Role of high-volume plasmapheresis in the management of paediatric acute liver failure

OBJECTIVES

Paediatric acute liver failure (PALF) is a life-threatening disease. Management aims to support hepatic regeneration or to bridge to liver transplantation. High-volume plasmapheresis (HVP) removes protein-bound substances, alleviates inflammation, and improves survival in adult acute liver failure. However, experience with HVP in PALF is limited. Aim of this study is to report on feasibility, safety, efficacy and outcomes of HVP in PALF.

METHODS

Retrospective observational study in children with PALF. HVP was performed upon identification of negative prognostic indicators, in toxic aetiology or multiorgan failure (MOF). Exchanged volume with fresh-frozen plasma corresponded to 1.5-2.0 times the patient's estimated plasma volume. One daily cycle was performed until the patient met criteria for discontinuation, that is, liver regeneration, liver transplantation, or death.

RESULTS

Twenty-two children with PALF (body weight 2.5-106 kg) received 1-7 HVP cycles. No bleeding or procedure-related mortality occurred. Alkalosis, hypothermia and reduction in platelets were observed. Haemolysis led to HVP termination in one infant. Seven children (32%) survived with their native livers, 13 patients (59%) underwent liver transplantation. Two infants died due to MOF. Overall survival was 86%. International normalization ratio (INR), alanine aminotransaminases (ALT), bilirubin and inotropic support were reduced significantly (p < 0.05) after the first HVP-cycle (median): INR 2.85 versus 1.5; ALT 1280 versus 434 U/L; bilirubin 12.7 versus 6.7 mg/dL; norepinephrine dosage 0.083 versus 0.009 µg/kg/min. Median soluble-interleukin-2-receptor dropped significantly following HVP (n = 7): 2407 versus 950 U/mL (p < 0.02).

CONCLUSIONS

HVP in PALF is feasible, safe, improves markers of liver failure and inflammation and is associated with lowering inotropic support. Prospective and controlled studies are required to confirm efficacy of HVP in PALF.

Current management of symptomatic vesicoureteral reflux in pediatric kidney transplantation-A European survey among surgical transplant professionals

BACKGROUND

Vesicoureteral reflux (VUR) is common in children and adolescents undergoing kidney transplantation (KTx) and may adversely affect allograft kidney function.

METHODS

To explore the current management of symptomatic native and allograft VUR in pediatric KTx recipients, an online survey was distributed to European surgical transplant professionals.

RESULTS

Surgeons from 40 pediatric KTx centers in 18 countries participated in this survey. Symptomatic native kidney VUR was treated before or during KTx by 68% of the centers (all/selected patients: 33%/67%; before/during KTx: 89%/11%), with a preference for endoscopic treatment (59%). At KTx, 90% favored an anti-reflux ureteral reimplantation procedure (extravesical/transvesical approach: 92%/8%; preferred extravesical technique: Lich-Gregoir [85%]). Management strategies for symptomatic allograft VUR included surgical repair (90%), continuous antibiotic prophylaxis (51%), bladder training (49%), or noninterventional surveillance (21%). Redo ureteral implantation and endoscopic intervention for allograft VUR were equally reported (51%/49%).

CONCLUSIONS

This survey shows uniformity in some surgical aspects of the pediatric KTx procedure. However, with regard to VUR, there is a significant variation in practice patterns that need to be addressed by future well-designed and prospective studies. In this way, more robust data could be translated into consensus guidelines for a more standardized and evidence-based management of this common condition in pediatric KTx.

Non-surgical management in children with non-refluxing primary megaureter: a systematic review and meta-analysis

BACKGROUND

Children with non-refluxing primary megaureter are mostly managed by a watchful approach with close follow-up and serial imaging.

OBJECTIVES

This systematic review and meta-analysis aimed to determine whether there is sufficient evidence to support the current non-surgical management strategy in these patients.

DATA SOURCES

A comprehensive search including electronic literature databases, clinical trial registries, and conference proceedings was performed.

DATA SYNTHESIS METHODS

Outcomes were estimated as pooled prevalence. If meta-analytical calculations were not appropriate, outcomes were provided in a descriptive manner.

RESULTS

Data from 8 studies (290 patients/354 renal units) were included. For the primary outcome, differential renal function estimated by functional imaging, meta-analysis was impossible due to reported data not being precise. Pooled prevalence for secondary surgery was 13% (95% confidence interval: 8-19%) and for resolution 61% (95% confidence interval: 42-78%). The risk of bias was moderate or high in most studies.

LIMITATIONS

This analysis was limited by the low number of eligible studies with few participants and high clinical heterogeneity, and the poor quality of the available data.

CONCLUSIONS

The low pooled prevalence of secondary surgical intervention and high pooled prevalence of resolution may support the current non-surgical management in children with non-refluxing primary megaureter. However, these results should be interpreted cautiously due to the limited available body of evidence. Future studies should overcome existing limitations of imaging methods by using standardized, comparable criteria and report outcome parameters in a quantitative manner. This would allow more sufficient data synthesis to provide evidence-based recommendations for clinical decision-making and counseling.

SYSTEMATIC REVIEW REGISTRATION

The protocol was registered on PROSPERO under CRD42019134502.

Effects of Burosumab Treatment on Mineral Metabolism in Children and Adolescents With X-linked Hypophosphatemia

CONTEXT

Burosumab has been approved for the treatment of children and adults with X-linked hypophosphatemia (XLH). Real-world data and evidence for its efficacy in adolescents are lacking.

OBJECTIVE

To assess the effects of 12 months of burosumab treatment on mineral metabolism in children (aged <12 years) and adolescents (aged 12-18 years) with XLH.

DESIGN

Prospective national registry.

SETTING

Hospital clinics.

PATIENTS

A total of 93 patients with XLH (65 children, 28 adolescents).

MAIN OUTCOME MEASURES

Z scores for serum phosphate, alkaline phosphatase (ALP), and renal tubular reabsorption of phosphate per glomerular filtration rate (TmP/GFR) at 12 months.

RESULTS

At baseline, patients showed hypophosphatemia (-4.4 SD), reduced TmP/GFR (-6.5 SD), and elevated ALP (2.7 SD, each P < .001 vs healthy children) irrespective of age, suggesting active rickets despite prior therapy with oral phosphate and active vitamin D in 88% of patients. Burosumab treatment resulted in comparable increases in serum phosphate and TmP/GFR in children and adolescents with XLH and a steady decline in serum ALP (each P < .001 vs baseline). At 12 months, serum phosphate, TmP/GFR, and ALP levels were within the age-related normal range in approximately 42%, 27%, and 80% of patients in both groups, respectively, with a lower, weight-based final burosumab dose in adolescents compared with children (0.72 vs 1.06 mg/kg, P < .01).

CONCLUSIONS

In this real-world setting, 12 months of burosumab treatment was equally effective in normalizing serum ALP in adolescents and children, despite persistent mild hypophosphatemia in one-half of patients, suggesting that complete normalization of serum phosphate is not mandatory for substantial improvement of rickets in these patients. Adolescents appear to require lower weight-based burosumab dosage than children.

Corrigendum: Molecular HLA mismatching for prediction of primary humoral alloimmunity and graft function deterioration in paediatric kidney transplantation

[This corrects the article DOI: 10.3389/fimmu.2023.1092335.].

Molecular HLA mismatching for prediction of primary humoral alloimmunity and graft function deterioration in paediatric kidney transplantation

Introduction

Rejection remains the main cause of allograft failure in paediatric kidney transplantation and is driven by donor-recipient HLA mismatching. Modern computational algorithms enable assessment of HLA mismatch immunogenicity at the molecular level (molecular-mismatch, molMM). Whilst molMM has been shown to correlate with alloimmune outcomes, evidence demonstrating improved prediction performance against traditional antigen mismatching (antMM) is lacking.

Methods

We analysed 177 patients from the CERTAIN registry (median follow-up 4.5 years). molMM scores included Amino-Acid-Mismatch-Score (AAMS), Electrostatic-Mismatch-Score (EMS3D) and netMHCIIpan (netMHC1k: peptide binding affinity ≤1000 nM; netMHC: binding affinity ≤500 nM plus rank <2%). We stratified patients into high/low-risk groups based on risk models of DSA development.

