Fludrocortisone-a treatment for tubulopathy post-paediatric renal transplantation: A national paediatric nephrology unit experience

Calcineurin inhibitors post-renal transplantation are recognized to cause tubulopathies in the form of hyponatremia, hyperkalemia, and acidosis. Sodium supplementation may be required, increasing medication burden and potentially resulting in poor compliance. Fludrocortisone has been beneficial in addressing tubulopathies in adult studies, with limited paediatric data available. A retrospective review of data from an electronic renal database from December 2014 to January 2016 was carried out. Forty-seven post-transplant patients were reviewed with 23 (49%) patients on sodium chloride or bicarbonate. Nine patients, aged 8.3 years (range 4.9-16.4), commenced fludrocortisone 22 months (range 1-80) after transplant and were followed up for 9 months (range 2-20). All patients stopped sodium bicarbonate; all had a reduction or no increase in total daily doses of sodium chloride. Potassium levels were significantly lower on fludrocortisone, 5.2 vs 4.5 mmol/L, P = .04. No difference was noted in renal function (eGFR 77.8 vs 81.7 mL/min/1.73 m² , P = .45) and no significant increase in systolic blood pressure (z-scores 0.99 vs 0.85, P = .92). No side effects secondary to treatment with fludrocortisone were reported. A significant proportion of renal transplant patients were on sodium supplementation and fludrocortisone reduced sodium supplementation without significant effects on renal function or blood pressure. Fludrocortisone appears to be safe and effective for tubulopathies in children post-transplantation.

Disparities in policies, practices and rates of pediatric kidney transplantation in Europe

We aimed to provide an overview of kidney allocation policies related to children and pediatric kidney transplantation (KTx) practices and rates in Europe, and to study factors associated with KTx rates. A survey was distributed among renal registry representatives in 38 European countries. Additional data were obtained from the ESPN/ERA-EDTA and ERA-EDTA registries. Thirty-two countries (84%) responded. The median incidence rate of pediatric KTx was 5.7 (range 0-13.5) per million children (pmc). A median proportion of 17% (interquartile range 2-29) of KTx was performed preemptively, while the median proportion of living donor KTx was 43% (interquartile range 10-52). The median percentage of children on renal replacement therapy (RRT) with a functioning graft was 62%. The level of pediatric prioritization was associated with a decreased waiting time for deceased donor KTx, an increased pediatric KTx rate, and a lower proportion of living donor KTx. The rates of pediatric KTx, distribution of donor source and time on waiting list vary considerably between European countries. The lack of harmonization in kidney allocation to children raises medical and ethical issues. Harmonization of pediatric allocation policies should be prioritized.

Prevalence and subtypes of radiological cerebrovascular disease in late-onset isolated seizures and epilepsy

BACKGROUND

Late-onset epilepsy (LOE), onset over 60, is often attributed to cerebrovascular disease (CVD), and is associated with increased stroke risk. We investigated the radiological prevalence of CVD in LOE.

METHODS

We undertook a retrospective case-control study of patients with LOE and age and sex-matched controls, also matched for imaging modality. Radiological CVD was recorded, with radiological findings by an experienced consultant neuroradiologist usi a structured proforma.

RESULTS

105 cases and 105 controls were studied, comprising 61 (58.1%) males, mean (±SD) age (years) 72.7±7.48 (cases), 72.4±7.02 (controls). 9 cases had isolated seizures rather than LOE. Imaging modality (in cases and controls) was CT in 59 and MRI in 46. Radiological CVD was more prevalent amongst cases (65.7%) than controls (33.3%) (p<0.0001, Chi-square), odds ratio 3.83 (95% CI 2.16-6.79). Large vessel disease (LVD) (single or multiple cortical or subcortical infarcts>1.5 cm) was present in 23 (21.9%) cases and 2 (1.9%) (p<0.001) controls, with small vessel disease (SVD) (periventricular or subcortical white matter lesions (WMLs), including leukoaraiosis (LA)) present in 52 (49.5%) cases (LA in 4) and 34 (32.3%) controls (LA in 0) (p<0.05). When WMLs were rated using a semiquantitative visual rating scale, a trend towards greater severity was observed amongst cases compared to controls.

CONCLUSIONS

Radiological CVD is significantly more prevalent in patients with LOE than controls, including signs of both LVD and SVD. SVD also appears to be of greater severity. Further studies are needed in this area.

