally treated posttransplant patients.

Risk Assessment for Arrhythmia in Pediatric Renal Transplant Recipients

OBJECTIVES

Renal transplant recipients are at risk for ventricular arrhythmia and sudden death. To assess that risk, we compared the ventricular repolarization markers of pediatric renal transplant recipients with those of healthy children.

MATERIALS AND METHODS

We included 30 children and adolescents who were followed for at least 6 months after renal transplant; 30 age- and sex-matched children were included for the control group. Demographic features, medications, and laboratory findings were recorded. Blood pressure measurements, ventricular repolarization indexes including QT dispersion, corrected QT dispersion, T-wave peak-to-end interval dispersion, the T-wave peak-to-end interval∕QT ratio, the T-wave peak-to-end interval∕corrected QT ratio, left ventricular mass index, and relative wall thickness were compared between groups. In addition, the correlations of ventricular repolarization indexes with other variables were evaluated.

RESULTS

Blood pressure standard deviation scores, the mean heart rate, QT dispersion, corrected QT dispersion, the T-wave peak-to-end interval∕QT ratio, the T-wave peak-to-end interval/corrected QT ratio, left ventricular mass index, and relative wall thickness values were significantly higher in renal transplant patients, whereas T-wave peak-to-end interval dispersion, ejection fraction, and fractional shortening were similar between groups. Although ventricular repolarization indexes were similar in patients with and without left ventricular hypertrophy, only corrected QT dispersion was significantly higher in patients with hypertension (P = .006). The only variable that significantly predicted prolonged corrected QT dispersion was the systolic blood pressure standard deviation score (P = .005, β = .403).

CONCLUSIONS

Ventricular repolarization anomalies, hypertension, left ventricular hypertrophy, and cardiac geometry irregularity may be observed after renal transplant in pediatric recipients despite acceptable allograft functions and normal serum electrolyte levels. Control of systolic blood pressure would decrease the risk of ventricular repolarization abnormalities, namely, the corrected QT dispersion. Follow-up of cardiovascular risks with noninvasive methods is recommended in all pediatric renal transplant recipients.

Longitudinal Changes in Cardiac Structure and Function in Pediatric Kidney Transplant Recipients

BACKGROUND

Cardiovascular disease results in increased morbidity and mortality in pediatric kidney transplant recipients. Longitudinal changes in cardiac structure and function and the association with blood pressure control over time in pediatric kidney transplant recipients are unknown.

METHODS

To determine the influence of blood pressure control on cardiac changes following pediatric kidney transplant, we conducted a retrospective cohort study of children who received their first kidney transplant at the Hospital for Sick Children from 2004 to 2015. Children were followed until transfer to adult care or censoring in July 2018. Cardiac structure and function parameters were collected from clinical echocardiograms and assessed using standardized scores. Blood pressure control was determined by systolic blood pressure Z scores (above or below the 90th percentile) in combination with antihypertensive medications. A segmented mixed-effects model assessed Z scores of interventricular septum thickness, left ventricular end-diastolic dimension, and left ventricular posterior wall dimension.

RESULTS

Of 142 children included, 58% were men, mean age at transplant was 11 (±4.5) years, and average follow-up time was 4 (±3) years. All cardiac structural Z scores improved during follow-up. Interventricular septum thickness normalized at 4.0 years post-transplant. Left ventricular end-diastolic dimension normalized at 1.5 years post-transplant. Left ventricular posterior wall dimension normalized at 6.3 years post-transplant. Left ventricular mass index showed sustained improvement up to 12 years post-transplant. Individuals with uncontrolled blood pressure had increased left ventricular mass (β=2.97 [95% CI, 0.77-5.16]).

CONCLUSIONS

Cardiac structural abnormalities improve following kidney transplantation and normalize within 7 years, especially with controlled blood pressure. Strict blood pressure control is critical after pediatric kidney transplantation.