Results

Donor-specific HLA antibodies (DSA) predominantly targeted the highest scoring molMM donor antigen within each HLA locus. MolMM scores offered superior discrimination versus antMM in predicting de novo DSA for all HLA loci; the EMS3D algorithm had particularly consistent performance (area under the receiver operating characteristic curve (AUC) >0.7 for all HLA loci vs. 0.52-0.70 for antMM). ABMR (but not TCMR) was associated with HLA-DQ molMM scores (AAMS, EMS3D and netMHC). Patients with high-risk HLA-DQ molMM had increased risk of graft function deterioration (50% reduction in baseline eGFR (eGFR50), adjusted HR: 3.5, 95% CI 1.6-8.2 high vs. low EMS3D). Multivariable modelling of the eGFR50 outcome using EMS3D HLA-DQ stratification showed better discrimination (AUC EMS3D vs. antMM at 2 years: 0.81 vs. 0.77, at 4.5 years: 0.72 vs. 0.64) and stratified more patients into the low-risk group, compared to traditional antMM.

Conclusion

Molecular mismatching was superior to antigen mismatching in predicting humoral alloimmunity. Molecular HLA-DQ mismatching appears to be a significant prognostic factor for graft function deterioration in paediatric kidney transplantation.

Diagnostic and therapeutic management of vesico-ureteral reflux in pediatric kidney transplantation-Results of an online survey on behalf of the European Society for Paediatric Nephrology

BACKGROUND

Vesico-ureteral reflux (VUR) is considered to be a risk factor for recurrent febrile urinary tract infections and impaired renal transplant survival.

METHODS

An online survey supported by the European Society for Paediatric Nephrology was designed to evaluate current management strategies of VUR in native and transplanted kidneys of recipients aged <18 years.

RESULTS

Seventy-three pediatric transplant centers from 32 countries contributed to the survey. All centers performed urological evaluation prior to pediatric kidney transplantation (KTx) with subsequent interdisciplinary discussion. Screening for VUR in native kidneys (30% in all, 70% in selected patients) led to surgical intervention in 78% (11% in all, 89% in selected patients) with a decided preference of endoscopic intervention over ureterocystoneostomy. Following KTx, continuous antibiotic prophylaxis was applied in 65% of the patients and screening for allograft VUR performed in 93% of selected patients. The main management strategies of symptomatic allograft VUR were continuous antibiotic prophylaxis (83%) and surgical treatment (74%) (endoscopic intervention 55%, redo ureterocystoneostomy 26%).

CONCLUSIONS

This survey demonstrates the high variability in the management of VUR in pediatric KTx recipients, points to knowledge gaps, and might serve as a starting point for improving the care for patients with VUR in native and transplanted kidneys.

Hyperparathyroidism Is an Independent Risk Factor for Allograft Dysfunction in Pediatric Kidney Transplantation

Introduction

Little is known about the consequences of deranged chronic kidney disease-mineral and bone disorder (CKD-MBD) parameters on kidney allograft function in children. We examined a relationship between these parameters over time and allograft outcome.

Methods

This registry study from the Cooperative European Paediatric Renal Transplant Initiative (CERTAIN) collected data at baseline, months 1, 3, 6, 9, and 12 after transplant; and every 6 months thereafter up to 5 years. Survival analysis for a composite end point of graft loss or estimated glomerular filtration rate (eGFR) ≤30 ml/min per 1.73 m² or a ≥50% decline from eGFR at month 1 posttransplant was performed. Associations of parathyroid hormone (PTH), calcium, phosphate, and 25-hydroxyvitamin D (25(OH)D) with allograft outcome were investigated using conventional stratified Cox proportional hazards models and further verified with marginal structural models with time-varying covariates.

Results

We report on 1210 patients (61% boys) from 16 European countries. The composite end point was reached in 250 grafts (21%), of which 11 (4%) were allograft losses. In the conventional Cox proportional hazards models adjusted for potential confounders, only hyperparathyroidism (hazard ratio [HR], 2.94; 95% confidence interval [CI], 1.82-4.74) and hyperphosphatemia (HR, 1.94; 95% CI, 1.28-2.92) were associated with the composite end point. Marginal structural models showed similar results for hyperparathyroidism (HR, 2.74; 95% CI, 1.71-4.38), whereas hyperphosphatemia was no longer significant (HR, 1.35; 95% CI, 0.87-2.09), suggesting that its association with graft dysfunction can be ascribed to a decline in eGFR.

Conclusion

Hyperparathyroidism is a potential independent risk factor for allograft dysfunction in children.

Extracorporeal photopheresis versus standard treatment for acute graft-versus-host disease after haematopoietic stem cell transplantation in children and adolescents

BACKGROUND

Acute graft-versus-host disease (aGvHD) is a major cause of morbidity and mortality after haematopoietic stem cell transplantation (HSCT), occurring in 8% to 85% of paediatric recipients. Currently, the therapeutic mainstay for aGvHD is treatment with corticosteroids. However, there is no established standard treatment for steroid-refractory aGvHD. Extracorporeal photopheresis (ECP) is a type of immunomodulatory method amongst different therapeutic options that involves ex vivo collection of peripheral mononuclear cells, exposure to the photoactive agent 8-methoxypsoralen and ultraviolet-A radiation, and reinfusion of these treated blood cells to the patient. The mechanisms of action of ECP are not completely understood. This is the second update of a Cochrane Review first published in 2014 and updated in 2015.

OBJECTIVES

To evaluate the effectiveness and safety of ECP for the management of aGvHD in children and adolescents after HSCT.

SEARCH METHODS

We searched the Cochrane Register of Controlled Trials (CENTRAL), MEDLINE (PubMed) and Embase (Ovid) databases from their inception to 25 January 2021. We searched the reference lists of potentially relevant studies without any language restrictions. We searched five conference proceedings and nine clinical trial registries on 9 November 2020 and 12 November 2020, respectively.

SELECTION CRITERIA

We sought to include randomised controlled trials (RCTs) comparing ECP with or without standard treatment versus standard treatment alone in children and adolescents with aGvHD after HSCT.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed the study selection. We resolved disagreement in the selection of trials by consultation with a third review author.

MAIN RESULTS

We identified no additional studies in the 2021 review update, so there are still no studies that meet the criteria for inclusion in this review.

AUTHORS' CONCLUSIONS

The efficacy of ECP in the treatment of aGvHD in children and adolescents after HSCT is unknown, and its use should be restricted to within the context of RCTs. Such studies should address a comparison of ECP alone or in combination with standard treatment versus standard treatment alone. The 2021 review update brought about no additions to these conclusions.

Timing of reconstruction of the lower urinary tract in pediatric kidney transplant recipients: A CERTAIN multicenter analysis of current practice

BACKGROUND

Preexistent LUTD are considered a hostile environment, which might negatively impact KTx survival. In such cases, surgical reconstruction of the bladder is required. However, there is still disagreement on the optimal timing of the reconstruction procedure.

METHODS

This is a multicenter analysis of data from the CERTAIN Registry. Included were 62 children aged 8.18 ± 4.90 years, with LUTD. Study endpoints were the duration of initial posttransplant hospitalization, febrile UTIs, and a composite failure endpoint comprising decline of eGFR, graft loss, or death up to 5 years posttransplant. Outcome was compared to matched controls without bladder dysfunction.

RESULTS

Forty-one patients (66.1%) underwent pretransplant and 14 patients (22.6%) posttransplant reconstruction. Bladder augmentation was performed more frequently in the pretransplant (61%) than in the posttransplant group (21%, p = .013). Outcome in the pre- and posttransplant groups and in the subgroups of patients on pretransplant PD with major bladder surgery either pre- (n = 14) or posttransplant (n = 7) was comparable. Outcomes of the main study cohort and the matched control cohort (n = 119) were comparable during the first 4 years posttransplant; at year 5, there were more events of transplant dysfunction in the study cohort with LUTD than in controls (p = .03).