CVD and Characterization of Al-Cu Metallization Thin Films

The chemical vapor deposition of Al-Cu thin films on Si, SiO2, and TiN substrates was examined in a vertical low pressure cold wall reactor using trimethylamine alane (TMAA1) at 20 C as the Al source. The Cu sources bis-(hexafluoroacetylacetonato)copper(H)(CuHFA), (cyclopentadienyl)copper(I) triethylphosphine (CpCuPEt3), and (hexafluoroacetylacetonato)copper(I) trimethylphosphine (HfaCuPMe3), were compared. The Cu content of the films was controlled up to“5 wt% by simply varying the temperature of the Cu source. Codeposited Al-Cu films with excellent conductivity, purity, and adhesion properties were obtained with all Cu sources. Optimal film smoothness was achieved at∼350 C. The compounds differed in the ease of control over the %Cu in the films. CuHFA exhibited a massive parasitic reaction which made control very difficult. The Cu(I) complexes showed very minor parasitic reactions. Analysis of films with high Cu content by SEM-EDS showed clear segregation of Cu and Al, consistent with the low solubility of Cu in Al. Films with >2% Cu appeared homogeneous on a μm scale by both SEM-EDS and SIMS depth profiling. TEM of film cross sections revealed a polycrystalline Al film with small (20–100 Å) Cu-rich particles dispersed throughout the Al grains. These particles exhibited bright field-dark field contrast characteristic of crystalline material.

A randomized trial to assess the impact of early steroid withdrawal on growth in pediatric renal transplantation: the TWIST study

Minimizing steroid exposure in pediatric renal transplant recipients can improve linear growth and reduce metabolic disorders. This randomized multicenter study investigated the impact of early steroid withdrawal on mean change in height standard deviation score (SDS) and the safety and efficacy of two immunosuppressive regimens during the first 6 months after transplantation. Children received tacrolimus, MMF, two doses of daclizumab and steroids until day 4 (TAC/MMF/DAC, n=98) or tacrolimus, MMF and standard-dose steroids (TAC/MMF/STR, n=98). Mean change in height SDS was 0.16 +/- 0.32 with TAC/MMF/DAC and 0.03 +/- 0.32 with TAC/MMF/STR. The mean treatment group difference was 0.13 (p < 0.005 [95% CI 0.04-0.22]), 0.21 in prepubertal (p = 0.009 [95% CI 0.05-0.36]) and 0.05 in pubertal children (p = ns). Frequency of biopsy-proven acute rejection was 10.2%, TAC/MMF/DAC, and 7.1%, TAC/MMF/STR. Patient and graft survival and renal function were similar. Significantly greater reductions in total cholesterol and triglycerides but significantly higher incidences of infection and anemia were found with TAC/MMF/DAC (p < 0.05 all comparisons). Early steroid withdrawal significantly aided growth at 6 months more so in prepubertal than pubertal children. This was accompanied by significantly better lipid and glucose metabolism profiles without increases in graft rejection or loss.

Growth and body composition in children with chronic kidney disease

Growth failure is a common yet complex problem of childhood chronic kidney disease caused by multiple factors encountered due to the primary disease or secondary to the renal impairment. This review seeks to describe the various patho-physiological mechanisms contributing to growth failure in the various stages of childhood with particular emphasis on nutritional problems and endocrine dysfunction encountered whilst managing these children. In addition, we shall examine the role of body composition in chronic kidney disease, their relationship with growth and nutrition and the potential effect of abnormalities in fat mass and lean mass on long-term morbidity and mortality.

Use of rapamycin in a transplant patient who developed cyclosporin neurotoxicity

We describe the case of a paediatric kidney transplant patient who developed cyclosporin neurotoxicity on day 7 post-transplant. Consequently, her cyclosporin was stopped and she was commenced on rapamycin. Over the next 3 weeks her creatinine remained elevated and she had several episodes of biopsy proven rejection, despite increasing the initial dose of rapamycin by tenfold. Her whole blood rapamycin levels also remained well below the target range of 10-20 ng/ml. On day 38 post-transplant, the decision was made to add tacrolimus to her immunosuppression. At the same time, phenytoin, which had been commenced during her episode of cyclosporin neurotoxicity, was withdrawn. After this point her rapamycin blood levels rapidly increased to within the therapeutic range and she improved clinically. We propose that phenytoin, as a p450 cytochrome enzyme inducer, increased the metabolism of rapamycin in this patient and hence decreased the initial therapeutic effectiveness of this drug.