Cardiovascular Risk Factors are Inversely Associated With Omega-3 Polyunsaturated Fatty Acid Plasma Levels in Pediatric Kidney Transplant Recipients

OBJECTIVES

High plasma levels of the omega-3 fatty acids eicosapentaenoic acid (EPA), docosahexaenoic acid, and docosapentaenoic acid associates with positive outcomes in adult renal transplant recipients. However, data from pediatric populations are scarce. The aim of the study was to assess the fatty acid profile in a pediatric renal transplantation cohort and to examine the associations between plasma omega-3 fatty acids and cardiovascular disease (CVD) risk factors.

METHODS

In this cross-sectional study comprising 53 children (median age, 12.2 years; 32 boys) with a renal transplant, we assessed the prevalence of CVD risk factors as well as markers of end organ damage: carotid intima-media thickness (cIMT) and left ventricular mass index. The associations between plasma omega-3 fatty acids and CVD risk factors were assessed.

RESULTS

Twenty-five (47%) patients were preemptively transplanted. Seventy-six percent had dyslipidemia and 51% had hypertension. The mean left ventricular mass index was 40.4 ± 14.3 g/m^2.7, and 14% had left ventricular hypertrophy. The mean cIMT was 0.41 ± 0.04 mm. In a multivariate linear regression, EPA levels were inversely associated to blood pressure (β coeff. = -0.37, P = .007), triglycerides (β coeff. = -0.44, P = .01), and high-density lipoprotein cholesterol (β coeff. = -0.41, P = .01).

CONCLUSION

EPA levels are inversely associated with components of the metabolic syndrome, which may provide support for specific dietary advice or supplementation in this patient population. cIMT is less pronounced in our cohort than in comparable cohorts with lower rate of preemptive transplantations. Our results need replication in prospective cohorts.

Pediatric kidney transplantation is different from adult kidney transplantation

Kidney transplantation (KT) is the gold standard for renal replacement therapy in pediatric patients with end-stage renal disease. Recently, it has been observed that the outcome of pediatric KT is nearly identical to that in adults owing to the development and application of a variety of immunosuppressants and newer surgical techniques. However, owing to several differences in characteristics between children and adults, pediatric KT requires that additional information be learned and is associated with added concerns. These differences include post-KT complications, donor-recipient size mismatch, problems related to growth, and nonadherence to therapy, among others. This review was aimed at elucidating the clinical characteristics of pediatric KT that differ from those observed in adults.

Cardiovascular risks in chronic kidney disease pediatric patients

One of the common factors for the premature death in children is advanced chronic kidney disease (CKD). Most often cardiovascular disease (CVD) is the reason for mortality. The cardiovascular (CV) morbidity starts early in the disease process and renal transplanted children (CKD-T) are also at risk. The present review is focused on the current views of the cardiovascular risks during CKD in pediatric patients. Variable data sources for the latest literature collection were explored which mainly included PubMed and Google Scholar. The most important risk factors for subclinical CVD were a young age, elevated BMI and systolic blood pressure z-scores as well as a low GFR and present albuminuria. Increasing blood pressure and BMI over follow-up were also important cardiac risk factors longitudinally. The present review concludes that altered cardiac function and remodeling are a concurrent part of the CKD process, start early in the disease development, and persist after renal transplantation. The findings suggest that children with CKD or CKD-T are at high risk for future CVD where younger patients with elevated BMI and slightly increased blood pressures, as well as present albuminuria, are those at greatest risk, thus indicating targets for future interventions.

Factors associated with cardiovascular target organ damage in children after renal transplantation

BACKGROUND

Cardiovascular disease is the second-most common cause of death in pediatric renal transplant recipients. The aim of this study was to evaluate subclinical cardiovascular target organ damage defined as the presence of arterio- and atherosclerotic lesions and cardiac remodeling and to analyze contributing risk factors in a large cohort of children after renal transplantation (RT).

METHODS

A total of 109 children aged 13.1 ± 3.3 years who had undergone RT at one of three German transplant centers were enrolled in this study. Patients had been transplanted a mean of 5.5 (±4.0) years prior to being enrolled in the study. Anthropometric data, laboratory values and office- and 24-h ambulatory blood pressure monitoring (ABPM) were evaluated. Cardiovascular target organ damage was determined through non-invasive measurements of aortic pulse wave velocity (PWV), carotid intima-media thickness (IMT) and left ventricular mass (LVM).