CONCLUSIONS

This multicenter analysis of the current practice of LUTD reconstruction in pediatric KTx recipients shows that pre- or posttransplant surgical reconstruction of the lower urinary tract is associated with a comparable 5-year outcome.

Extracorporeal photopheresis versus alternative treatment for chronic graft-versus-host disease after haematopoietic stem cell transplantation in children and adolescents

BACKGROUND

Chronic graft-versus-host disease (cGvHD) is a major cause of morbidity and mortality after haematopoietic stem cell transplantation, occurring in 6% to 65% of the paediatric recipients. Currently, the therapeutic mainstay for cGvHD is treatment with corticosteroids, frequently combined with other immunosuppressive agents in people with steroid-refractory manifestations. There is no established standard treatment for steroid-refractory cGvHD. The therapeutic options for these patients include extracorporeal photopheresis (ECP), an immunomodulatory treatment that involves ex vivo collection of mononuclear cells from peripheral blood, exposure to the photoactive agent 8-methoxypsoralen, ultraviolet radiation and re-infusion of the processed cell product. The mechanisms of action of ECP are not completely understood. This is the second update of a Cochrane Review first published in 2014 and first updated in 2015.

OBJECTIVES

To evaluate the effectiveness and safety of ECP for the management of cGvHD in children and adolescents after haematopoietic stem cell transplantation.

SEARCH METHODS

We searched the Cochrane Register of Controlled Trials (CENTRAL) (2021), MEDLINE (PubMed) and Embase databases from their inception to 25 January 2021. We searched the reference lists of potentially relevant studies without any language restrictions. We searched five conference proceedings and nine clinical trial registries on 9 November 2020 and 12 November 2020, respectively.

SELECTION CRITERIA

We aimed to include randomised controlled trials (RCTs) comparing ECP with or without alternative treatment versus alternative treatment alone in children and adolescents with cGvHD after haematopoietic stem cell transplantation.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed the study selection. We resolved disagreements in the selection of trials by consultation with a third review author.

MAIN RESULTS

We found no studies meeting the criteria for inclusion in this 2021 review update.

AUTHORS' CONCLUSIONS

We could not evaluate the efficacy of ECP in the treatment of cGvHD in children and adolescents after haematopoietic stem cell transplantation since the second review update again found no RCTs. Current recommendations are based on retrospective or observational studies only. Thus, ideally, ECP should be applied in the context of controlled trials only. However, performing RCTs in this population will be challenging due to the limited number of eligible participants, variable disease presentation and the lack of well-defined response criteria. International collaboration, multicentre trials and appropriate funding for such trials will be needed. If treatment decisions based on clinical data are made in favour of ECP, recipients should be carefully monitored for beneficial and harmful effects. In addition, efforts should be made to share this information with other clinicians, for example by setting up registries for children and adolescents treated with ECP.

Patients With Infantile Nephropathic Cystinosis in Germany and Austria: A Retrospective Cohort Study

Background

Infantile nephropathic cystinosis (INC) is a rare lysosomal storage disorder resulting in progressive chronic kidney disease (CKD) and a variety of extrarenal manifestations. This orphan disease remains a challenge for patients, their families and health care providers. There is currently no comprehensive study on patients' clinical course in Germany and Austria.

Methods

A retrospective cohort study including 74 patients at eleven centers of care was conducted. Data on time of diagnosis, CKD stage, leukocyte cystine levels (LCL), extrarenal manifestations, and treatment was collected from medical charts and subsequently analyzed using explorative statistics. Age at initiation of kidney replacement therapy (KRT) was evaluated by Kaplan-Meier analyses for different groups of patients.

Results

Patients were diagnosed at a median age of 15 months (IQR: 10-29, range: 0-110), more recent year of birth was not associated with earlier diagnosis. Oral cystine-depleting therapy (i.e., cysteamine) was prescribed at a median dose of 1.26 g/m² per day (IQR: 1.03-1.48, range: 0.22-1.99). 69.2% of all 198 LCL measurements of 67 patients were within the desired target range (≤ 1 nmol cystine/mg protein). Median time-averaged LCLs per patient (n = 65) amounted to 0.57 nmol cystine/mg protein (IQR: 0.33-0.98, range: 0.07-3.13) when considering only values at least 1 year after initiation of therapy. The overall median height of 242 measurements of 68 patients was at the 7^th percentile (IQR: 1-25, range: 1-99). 40.5% of the values were ≤ the 3^rd percentile. Patient sex and year of birth were not associated with age at initiation of KRT, but patients diagnosed before the age of 18 months required KRT significantly later than those patients diagnosed at the age of ≥ 18 months (p = 0.033): median renal survival was 21 years (95% CI: 16, -) vs. 13 years (95% CI, 10, -), respectively.

Conclusion

Early diagnosis and initiation of cystine depleting therapy is important for renal survival in children with INC. Cysteamine doses and LCL showed that treatment in this cohort met international standards although there is great interindividual variety. Patient growth and other aspects of the disease should be managed more effectively in the future.

Prophylactic antithrombotic management in adult and pediatric kidney transplantation: A systematic review and meta-analysis

BACKGROUND

RGT is a major cause for early graft loss after KTx. Although evidence-based recommendations are lacking, aP is often used to prevent RGT. This systematic review aimed to determine the effectiveness and safety of aP in adult and pediatric KTx recipients.

METHODS

MEDLINE, EMBASE, Cochrane Controlled Trials Register, conference proceedings, and electronic databases for trial registries were searched for eligible studies using search terms relevant to this review (April 21, 2020). The systematic review was carried out following the recommendations of the Cochrane Collaboration and the Prefered Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement.

RESULTS

Twelve studies comprising 2370 patients (adult = 1415, pediatric = 955) were included, of which three were RCTs. The overall risk for developing RGT was lower in the group with aP compared with the control group (RR 0.24, 95% confidence interval 0.12-0.49). The antithrombotic drugs used were heparin (7/12), acetylsalicylic acid (2/12), a combination of both (2/12), and dipyridamole (1/12) with a high variability in timing, dosing, and mode of application. Adverse effects were reported rarely, with minor bleeding as the main complication. The non-randomized studies had significant risks of bias in the domains of patient selection, confounder, and measurement of outcomes.

CONCLUSION

Based on pooled analysis, aP seems to reduce the risk of RGT in KTx. However, the reliability of these results is limited, as the quality of the available studies is poor and information on adverse effects associated with aP is scarce. Additional high-quality research is urgently needed to provide sufficient data supporting the use of aP in KTx.

Febrile Urinary Tract Infections in Children with Primary Non-Refluxing Megaureter: A Systematic Review and Meta-Analysis

BACKGROUND

Knowledge of the baseline risk of febrile urinary tract infections in patients with primary non-refluxing megaureter can help clinicians to make informed decisions for offering continuous antibiotic prophylaxis.

OBJECTIVE

The primary objective of this systematic review was to determine the pooled prevalence of febrile urinary tract infections in patients with primary non-refluxing megaureter selected for primary non-surgical management independent of associated attributed risk factors at initial presentation in order to assess the value of continuous antibiotic prophylaxis.

METHODS

MEDLINE, EMBASE, and Cochrane Controlled Trials Register electronic databases were searched for eligible studies without language and time restriction. The systematic review was carried out following the recommendations of the Cochrane Collaboration and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. (PROSPERO registration number CRD42018104752).

RESULTS

Of 25 871 records, 16 studies (n=749 patients) were eligible for inclusion. The overall pooled prevalence of febrile urinary tract infections in patients with primary non-refluxing megaureter was 14.35% (95% confidence interval: 8.8-22.6). The calculated number needed to treat for patients on continuous antibiotic prophylaxis to prevent one single febrile urinary tract infection over the course of 1-2 years would be 4.3.

CONCLUSION

Based on the current available evidence the use of continuous antibiotic prophylaxis for children with PM selected for primary non-surgical treatment should be taken into consideration, at least in patients with urinary outflow impairment, higher grade of ureteral dilatation, and for children in the first months of life.