Growth hormone and markers of immune function in children with renal transplants

Lymphocyte subsets and T cell activation markers were measured in ten children with renal transplants for up to 1 year before and during their 1st year of recombinant human growth hormone (rhGH) treatment. The number of lymphocytes, helper or cytotoxic T cells or natural killer cells, and the T cell expression of CD25, CD26 and HLA-DR antigens were not altered by rhGH. B cell numbers declined both before and during treatment. There was no difference in lymphocyte subset numbers between children with and without rejection episodes.

Randomised controlled trial of recombinant human growth hormone in prepubertal and pubertal renal transplant recipients. British Association for Pediatric Nephrology

AIMS

To evaluate the efficacy (height velocity (HV), change in height standard deviation score (delta HSDS)), and safety (glomerular filtration rate (GFR), incidence of rejection, and calcium and glucose metabolism) of recombinant human growth hormone (rhGH) treatment after renal transplantation.

DESIGN

A two year randomised controlled trial.

SUBJECTS

Fifteen prepubertal and seven pubertal children: mean (SD) age, 13.0 (2.6) and 15.2 (2.4) years, respectively; mean (SD) GFR, 51 (30) and 48 (17) ml/min/1.73 m2, respectively. Six prepubertal and three pubertal children were controls during the first year; all received rhGH in the second year.

RESULTS

In the first year, mean (SE) HV and delta HSDS in the prepubertal treated group increased compared with controls: 8.1 (0.9) v 3.7 (0.6) cm/year and 0.6 (0.1) v -0.3 (0.2), respectively. In the pubertal treated group, mean (SE) HV and delta HSDS were also greater: 10.1 (0.6) v 3.9 (1.3) cm/year and 0.6 (0.1) v -0.1 (0.2), respectively. Comparing all treated and control children, there was no significant change in GFR: treated group, mean (SE) 9.9 (5.4) ml/min/1.73 m2 v control group, -1.6 (7.6) ml/min/1.73 m2. There were also no differences in the incidence of rejection in the first year: eight episodes in 13 patients v five episodes in nine patients, respectively. Phosphate, alkaline phosphatase (ALP), parathyroid hormone (PTH), and fasting insulin concentrations rose during the first year of treatment, but not thereafter. In the second year of treatment, HV remained above baseline.

CONCLUSION

Treatment with rhGH improves growth in prepubertal and pubertal children with renal transplants, with no significant change in GFR or the incidence of rejection. Phosphate, ALP, PTH, and insulin increased during the first year of treatment.

Catch-up growth occurs after renal transplantation in children of pubertal age

OBJECTIVE

Assessment of growth after renal transplantation in children of pubertal age by analyzing the annual increment in height standard deviation score (Ht SDS) in all girls > or =10 years and boys > or =11 years of age at the time of transplantation until latest follow-up (minimum 2 years).

PATIENTS

A total of 59 grafts were placed in 54 recipients (30 boys) between December 1984 and January 1995. Mean (range) age at transplantation was 13.6 years (10.1 to 17.7 years). Fifty-one percent had congenital renal disease, 36% acquired renal disease, and 13% had hereditary nephropathies. Eighty-seven percent were first grafts; of these, 29% were performed pre-emptively, and 23% were from living related donors.

RESULTS

Mean (SD) Ht SDS at transplantation was -1.8 (0.2) and increased significantly thereafter, such that it was -1.6 (0.2) at 1 year, n = 52; -1.5 (0.2) at 2 years, n = 47; -1.0 (0.2) at 3 years, n = 27; -0.7 (0.3) at 4 years, n = 19; and -0.6 (0.3), n = 13, at 5 years after transplantation (analysis of variance, P < .001). The greatest improvement in Ht SDS in the first year was seen in children with the highest glomerular filtration rate (r = 0.429, P = .002) and in those who were shortest at the time of transplantation (r = -0.356, P = .009).

CONCLUSION

Catch-up growth occurs in children receiving renal transplants during the expected time of puberty.

Recombinant human growth hormone (rhGH) treatment of infants and young children with chronic renal failure

Infants with chronic renal failure often grow badly despite medical management. rhGH treatment results in good catch-up growth and should be used in infants who do not respond to conservative management.