RESULTS

Elevated PWV or IMT values were detected in 22 and 58% of patients, respectively. Left ventricular hypertrophy was found in as many as 43% of patients. The prevalence of uncontrolled or untreated hypertension was 41%, of which 16% of cases were only detected by ABPM measurements. In the multivariable analysis, higher diastolic blood pressure, everolimus intake and lower estimated glomerular filtration rate were independently associated with high PWV. Higher systolic blood pressure and body mass index were associated with elevated LVM.

CONCLUSIONS

Our results showed an alarming burden of cardiovascular subclinical organ damage in children after RT. Hypertension, obesity, immunosuppressive regimen and renal function emerged as independent risk factors of organ damage. Whereas the latter is not modifiable, the results of our study strongly indicate that the management of children after RT should focus on the control of blood pressure and weight.

Ambulatory Blood Pressure Control in Children and Young Adults After Kidney Transplantation

BACKGROUND

Ambulatory blood pressure (BP) monitoring (ABPM) is the preferred method to characterize BP status, and its use in kidney transplant recipients is increasing. Data on longitudinal ambulatory BP (ABP) trends in pediatric and young adult kidney transplant recipients are limited.

METHODS

Retrospective review of a large cohort of children and young adults following kidney transplantation and evaluation of their ABP status over time and its associations with any patient and clinical characteristics.

RESULTS

Two hundred and two patients had baseline ABPM available for analysis, and 123 of them had a follow up (median time 2.3 years) ABPM. At the time of follow up, more patients were treated for hypertension (80% vs. 72%, P = 0.02), and less patients had ambulatory hypertension (36% vs. 54%, P = 0.005), uncontrolled or untreated, compared with baseline, with 45% of all patients classified as having controlled hypertension (compared to 26% at baseline, P = 0.002). Prevalence of ambulatory hypertension decreased only in patients who were less than 18 years old at baseline. High baseline mean 24-hour systolic BP was independently associated with persistent hypertension.

CONCLUSIONS

In young kidney transplant recipients followed by ABPM, the prevalence of ambulatory hypertension decreases over time, mainly due to the increased number of patients with controlled hypertension.

Cardiometabolic risks vary by weight status in pediatric kidney and liver transplant recipients: A cross-sectional, single-center study in the USA

There is an increasing need to understand long-term metabolic changes and resultant comorbidities because life expectancy is increasing after pediatric kidney and liver transplants. We evaluated differences in classic and novel cardiometabolic biomarkers among obese and normal weight adolescent transplant recipients. We enrolled a total of 80 adolescent (mean±SD, 14.8 years ±3.0) transplant recipients (63 kidney, 17 liver) with mean duration from transplantation of 6.0 (±4.1) years. Among kidney transplant recipients, overweight and obese individuals had higher leptin (16.7 vs 7.5 μg/mL, P<.001), lower HDL (1.1 vs 1.3 mmol/L, P=.02), higher free fatty acid (0.6 vs 0.5 mmol/L, P=.03), higher apoB-to-apoA1 ratio (0.8 vs 0.6, P=.03), and higher glucose (5.8 vs 4.3 mmol/L, P=.03) concentrations compared to normal weight individuals. Regardless of obesity status, over half of all participants (57.5%) were considered at high cardiometabolic risk using consensus guidelines, and this was more pronounced for kidney transplant recipients (61.9%). Post-transplantation adolescents have increased cardiometabolic risk characterized by traditional risk factors of obesity and diabetes. The presence of obesity significantly worsens biomarkers of cardiometabolic risk. Future studies should explore whether treatment of obesity can improve the health and long-term outcomes for children undergoing solid organ transplant.

Assessing longitudinal trends in cardiac function among pediatric patients with chronic kidney disease

BACKGROUND

Left ventricular diastolic dysfunction (LVDD) is an early marker of cardiac disease in pediatric chronic kidney disease (CKD), but few studies have analyzed longitudinal trends. We conducted a prospective 3-year follow-up study in pediatric CKD and kidney transplant (CKD-T) patients.