Current practice of antithrombotic prophylaxis in pediatric kidney transplantation-Results of an international survey on behalf of the European Society for Paediatric Nephrology

BACKGROUND

Renal graft thrombosis (RGT) is one of the main causes for early graft loss in pediatric kidney transplantation (KTx). Despite the lack of evidence-based recommendations, antithrombotic prophylaxis (aP) is used to prevent RGT.

METHODS

An online survey supported by the European Society for Pediatric Nephrology was developed to investigate the current practice of aP in pediatric KTx recipients <18 years.

RESULTS

A total of 80 pediatric KTx centers from 37 countries participated in the survey. Antithrombotic prophylaxis was performed in 96% of the pediatric renal transplant centers (all/selected patients: 54%/42%). The main overall used drugs were as follows: low-molecular-weight heparin (89%), unfractionated heparin (UFH) (69%), and acetylsalicylic acid (ASS) (55%). Ten different aP management strategies were identified as follows: 51% used a single drug and 48% combined two drugs sequentially. The corresponding centers started aP predominantly within 24 hours after pediatric KTx; 51% preferred UFH for starting aP. In centers switching to a second drug (51%), this change was performed after 10 ± 6 days; of these 57% preferred ASS for maintenance aP. Reported median aP duration was 51 days (range 1-360).

CONCLUSIONS

Despite the use of aP in almost all responding pediatric KTx centers, there is no uniform management strategy. Notwithstanding, UFH seems to be the preferred drug for the early post-operative period of pediatric KTx, and ASS for maintenance prophylaxis following pediatric KTx. Prospective studies are needed to further evaluate the benefits and risks of aP, preferably resulting in guidelines for the management in pediatric KTx.

Paediatric end-stage renal disease and renal replacement therapy in Switzerland: survival and treatment trends over four decades

BACKGROUND

Renal replacement therapy for paediatric end-stage renal disease (ESRD) has developed steadily since its introduction five decades ago. Continuous and long-term analysis of patient outcomes is essential for quality control.

METHODS

The Swiss Paediatric Renal Registry, founded in 1970, includes patients diagnosed with ESRD, defined as dialysis for more than three months or renal transplantation, at age &lt;20 years. Here we describe the incidence, primary renal disease, treatment modalities and long-term outcomes over 45 years.

RESULTS

This paper reports on 367 children and adolescents treated with chronic renal replacement therapy in Switzerland. Incidence was 5.4 per million children per year, with a tendency to increase over time. The primary renal disease was congenital anomalies of the kidney and the urinary tract in 133 (36%), monogenetic hereditary diseases in 122 (33%) and acquired diseases in 112 (31%) patients. The first renal replacement therapy was haemodialysis in 194 (53%), peritoneal dialysis in 116 (32%) and pre-emptive renal transplantation in 57 (15%) patients. Over the years, pre-emptive renal transplantation became more frequent (34% of all first renal replacement therapies in 2006&ndash;2015), reducing the duration of dialysis. Median time on dialysis until transplantation decreased from 1.60 years in 1981&ndash;90 to 0.34 years in 2010&ndash;15. Over the four decades 1970&ndash;80, 1981&ndash;90,1991&ndash;2000 and 2001&ndash;10, the one-year graft survival rate improved from 0.76 to 0.80, 0.89 and then 0.96; and the five-year graft survival rate improved from 0.44 to 0.64, 0.84 and 0.89, respectively. The five-year patient survival rates for the four decades were 0.83, 0.99, 0.93 and 0.94; and the 10-year patient survival rates were 0.75, 0.96, 0.88 and 0.94, respectively. In the four cohorts starting renal replacement therapy in the 70s, 80s, 90s and 00s, the number of children alive after five years of renal replacement therapy increased from 15 to 24, 47 and then 45 respectively. In total, 29 patients (8%) died during chronic renal replacement therapy with ESRD before the age of 20 years.

CONCLUSION

Over time, a higher number of children on renal replacement therapy survived, graft survival improved, and the duration of dialysis before renal transplantation decreased.

CASPR2 autoimmunity in children expanding to mild encephalopathy with hypertension

OBJECTIVE

To delineate autoimmune disease in association with contactin-associated protein 2 (CASPR2) antibodies in childhood, we reviewed the clinical phenotype of children with CASPR2 antibodies.

METHODS

Retrospective assessment of patients recruited through laboratories specialized in autoimmune CNS disease.

RESULTS

Ten children with serum CASPR2 antibodies were identified (age at manifestation 18 months to 17 years). Eight children with CASPR2 antibody titers from ≥1:160 to 1:5,120 had complex autoimmune diseases with an age-dependent clinical phenotype. Two children with structural epilepsy due to CNS malformations harbored nonspecific low-titer CASPR2 antibodies (serum titers 1:80). The clinical symptoms of the 8 children with high-titer CASPR2 antibodies were general weakness (8/8), sleep dysregulation (8/8), dysautonomia (8/8) encephalopathy (7/8), neuropathic pain (7/8), neuromyotonia (3/8), and flaccid paresis (3/8). Adolescents (3/8) showed pain, neuromyotonia, and encephalopathy, whereas younger children (5/8) displayed severe hypertension, encephalopathy, and hormonal dysfunction mimicking a systemic disease. No tumors were identified. Motor symptoms remitted with immunotherapy. Mild behavioral changes persisted in 1 child, and autism spectrum disorder was diagnosed during follow-up in a young boy.

CONCLUSION

High-titer CASPR2 antibodies are associated with Morvan syndrome in children as young as 2 years. However, CASPR2 autoimmunity mimics systemic disease and hypertensive encephalopathy in children younger than 7 years. The outcome following immunotherapy was mostly favorable; long-term behavioral impairment may occur in younger children.

Timing of voiding cystourethrography after febrile urinary tract infection in children: a systematic review

BACKGROUND

Despite a trend towards early voiding cystourethrography (VCUG) after febrile urinary tract infection (fUTI) in children, clinical guidelines do not comment on the optimal timing and current practice varies considerably.

OBJECTIVE

To assess whether the detection rate of vesicoureteric reflux (VUR) in children depends on the time period of VCUG procedure after onset of antibiotic therapy.

METHODS

MEDLINE, EMBASE and Cochrane Controlled Trials Register electronic databases were searched for eligible studies without language or time restriction (19 November 2018). Inclusion criteria were (1) patients <18 years of age; (2) VCUG performed in patients with fUTI after onset of antibiotic therapy either in the same patient population or in two or more different patient populations within one study at different time periods; and (3) with reported detection rate of VUR. The systematic review was carried out following the recommendations of the Cochrane Collaboration and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

RESULTS

Of 4175 records, nine studies were included (number of patients, n=1745) for the main outcome prevalence of VUR by VCUG <8 days compared with VCUG ≥8 days after onset of antibiotic therapy. Pooled overall prevalence of VUR was not significantly different between the early and the late VCUG groups (risk ratio 0.98, 95% CI 0.81 to 1.19). Prevalence of VUR stratified by grade was not significantly different between the two groups.

CONCLUSION

Early VCUG within 8 days after onset of antibiotic therapy does not affect the prevalence of VUR.

TRIAL REGISTRATION NUMBER

CRD42018117545.

Association between timing of dialysis initiation and clinical outcomes in the paediatric population: an ESPN/ERA-EDTA registry study

BACKGROUND

There is no consensus regarding the timing of dialysis therapy initiation for end-stage kidney disease (ESKD) in children. As studies investigating the association between timing of dialysis initiation and clinical outcomes are lacking, we aimed to study this relationship in a cohort of European children who started maintenance dialysis treatment.

METHODS

We used data on 2963 children from 21 different countries included in the European Society of Pediatric Nephrology/European Renal Association-European Dialysis and Transplant Association Registry who started renal replacement therapy before 18 years of age between 2000 and 2014. We compared two groups according to the estimated glomerular filtration rate (eGFR) at start: eGFR ≥8 mL/min/1.73 m2 (early starters) and eGFR <8 mL/min/1.73 m2 (late starters). The primary outcomes were patient survival and access to transplantation. Secondary outcomes were growth and cardiovascular risk factors. Sensitivity analyses were performed to account for selection- and lead time-bias.