Use of recombinant human growth hormone (rhGH) in pubertal patients with renal disease

Growth during puberty in renal failure and following renal transplantation is often poor. Treatment with rhGH improved height SDS in 13 pubertal children with renal disease.

Factors influencing the response to growth hormone in children with renal disease

The effects of age, height velocity over the preceding year, glomerular filtration rate (GFR) and prednisolone dose on growth response have been assessed by single and multiple linear regression analysis in 23 prepubertal children [age, mean (SD), 8.2 (2.5) years] with chronic renal failure (CRF) and 16 prepubertal children [12.1 (2.3) years] with renal transplants treated for 1 year with recombinant human growth hormone (rhGH), 30 U/m2 per week. Height velocity [mean (SD), cm/year] increased from 4.7 (1.3) to 9.7 (2.1) (P < 0.0001) in the CRF group and 3.1 (1.6) to 7.3 (2.8) (P < 0.0001) in the transplant group. In the CRF group, there was a correlation between age and height velocity, both in the pretreatment year (r = -0.755, P < 0.0001) and during treatment (r = -0.421, P = 0.045). There was no correlation between pretreatment height velocity or GFR and response to rhGH. In the transplanted children height velocity during the treatment year correlated with age (r = -0.647, P = 0.007), prednisolone dose (r = -0.689, P = 0.003), GFR (r = 0.542, P = 0.030) and pretreatment height velocity (r = 0.655, P = 0.006). Multiple regression analysis showed prednisolone dose and age to be the most important predictors of response.

Effects of recombinant human growth hormone on renal function in children with renal transplants

OBJECTIVE

To provide accurate measurement of renal function during treatment with recombinant human growth hormone (rhGH).

METHODS

We measured glomerular filtration rate and effective renal plasma flow by clearance of inulin and para-aminohippuric acid before rhGH therapy, after 1 week, and then at 6-month intervals for up to 2 years of treatment in 16 children (mean (SD) age = 13.1 (2.2) years; glomerular filtration rate = 52 (27) ml/min per 1.73 m2). The mean (SD) time from transplantation was 6.5 (3.6) years.

RESULTS

Linear growth velocity during rhGH therapy increased from 4.0 (1.8) to 8.8 (2.6) cm/yr (p < 0.0001). One child was withdrawn after 9 months because of abnormal glucose tolerance, and another child received a second renal transplant after 18 months. Glomerular filtration rate increased to 57 (29) ml/min per 1.73 m2 at 1 week (p = 0.004), remained improved at 6 months (63 (30); p = 0.013), but was not significantly better at 1 year (59 (33)). Effective renal plasma flow on day 1 was 237 (127) ml/min per 1.73 m2 and was unchanged on day 8 (244 (123)), at 6 months (271 (149)), and after 1 year (269 (157)). During the study there was no significant change in filtration fraction, blood pressure, or kidney volume, and excretion of microalbumin and N-acetylglucosaminidase was unaltered. There was one rejection episode per 14.8 patient-months in the year before treatment, 1 per 18.9 patient-months during the first year of treatment, and 1 per 13 patient-months during the second year of rhGH therapy.

CONCLUSION

Treatment with rhGH improves growth in children with renal transplants. Glomerular filtration rate was increased after 1 week and 6 months of rhGH therapy but returned to baseline values thereafter. The data indicate the need for long-term follow-up of children with renal transplants who are receiving rhGH.

The hypothalamo-pituitary-growth hormone insulin-like growth factor 1 axis in children with chronic renal failure

Growth hormone (GH) levels are high in children with chronic renal failure (CRF), and there is increased hypothalamic sensitivity to the factors that normally modulate GH secretion. GH binding protein (GHBP) is decreased, which may reflect decreased GH receptor activity. IGFBP3 levels are normal in both CRF and transplanted children when measured by immunoradiometric assay, but intact IGFBP3 is low in transplanted children with an excess of small fragments, measured by Western immunoblotting. These fragments may interfere with IGF1 bioactivity.