METHODS

The patient cohort comprised 30 CKD and 42 CKD-T patients. The results of annual clinical and echocardiographic analyses using tissue Doppler imaging (TDI) and pulse wave Doppler (PWD) were assessed, and associations to predictive risk factors were studied using multivariate modeling.

RESULTS

The mean age of CKD and CKD-T patients at inclusion was 9.8 ± 4.4 and 11.8 ± 4.3 years, respectively; the glomerular filtration rate was 35.3 ± 18.3 and 60.3 ± 18.8 mL/min/1.73 m(2), respectively. The prevalence of left ventricular diastolic dysfunction (LVDD), as assessed using TDI (lateral z-score e') was 7.1 and 12.5 % in CKD and CKD-T patients, respectively; the corresponding values with PWD E were 3.3 and 2.4 %, respectively. In unadjusted analyses, both TDI and PWD markers of diastolic function worsened over the follow-up period; following adjustments, an elevated systolic ambulatory blood pressure was the most important predictor of cardiac disease.

CONCLUSIONS

Children with CKD show early signs of LVDD, with TDI being more sensitive than PWD in terms of diagnostic potential. An increased ambulatory systolic blood pressure predicted progression in diastolic function, suggesting opportunities for future interventions.

Long-Term Changes in Blood Pressure After Pediatric Kidney Transplantation

BACKGROUND

Hypertension presents high prevalence rates following kidney transplantation (Tx). The aims of the present study were to investigate the prevalence and possible risk factors for hypertension and blood pressure (BP) control over time after pediatric kidney Tx, as well as to assess possible effects of hypertension on graft survival.

METHODS

We reviewed the medical records of all pediatric kidney recipients followed up in our pediatric nephrology department. Hypertension was defined as systolic and/or diastolic BP greater than the 95th percentile for age and sex, or as being on antihypertensive medication. BP control was defined as normotension while on antihypertensive medication.

RESULTS

The study population included 74 pediatric kidney recipients (median age 11 years). The prevalence of hypertension was found 77% before Tx, 82.4%, 71.7%, and 61% at 1, 5, and 10 years after Tx, respectively. Deceased donor Tx and pre-transplant hypertension on antihypertensive medication were significant risk factors for hypertension after kidney Tx over the follow-up period. BP control among patients on antihypertensive treatment was 16.7% before Tx, 43.8%, 66.7%, and 42.9% at 1, 5, and 10 years post-Tx, respectively. Hypertensive patients at 10 years post-Tx had 8.079 times higher hazard of graft loss compared to normotensives (95% CI 1.561-41.807, P < 0.05).

CONCLUSIONS

Hypertension remains a frequent complication in pediatric kidney recipients even years after kidney Tx. BP control by antihypertensive treatment is unsatisfactory in about half of the patients. The adverse effects of hypertension on graft survival may appear in the long-term.

Paediatric obesity and renal transplantation: current challenges and solutions

The increased incidence of obesity in the paediatric population poses significant challenges to renal transplantation. Whilst the body mass index appears to be widely used as a measure of obesity in adults, there are no standardised definitions in the paediatric population, making comparative analyses difficult. In the paediatric transplant population, obesity is associated with an increased incidence of surgical complications, diabetes, hyperlipidaemia and cardiovascular morbidity, leading to diminished graft function and impacting patient and graft survival. Management of obesity in renal transplantation requires multiple interventions starting with life-style and behavioural modification combined with medical and possibly surgical therapies, representing a unique challenge in the childhood setting. In this review we discuss the current challenges of obesity and potential solutions in the setting of paediatric transplantation.

Long-term effects of paediatric kidney transplantation

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.