RESULTS

The median eGFR at the start of dialysis was 6.1 for late versus 10.5 mL/min/1.73 m2 for early starters. Early starters were older [median: 11.0, interquartile range (IQR): 5.7-14.5 versus 9.4, IQR: 2.6-14.1 years]. There were no differences observed between the two groups in mortality and access to transplantation at 1, 2 and 5 years of follow-up. One-year evolution of height standard deviation scores was similar among the groups, whereas hypertension was more prevalent among late initiators. Sensitivity analyses resulted in similar findings.

CONCLUSIONS

We found no evidence for a clinically relevant benefit of early start of dialysis in children with ESKD. Presence of cardiovascular risk factors, such as high blood pressure, should be taken into account when deciding to initiate or postpone dialysis in children with ESKD, as this affects the survival.

Membranoproliferative glomerulonephritis and C3 glomerulopathy in children: change in treatment modality? A report of a case series

Background

Membranoproliferative glomerulonephritis (MPGN) with immune complexes and C3 glomerulopathy (C3G) in children are rare and have a variable outcome, with some patients progressing to end-stage renal disease (ESRD). Mutations in genes encoding regulatory proteins of the alternative complement pathway and of complement C3 (C3) have been identified as concausative factors.

Methods

Three children with MPGN type I, four with C3G, i.e. three with C3 glomerulonephritis (C3GN) and one with dense deposit disease (DDD), were followed. Clinical, autoimmune data, histological characteristics, estimated glomerular filtration rate (eGFR), proteinuria, serum C3, genetic and biochemical analysis were assessed.

Results

The median age at onset was 7.3 years and the median eGFR was 72 mL/min/1.73 m². Six children had marked proteinuria. All were treated with renin-angiotensin-aldosterone system (RAAS) blockers. Three were given one or more immunosuppressive drugs and two eculizumab. At the last median follow-up of 9 years after diagnosis, three children had normal eGFR and no or mild proteinuria on RAAS blockers only. Among four patients without remission of proteinuria, genetic analysis revealed mutations in complement regulator proteins of the alternative pathway. None of the three patients with immunosuppressive treatment achieved partial or complete remission of proteinuria and two progressed to ESRD and renal transplantation. Two patients treated with eculizumab revealed relevant decreases in proteinuria.

Conclusions

In children with MPGN type I and C3G, the outcomes of renal function and response to treatment modality show great variability independent from histological diagnosis at disease onset. In case of severe clinical presentation at disease onset, early genetic and biochemical analysis of the alternative pathway dysregulation is recommended. Treatment with eculizumab appears to be an option to slow disease progression in single cases.

Primary non-surgical management of unilateral ureteropelvic junction obstruction in children: a systematic review

Ureteropelvic junction obstruction (UPJO) is the most common obstructive uropathy and its optimal management remains controversial. However, there is a current trend towards non-surgical management. We aimed to determine the effects of the non-surgical management in children with unilateral UPJO. For a systematic review, we searched MEDLINE, EMBASE, CENTRAL, clinical trials registries, and selected conference proceedings for eligible studies. Any type of study reporting the outcomes renal function, secondary surgical intervention, drainage pattern or hydronephrosis of non-surgical management in children with unilateral UPJO was included. Data from 20 studies were extracted and evaluated by two independent authors. The pooled prevalence was 21% for split renal function deterioration, 27.9% for secondary surgical intervention, 3.2% for progressive hydronephrosis, and 82.2% for improved drainage pattern. Not all patients with surgical intervention regained split renal function from enrolment. Renal imaging methods did not strongly correlate with each other. Many studies had to be excluded because of a lack of detection of an obstruction or mixed populations with bilateral UPJO or other uropathies. The variable definitions of UPJO, different criteria for surgical intervention, incongruity of management protocols, and the imprecise reporting of outcomes were limiting factors in the comparability of the results, leading to heterogeneity in meta-analyses. Although the available evidence cannot recommend or refute the current non-surgical management, the systematic review clarifies aspects of the ongoing controversy by providing realistic estimates for non-surgical management in children with unilateral UPJO. Additionally, it reveals unclear potential risks, particularly for long-term outcomes, which were rarely reported.

To screen or not to screen for vesicoureteral reflux in children with ureteropelvic junction obstruction: a systematic review

Ureteropelvic junction obstruction (UPJO) and vesicoureteral reflux (VUR) are the most common uropathies. The co-occurrence of both anomalies has led to the practice of screening for VUR in children with UPJO to prevent deterioration of kidney function due to renal scarring following urinary tract infections (UTIs). We determined the prevalence of VUR in children with UPJO for a critical assessment of VUR screening by voiding cystourethrography (VCUG). A systematic search strategy in MEDLINE, EMBASE, and CENTRAL was carried out for all articles that included VCUG, and renal scintigraphy or any other appropriate imaging technique for the diagnosis of UPJO. Twenty studies were eligible for inclusion. We found a pooled prevalence for VUR of 8.2 % (95 % CI = 3.6-12.7), about a threefold increase compared to the general pediatric population. VUR occurred bilateral or contralateral to the kidney with UPJO in 5.7 % (95 % CI = 3.0-8.5), equivalent to 75 % of all children with VUR. Considering the effect size of VUR treatment with antibiotics, about 207 and 278 children would need to undergo VCUG to prevent one febrile UTI and one case of renal scarring by 1-2 years, respectively.

CONCLUSION

Against this background, screening for VUR needs to be scrutinized and restricted to selected risk groups. What is known: • Screening of patients with ureteropelvic junction obstruction (UPJO) for vesicoureteral reflux (VUR) is recommended based on a small number of repeatedly cited studies. • The lack of conclusive evidence results in different treatment strategies and leads to difficulties when communicating diagnoses and treatment options to parents. What is new: • A robust prevalence for VUR in children with UPJO based on all published evidence and the resulting number needed to screen are given for decision-making in daily clinical practice. • The results may be a precursor for implementation into guidelines.

Balancing competing needs in kidney transplantation: does an allocation system prioritizing children affect the renal transplant function?

Children often merit priority in access to deceased donor kidneys by organ-sharing organizations. We report the impact of the new Swiss Organ Allocation System (SOAS) introduced in 2007, offering all kidney allografts from deceased donors <60 years preferentially to children. The retrospective cohort study included all paediatric transplant patients (<20 years of age) before (n = 19) and after (n = 32) the new SOAS (from 2001 to 2014). Estimated glomerular filtration rate (eGFR), urine protein-to-creatinine ratio (UPC), need for antihypertensive medication, waiting times to kidney transplantation (KTX), number of pre-emptive transplantations and rejections, and the proportion of living donor transplants were considered as outcome parameters. Patients after the new SOAS had significantly better eGFRs 2 years after KTX (Mean Difference, MD = 25.7 ml/min/1.73 m² , P = 0.025), lower UPC ratios (Median Difference, MeD = -14.5 g/mol, P = 0.004), decreased waiting times to KTX (MeD = -97 days, P = 0.021) and a higher proportion of pre-emptive transplantations (Odds Ratio = 9.4, 95% CI = 1.1-80.3, P = 0.018), while the need for antihypertensive medication, number of rejections and living donor transplantations remained stable. The new SOAS is associated with improved short-term clinical outcomes and more rapid access to KTX. Despite lacking long-term research, the study results should encourage other policy makers to adopt the SOAS approach.

Lying Down after Premature Rupture of the Membranes in Term Singleton Pregnancies: An Evidence-Based Recommendation?