Recombinant human growth hormone treatment in infants with chronic renal failure

Poor growth is a particular problem for children with congenital renal disease. A one year trial of the use of recombinant human growth hormone (rhGH) in eight infants and young children with chronic renal failure is reported here. At entry bone age was less than 2 years, mean (range) chronological age 1.9 (1.3-2.7) years, and glomerular filtration rate (GFR) was 17 (9-42) ml/min/1.73 m2. Height standard deviation score (SDS) was -3.3 (-4.6 to -2.0) and height velocity SDS was -1.3 (-3.1 to 0.7). One child was withdrawn when he received a renal transplant after 9.5 months. Two children required dialysis, but remained in the trial. Treatment with rhGH resulted in an increase in height SDS to -2.2 (-4.2 to -0.9), p = 0.0002, and height velocity SDS to 1.1 (-0.7 to 2.6), p = 0.006. There was no change in GFR and no serious adverse events. There was no effect on plasma lipids, calcium, phosphate, intact parathyroid hormone, or glucose. Alkaline phosphatase rose significantly. Thus rhGH improved growth in eight infants with chronic renal failure, with four children entering the normal range.

Differential effects of recombinant human growth hormone on glomerular filtration rate and renal plasma flow in chronic renal failure

In normal subjects recombinant human growth hormone (rhGH) increases glomerular filtration rate (GFR) and effective renal plasma flow (ERPF) through the action of insulin-like growth factor-I (IGF-I). We have measured clearance of inulin and para-aminohippuric acid in 18 children with chronic renal failure (CRF) during their 1st year of rhGH treatment to look at the immediate (first 3 h), short-term (1 week) and long-term (1 year) effects of treatment. On day 1 mean (range) age was 9.1 (4.9-13.9) years, GFR 19 (9-58) and ERPF 77 (34-271) ml/min per 1.73 m2. During treatment height velocity increased from 4.5 (1.7-6.5) to 9.5 (4.8-12.7) cm/year (P < 0.0001). Two children required dialysis after 0.75 years and 1 child was electively transplanted after 0.5 years. There were no other serious adverse events. GFR and ERPF were unchanged in the 3 h following rhGH. GFR remained constant on day 8, 22 (6-56) and after 1 year, 20 (9-59) ml/min per 1.73 m2. ERPF increased to 96 (33-276) ml/min per 1.73 m2 on day 8 (P = 0.005), and remained elevated, but not significantly so, at 99 (24-428) ml/min per 1.73 m2 at 1 year. Fasting IGF-I increased from 147 (46-315) ng/ml to 291 (61-673) by day 8 (P < 0.003), and to 341 (101-786) ng/ml at 1 year. There was no correlation between the change in IGF-I and renal function. Blood pressure, albumin excretion and dietary protein intake were unchanged by treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Correlation between pulmonary cytochrome P450 transcripts and the organ-selective pneumotoxicity of 3-methylindole

3-Methylindole (3MI) is a species- and organ-selective pneumotoxin; goats are the most susceptible species, mice are intermediate in susceptibility, and rabbits are the least susceptible species to its toxicity. Four different cDNA probes representative of human cytochrome P450 genes CYP2F1, CYP4B1, CYP2A6, and CYP2B6 were hybridized against RNA from lung and liver tissues of goat, mouse and rabbit. Transcripts representative of pulmonary P450s CYP2F1, CYP4B1 and CYP2B6 were present in goat lung. Transcripts for the CYP2F1 and CYP4B1 genes were observed in rabbit and mouse lung. In general, the probes selectively hybridized to pulmonary but not hepatic transcripts of all three species. The differences in susceptibilities among the three species could not be explained by the lack of 4B1 and 2F1 transcripts in the lungs of mice or rabbits that are less susceptible than goats, but the selective expression in the lung tissues of all three species may participate in the organ-selective bioactivation and pulmonary toxicity of 3MI in these species.

Congenital amputation of the toes with replantation at the site of a constriction band in the mid-calf. Case report

We present a case of congenital amputation of the toes with replantation at the site of a constriction band in the mid-calf. The theories of the etiology of constriction bands are discussed, and the importance of this case in supporting the amniotic constriction band theory is emphasized.

Fibrin-fibrinogen degradation products in children with renal disease

Fibrin/fibrinogen degradation products (FDP) were measured in the serum and urine of children with various forms of renal disease. Serum FDP was raised both with nephrosis and with active proliferative nephritis. Urine FDP was rarely present in nephrosis but was significantly increased during the active phase of proliferative nephritis and also in urinary tract infection with frank haematuria. Urinary FDP correlated with total urinary protein in proliferative nephritis but not in nephrosis, nor did it correlate with serum FDP in either condition. The major application of urinary FDP determination in clinical practice is as an indicator of activity and possible response to treatment in the management of active proliferative nephritis.