Percepções de enfermeiros e clientes sobre cuidados de enfermagem no transplante de rim

Objetivo Analisar as percepções de enfermeiros e dos transplantados sobre a consulta de enfermagem pré-transplante do transplante renal. Métodos Estudo qualitativo tendo a análise de conteúdo como aporte metodológico. Participaram dez enfermeiros com identificação de duas categorias (conteúdos e demandas dos usuários na fase de pré-transplante imediato; e concepções, comportamentos, expectativas e situações emergentes no trans/pós-transplante renal) e 20 transplantados com duas categorias (experiências prévias com restrições impostas pela diálise; e situações inesperadas ou conflituosas identificadas no transplante e na fase pós-transplante). O instrumento de pesquisa continha as variáveis relacionadas com a caracterização da amostra, questões norteadoras e situações de superação segundo percepções de enfermeiros especialistas e pessoas pós-transplantadas. Resultados Houve coincidência e complementariedade entre as abordagens dos sujeitos e as formas de enfrentamento no trans/pós-operatório. Conclusão A consulta de enfermagem no período pré-transplante renal é importante para a incorporação das orientações às vivências e comportamentos das pessoas transplantadas ao longo do processo de transplantação e após a realização do procedimento.

Challenges in pediatric renal transplantation

Transplantation in children is the best option to treat renal failure. Over the last 25 years the improvements in therapy have dramatically reduced the risk of early acute rejection and graft loss, however the long term results in terms of graft survival and morbidity still require search for new immunosuppressive regimens. Tolerance of the graft and minimization of side effects are the challenges for improving the outcome of children with a grafted kidney. Notwithstanding the difficulties in settling in children large multicenter trials to derive statistically useful data, many important contributions in the last years brought important modifications in the immunosuppressive therapy, including minimization protocols of steroids and calcineurin inhibitors and new induction drugs. New methods for diagnosis of anti HLA antibodies and some new protocols to improve both chance and outcome of transplantation in immunized subjects represent area of ongoing research of extreme interest for children.

Recent developments in kidney transplantation in children

PURPOSE OF REVIEW

Renal transplantation in childhood is a well established procedure with excellent short-term outcomes. However, waiting times for transplantation are still relatively long if living donation cannot be performed, and long-term outcomes after transplantation have not significantly improved during the last decade.

RECENT FINDINGS

This review describes alternative modalities to improve donation rates such as en bloc kidney transplantation from young donors, ABO-incompatible transplantation and kidney paired donation. This review also deals with long-term post-transplant morbidities, such as follows: first, medication side-effects (metabolic syndrome, cardiovascular disease) and with the benefits of steroid and calcineurin inhibitor drug minimization; second, the deleterious impact of viral infections and their management and third, chronic antibody-mediated rejection, its therapeutic and prevention possibilities.

SUMMARY

Donor shortage and long-term morbidities, after transplantation, are still relevant issues in paediatric renal transplantation medicine. Significant research and efforts have been made to advance the field and create novel approaches for improvement of transplantation rates and post-transplant graft or patient survival. These modalities are to be established in the routine setting.

Post-transplant hypertension in pediatric kidney transplant recipients

BACKGROUND

The aim of the study was to investigate the prevalence of post-transplant hypertension (HT) and to assess the blood pressure (BP) of transplanted children with possible risk factors.

METHODS

Office and ambulatory blood pressure measurements were performed for each patient.

RESULTS

Twenty-nine patients were included in the study, including 13 patients with newly diagnosed untreated HT according to the results of ambulatory blood pressure monitoring (ABPM). Fourteen patients were on antihypertensive medication, but only in five of these patients was the HT under control; nine patients receiving antihypertensive drugs had uncontrolled HT. Of the 29 patients, two had normotension without any antihypertensive drug(s). Standard deviation scores (SDS) of the nocturnal diastolic BP of the ABPM were positively correlated with the prednisolone dosage per kilogram (p = 0.013, r = 0.45) and negatively correlated with the time period after transplantation (p = 0.024, r = -0.41). Similarly, the SDS of the 24-h diastolic BP was positively correlated with the prednisolone dosage per kilogram (p = 0.006, r = 0.50) and negatively correlated with the time period after transplantation (p = 0.016, r = -0.44). Patients with alternate-day steroid treatment had lower nocturnal systolic (p = 0.016), nocturnal diastolic (p = 0.001) and 24-h diastolic (p = 0.008) SDS when compared to those receiving daily steroid medication.

CONCLUSION

The prevalence of HT among children after renal transplantation was high among our patient cohort, and steroids had direct impact on nocturnal and diastolic BP.