Objectives: In many countries pregnant women in term singleton pregnancies are advised by obstetricians and midwives to lie down immediately after rupture of membranes until engagement of the foetal head is confirmed. The horizontal positioning aims to prevent the prolapse of the umbilical cord. The objective of this systematic review is to assess the effects of the maternal lying down measure in term singleton pregnancies. Search methods: We searched the databases of MEDLINE/PubMed, EMBASE/Ovid and CENTRAL (Issue 10, 2015) from their inception until September 30^th, 2015. Additionally, we searched selected trial registers, the reference lists of potentially relevant studies and national and international obstetrical clinical guidelines. All types of studies without language restriction were selected. Main results: One retrospective study was found. Only one woman with a term singleton pregnancy had the event of an umbilical cord prolapse following premature rupture of membranes (0.008%). The study did not report on the presence of an engaged foetal head in this woman. Conclusions and implications: Recommendations cannot be made in favour or against the lying down positioning based solely on the single identified study. For that reason, the widespread recommendation given by obstetricians and midwives should be critically reassessed. Also, induction of maternal anxiety and increased costs to the healthcare system following transportation to the delivery unit have to be considered in the light of the given minimal risk of umbilical cord prolapse in conjuncture with lacking evidence for the utility of the common recommendation.

Surgery versus non-surgical management for unilateral ureteric-pelvic junction obstruction in newborns and infants less than two years of age

BACKGROUND

Unilateral ureteric-pelvic junction obstruction (UPJO) is the most common cause of obstructive uropathy and may lead to renal impairment and loss of renal function. The current diagnostic approach with renal imaging cannot reliably determine which newborns and infants less than two years of age have a significant obstruction and are at risk for permanent kidney damage. There is therefore no consensus on optimal therapeutic management of unilateral UPJO.

OBJECTIVES

To assess the effects of surgical versus non-surgical treatment options for newborns and infants less than two years of age with unilateral UPJO.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 6, 2016), MEDLINE/Ovid, and EMBASE/Ovid databases from their inception to 13 June 2016. We searched the reference lists of potentially relevant studies without using any language restriction. We also searched the following trial registers for relevant registered studies: www.clinicaltrials.gov/; ISRCTN registry (controlled-trials.com/); www.trialscentral.org/; apps.who.int/trialsearch/; www.drks.de/; and www.anzctr.org.au/trialSearch.aspx.

SELECTION CRITERIA

We selected randomised and quasi-randomised controlled trials comparing surgical with non-surgical interventions for the treatment of unilateral UPJO.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study eligibility and risk of bias of included studies and extracted data. In case of disagreements we consulted a third review author. The data reported in the two included studies did not allow us to perform a meta-analysis.

MAIN RESULTS

We found only two studies at high risk of bias that were eligible for inclusion in this review. The total sample size, including both trials, was small (n = 107 participants less than six months of age from the UK and USA), and not all prespecified outcome measures were assessed. Reported measures only accounted for the short-term follow-ups. The mean split renal function was not statistically different between the surgical and non-surgical group at the six-month or one-year time point (very low-quality evidence). The surgical group showed a significantly less obstructed drainage pattern and a lower urinary tract dilatation than the non-surgical group (very low-quality evidence). Transfer from the non-surgical group to the surgical group was reported for about one out of five participants. Split renal function after secondary surgical intervention was reported with variable results, but most of the participants reverted to pre-deteriorated values. The studies either provided no or insufficient data on the following outcome measures: postoperative complications, UPJO-associated clinical symptoms, costs of interventions, radiation exposure, quality of life, and adverse effects.

AUTHORS' CONCLUSIONS

We found limited evidence assessing the benefits and harms of surgical compared to non-surgical treatment options for newborns and infants less than two years of age with unilateral UPJO. The majority of participants in the non-surgical treatment group did not experience any significant deterioration of split renal function, and only about 20% of them underwent secondary surgical intervention, with minor risk of permanent deteriorated split renal function. The study follow-up period was too short to assess the long-term effects on split renal function in both treatment groups. We need further randomised controlled trials with sufficient statistical power and an adequate follow-up period to determine the optimal therapy for newborns and infants less than two years of age with unilateral UPJO.

Extracorporeal photopheresis versus alternative treatment for chronic graft-versus-host disease after haematopoietic stem cell transplantation in paediatric patients

BACKGROUND

Chronic graft-versus-host disease (GvHD) is a major cause of morbidity and mortality after haematopoietic stem cell transplantation occurring in 6% to 65% of the recipients. Currently, the therapeutic mainstay for chronic GvHD are corticosteroids that are frequently combined with other immunosuppressive agents in people with steroid-refractory manifestations. There is no established standard treatment for steroid-refractory chronic GvHD. The therapeutic options for these patients include extracorporeal photopheresis (ECP), an immunomodulatory treatment that involves ex vivo collection of mononuclear cells from peripheral blood, exposure to the photoactive agent 8-methoxypsoralen, ultraviolet radiation and re-infusion of the processed cell product. The mechanisms of action of ECP are not completely understood. This is an updated version of a Cochrane review first published in 2014.

OBJECTIVES

To evaluate the effectiveness and safety of ECP for the management of chronic GvHD in children and adolescents after haematopoietic stem cell transplantation.

SEARCH METHODS

We searched the Cochrane Register of Controlled Trials (CENTRAL) (Issue 9, 2015), MEDLINE and EMBASE databases from their inception to 23 September 2015. We searched the reference lists of potentially relevant studies without any language restriction. We searched eight trial registers and five conference proceedings on 29 September 2015.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing ECP with or without alternative treatment versus alternative treatment alone in paediatric patients with chronic GvHD after haematopoietic stem cell transplantation.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed the study selection. We resolved disagreements in the selection of trials by consultation with a third review author.

MAIN RESULTS

No additional studies were identified in this 2015 review update, in total leading to no studies meeting the criteria for inclusion in this review.

AUTHORS' CONCLUSIONS

The efficacy of ECP in the treatment of chronic GvHD in paediatric patients after haematopoietic stem cell transplantation based on RCTs cannot be evaluated since the original version of this review and the first review update found no RCTs. Current recommendations are based on retrospective or observational studies only. Thus, ideally, ECP should be applied in the context of controlled trials only. However, performing RCTs in this patient population will be challenging due to the limited number of patients, the variable disease presentation and the lack of well-defined response criteria. International collaboration, multicentre trials and appropriate funding for such trials will be needed. If treatment decisions based on clinical data are made in favour of ECP, patients should be carefully monitored for beneficial and harmful effects. In addition, efforts should be made to share this information with other clinicians, for example by setting up registries for paediatric patients that are treated with ECP.

Extracorporeal photopheresis versus standard treatment for acute graft-versus-host disease after haematopoietic stem cell transplantation in paediatric patients

BACKGROUND

Acute graft-versus-host disease (aGvHD) is a major cause of morbidity and mortality after haematopoietic stem cell transplantation (HSCT) occurring in 8% to 59% of the recipients. Currently, the therapeutic mainstay for aGvHD is corticosteroids. However, there is no established standard treatment for steroid-refractory aGvHD. Extracorporeal photopheresis (ECP) is a type of immunomodulatory method amongst different therapeutic options that involves ex vivo collection of peripheral mononuclear cells, exposure to the photoactive agent 8-methoxypsoralen and ultraviolet-A radiation, and re-infusion of these treated blood cells to the patient. The mechanisms of action of ECP are not completely understood. This is an updated version of a Cochrane review first published in 2014.

OBJECTIVES

To evaluate the effectiveness and safety of ECP for the management of aGvHD in children and adolescents after HSCT.

SEARCH METHODS

We searched the Cochrane Register of Controlled Trials (CENTRAL) (Issue 9, 2015), MEDLINE (PubMed) and EMBASE (Ovid) databases from their inception to 23 September 2015. We searched the reference lists of potentially relevant studies without any language restrictions. We searched eight trial registers and four conference proceedings on 29 September 2015.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing ECP with or without standard treatment versus standard treatment alone in paediatric patients with aGvHD after HSCT.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed the study selection. We resolved disagreement in the selection of trials by consultation with a third review author.

MAIN RESULTS

We identified no additional studies in the 2015 review update, in total leading to no studies meeting the criteria for inclusion in this review.

AUTHORS' CONCLUSIONS

The efficacy of ECP in the treatment of aGvHD in paediatric patients after HSCT is unknown and its use should be restricted within the context of RCTs. Such studies should address a comparison of ECP alone or in combination with standard treatment versus standard treatment alone. The 2015 review update brought about no additions to these conclusions.

Standardized multilevel transition program: Does it affect renal transplant outcome?

The transfer of renal transplant patients from pediatric to adult care is a crucial step with a high risk of subsequent graft loss. Therefore, the transition should be a thoroughly planned, well-designed and multidisciplinary process focused on the individual patient. Our pediatric nephrology department introduced a structured step-by-step transition program supported by a multidisciplinary team of health professionals. The purpose of our study was to determine the effects of the transition program on eGFR and number of ARs in comparison to a group without a transition program at one and three yr after transfer. We conducted a single-center retrospective cohort study of renal transplant patients prior to and after the introduction of the transition program. Multiple regression analysis revealed a significantly lower decline of eGFR in the group with transition program (-11.3 ± 44 mL/min/1.73 m(2) ) compared to the group without transition program (-28.4 ± 33 mL/min/1.73 m(2) ) at three yr after transfer. The number of AR episodes significantly decreased from 34.6% in the group without transition program to 9.1% in the group with transition program. The standardized multilevel transition program seems to have significant positive effects on eGFR and number of AR episodes in renal transplant patients.

Extracorporeal photopheresis versus alternative treatment for chronic graft-versus-host disease after haematopoietic stem cell transplantation in paediatric patients

BACKGROUND

Chronic graft-versus-host disease (GvHD) is a major cause of morbidity and mortality after haematopoietic stem cell transplantation occurring in 6% to 65% of the recipients. Currently, the therapeutic mainstay for chronic GvHD are corticosteroids that are frequently combined with other immunosuppressive agents in people with steroid-refractory manifestations. There is no established standard treatment for steroid-refractory chronic GvHD. The therapeutic options in these people include extracorporeal photopheresis (ECP), an immunomodulatory treatment that involves ex vivo collection of mononuclear cells from peripheral blood, exposure to the photoactive agent 8-methoxypsoralen, ultraviolet radiation and re-infusion of the processed cell product. The mechanisms of action of ECP are not completely understood.

OBJECTIVES

To evaluate the effectiveness and safety of ECP for the management of chronic GvHD in children and adolescents after haematopoietic stem cell transplantation.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (Issue 9, 2012), MEDLINE and EMBASE databases from their inception to 12 September 2012. We searched the reference lists of potentially relevant studies without any language restriction. We searched eight trial registers and five conference proceedings. We also contacted experts in the field.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing ECP with or without alternative treatment versus alternative treatment alone in paediatric patients with chronic GvHD after haematopoietic stem cell transplantation.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed the study selection. We resolved disagreements in the selection of trials by consultation with a third review author.

MAIN RESULTS

We found no studies meeting the criteria for inclusion in this review.

AUTHORS' CONCLUSIONS

The efficacy of ECP in the treatment of chronic GvHD in paediatric patients after haematopoietic stem cell transplantation based on RCTs can currently not be evaluated since we have found no such studies. Current recommendations are based on retrospective or observational studies only. Thus, ideally, ECP should be applied in the context of controlled trials only. However, performing RCTs in this patient population will be challenging due to the limited number of patients, the variable disease presentation and the lack of well-defined response criteria. International collaboration, multicentre trials and appropriate funding for such trials will be needed. If treatment decisions based on clinical grounds in favour of ECP are made, people should be carefully monitored for beneficial and harmful effects and efforts should be made to share this information with other clinicians, for example by setting up registries for paediatric patients that are treated with ECP.

Extracorporeal photopheresis versus standard treatment for acute graft-versus-host disease after haematopoietic stem cell transplantation in paediatric patients

BACKGROUND

Acute graft-versus host disease (aGvHD) is a major cause of morbidity and mortality after haematopoietic stem cell transplantation (HSCT) occurring in 8% to 59% of the recipients. Currently, the therapeutic mainstay for aGvHD is corticosteroids. However, there is no established standard treatment for steroid-refractory aGvHD. Extracorporeal photopheresis (ECP) is a type of immunomodulatory method amongst different therapeutic options that involves ex vivo collection of peripheral mononuclear cells, exposure to the photoactive agent 8-methoxypsoralen and ultraviolet-A radiation, and re-infusion of these treated blood cells to the patient. The mechanisms of action of ECP are not completely understood

OBJECTIVES

To evaluate the effectiveness and safety of ECP for the management of aGvHD in children and adolescents after HSCT.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (Issue 9, 2012), MEDLINE/PubMed and EMBASE (Ovid) databases from their inception to 12 September 2012. We searched the reference lists of potentially relevant studies without any language restriction. We searched eight trial registers and four conference proceedings. We also contacted an expert in the field to request information on unpublished study that involves ECP in aGvHD after HSCT.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing ECP with or without standard treatment versus standard treatment alone in paediatric patients with aGvHD after HSCT.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed the study selection. We resolved disagreement in the selection of trials by consultation with a third review author.

MAIN RESULTS

We found no studies meeting the criteria for inclusion in this review.

AUTHORS' CONCLUSIONS

The efficacy of ECP in the treatment of aGvHD in paediatric patients after HSCT is unknown and its use should be restricted within the context of RCTs. Such studies should address a comparison of ECP alone or in combination with standard treatment versus standard treatment alone. 

Renal ultrasound volume in children with primary vesicoureteral reflux allows functional assessment

OBJECTIVE

Renal scintigraphy represents the current diagnostic standard to assess split kidney function. We tested the hypothesis that the relative renal volume assessed by ultrasound provides an equally reliable but less invasive tool for assessment of kidney function as compared to renal scintigraphy in patients with primary vesicoureteral reflux.

METHODS

Renal ultrasound and renal scintigraphy were performed in 85 patients (median age 4.5 years, range 0.25-7.7) and repeated in 74 patients after 2-13 months (mean 7) of the primary investigation. Renal size was measured by ultrasound, and relative renal volume was calculated for each kidney by using the formula of a prolate ellipsoid. Renal function was estimated for each side (split renal function) by scintigraphy with (99m)Tc MAG3.

RESULTS

The mean difference between relative renal volume measured by ultrasound and split renal function determined by renal scintigraphy was 2.8% (standard deviation ± 4.1%; 95% confidence interval 10.8/-5.2%). There was a statistically significant correlation between relative renal volume estimated by ultrasound and split renal function estimated by renal scintigraphy at first examination (r = 0.98; p < 0.001) and at follow-up (r = 0.91; p < 0.001).

CONCLUSION

We conclude that ultrasound measurement of relative renal volume is capable of assessing split renal function in children with primary vesicoureteral reflux and, thus, should be considered instead of the more invasive MAG3 scintigraphy.

The Direct Assessment of Nonvertebral Fractures in Community Experience (DANCE) study: 2-year nonvertebral fragility fracture results

This observational study evaluated the occurrence of nonvertebral fragility fractures (NVFX) in over 4,000 men and women with osteoporosis treated with teriparatide (TPTD). The incidence of new NVFX decreased for patients receiving TPTD treatment for greater than 6 months. No new significant safety findings were observed in this large trial.

INTRODUCTION

The Direct Assessment of Nonvertebral Fractures in Community Experience (DANCE) study evaluated the occurrence of NVFX in patients receiving TPTD for osteoporosis in a real-world setting.

METHODS

DANCE is a multicenter, prospective, observational trial that examined the long-term effectiveness of TPTD in men and women with osteoporosis whom study physicians judged to be suitable for TPTD therapy. Patients received 20 μg TPTD per day by subcutaneous injection for up to 24 months and were followed for 24 months after treatment cessation. The incidence of patients experiencing a new NVFX, defined as a fracture associated with low trauma, was evaluated during four 6-month periods in both the treatment and cessation phases with >0 to ≤6 months serving as the reference. We also observed the spectrum and occurrence of serious adverse events.

RESULTS

Of the 4,167 patients enrolled, 4,085 took one or more doses of TPTD (safety population); 3,720 were included in the efficacy analysis. The incidence of patients experiencing a NVFX was 1.42, 0.91, 0.70, and 0.81 % for the four treatment periods, respectively, and 0.80, 0.68, 0.33, and 0.33 % for the four periods after treatment cessation. Differences for each period were statistically significant compared with the reference period (first 6-month interval, each p < 0.05). No new significant safety findings were observed.

CONCLUSIONS

In this study, the incidence of NVFX decreased for patients receiving TPTD for all three treatment periods >6 months compared to 0 to ≤6 months, and this trend persisted throughout the cessation phase. TPTD was generally well tolerated.

Prophylactic eculizumab prior to kidney transplantation for atypical hemolytic uremic syndrome

Atypical hemolytic uremic syndrome (aHUS) in childhood is a rare disease associated with high morbidity and mortality. Most cases progress to end-stage renal failure. In approximately 50% of affected patients, mutations in genes encoding complement proteins are causative of the impairment in the regulation of the complement alternative pathway. This leads to deficient host cell protection and inappropriate complement activation on platelets and endothelial cells, particularly in the kidneys. Complement factor H (FH) heterozygosity induces unregulated activation of the membrane attack complex (MAC) C5b-9. Present therapeutic strategies for aHUS include lifelong plasmapheresis and renal dialysis. Unfortunately, kidney transplantation is frequently an unsatisfactory intervention due to the high rate of post-transplantation HUS recurrence, particularly in patients with FH mutation. Combined liver-kidney transplantation is also associated with poor outcome, mostly as a result of premature liver failure secondary to uncontrolled complement activation. Eculizumab is a complement C5 antibody that inhibits complement factor 5a (C5a) and the formation of the MAC. Thus, this antibody may be a promising new agent for patients with an aHUS undergoing kidney transplantation. We present the first case of a young patient with aHUS who received eculizumab as prophylactic treatment prior to a successful kidney transplantation.

Subclinical activation of latent cytomegalovirus (CMV) infection and anti-CMV immune response in patients with atopic dermatitis

BACKGROUND

Microbiological infections are considered to be of pathophysiological importance in atopic dermatitis (AD). As yet, no information is available regarding cytomegalovirus (CMV) infection in this disease. This, however, is of interest because of the high prevalence of latent infections in the general population, the frequent reactivation in inflammatory diseases, and the immunomodulating capacity of CMV.

OBJECTIVES

To investigate the prevalence of latent CMV infection, the frequency of active CMV infection, and the immune response to CMV in patients with moderate to severe AD. Methods To detect active infection we analysed CMV antigen expression by peripheral blood mononuclear cells (PBMC) from 27 patients with moderate to severe AD in comparison with 53 healthy volunteers. We used three monoclonal antibodies recognizing different CMV-encoded antigens and immunocytological staining (alkaline phosphatase-antialkaline phosphatase technique).

RESULTS

Patients with AD had a higher mean frequency of CMV-positive PBMC: 2.25 per 10 000 vs. 0.74 per 10 000 in controls (P = 0.001) as well as a higher incidence of CMV antigenaemia: 29.6% vs. 7.5% (P < 0.01). Seropositivity for anti-CMV IgG antibodies indicated subclinical activation of latent infection. Remarkably, a clearance of CMV antigenaemia was observed during anti-eczematous treatment. Significantly higher plasma levels of tumour necrosis factor-alpha, which is involved in CMV reactivation, and interleukin-12, which is crucial for an antiviral cellular immune response, were observed in AD patients in comparison with healthy volunteers. Furthermore, a significantly enhanced frequency of circulating activated HLA-DR+ T cells especially in CMV-seropositive AD patients (19.3% vs. 13.5% in seronegative AD patients vs. 10.2% in controls) suggested that the active CMV infection triggers a cellular immune response. This was also supported by a high frequency of CMV-specific interferon-gamma-producing T cells in CMV-seropositive patients with AD.

CONCLUSIONS

Our data suggest that active, subclinical CMV infection is more frequent in patients with moderate to severe AD and may have immunopathophysiological relevance.

Superresolution of pulsed multiphoton Raman transitions

We have investigated higher order multiphoton Raman resonances with two pulsed optical frequencies. Multiphoton transfer with up to 50 photons is observed with milliwatts of laser power. We demonstrate that the spectral width of the multiphoton resonances can be far below the Fourier transform linewidth of the driving optical pulses. The functional dependence of the transition linewidth on the number of exchanged photons is found to vary with the pulse shape. Our experiment is performed with laser-cooled rubidium atoms confined in a CO2-laser optical dipole trap.

Controlled decoherence in multiple beam Ramsey interference

We have scattered photons from an interfering path of a multiple beam Ramsey interference experiment realized with a cesium atomic beam. It is demonstrated that in multiple beam interference the decoherence from photon scattering cannot only lead to a decrease but, under certain conditions, also to an increase of the Michelson fringe contrast. In all cases, the atomic quantum state loses information with photon scattering, as "which-path" information is carried away by the photon field. We outline an approach to quantify this which-path information from observed fringe signals, which allows for an appropriate measure of decoherence in multiple path interference.

Pancreatic cancer detection with magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography: a prospective controlled study

BACKGROUND

Magnetic resonance cholangiopancreatography (MRCP) is a non-invasive and increasingly used procedure in cases involving biliary and pancreatic diseases. However, the accuracy of MRCP in differential diagnosis between pancreatic cancer and chronic pancreatitis has never been documented in a large prospective controlled study.

METHODS

124 patients were recruited for the study, selected from 141 consecutive patients with an average age of 55 years (range 19-80) who presented to our department between February, 1996, and January, 1998, with a strong clinical suspicion of pancreatic cancer. MRCP images were interpreted by a radiologist and a gastroenterologist who were unaware of the clinical diagnosis of patients. The exact diagnosis was based upon histological evidence from biopsy examination (surgical and fine needle biopsy) or a follow-up of at least 12 months.

FINDINGS

Of the 124 patients, 37 (30%) had pancreatic carcinoma; 17 (14%) had other neoplastic pancreatic diseases; 57 (46%) had chronic pancreatitis; 13 (10%) pancreatic ducts were clear. The sensitivity of MRCP with respect to diagnosing pancreatic cancer was 84% and its specificity 97%. The corresponding values for endoscopic retrograde cholangiopancreatography (ERCP) were 70% and 94%, respectively.

INTERPRETATION

MRCP is as sensitive as ERCP when detecting pancreatic carcinomas. Furthermore, it is feasible to presume that the use of MRCP may prevent inappropriate explorations of the pancreatic and common bileducts in cases of suspected pancreatic carcinomas, where interventional endoscopic therapy (ie, palliative common-bileduct drainage) is unlikely.

Pancreatic cancer detection with magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography: a prospective controlled study

BACKGROUND

Magnetic resonance cholangiopancreatography (MRCP) is a non-invasive and increasingly used procedure in cases involving biliary and pancreatic diseases. However, the accuracy of MRCP in differential diagnosis between pancreatic cancer and chronic pancreatitis has never been documented in a large prospective controlled study.

METHODS

124 patients were recruited for the study, selected from 141 consecutive patients with an average age of 55 years (range 19-80) who presented to our department between February, 1996, and January, 1998, with a strong clinical suspicion of pancreatic cancer. MRCP images were interpreted by a radiologist and a gastroenterologist who were unaware of the clinical diagnosis of patients. The exact diagnosis was based upon histological evidence from biopsy examination (surgical and fine needle biopsy) or a follow-up of at least 12 months.

FINDINGS

Of the 124 patients, 37 (30%) had pancreatic carcinoma; 17 (14%) had other neoplastic pancreatic diseases; 57 (46%) had chronic pancreatitis; 13 (10%) pancreatic ducts were clear. The sensitivity of MRCP with respect to diagnosing pancreatic cancer was 84% and its specificity 97%. The corresponding values for endoscopic retrograde cholangiopancreatography (ERCP) were 70% and 94%, respectively.

INTERPRETATION

MRCP is as sensitive as ERCP when detecting pancreatic carcinomas. Furthermore, it is feasible to presume that the use of MRCP may prevent inappropriate explorations of the pancreatic and common bileducts in cases of suspected pancreatic carcinomas, where interventional endoscopic therapy (ie, palliative common-bileduct drainage) is unlikely.

Multiple endocrine neoplasia type 1 (MEN1) gene mutations in a subset of patients with sporadic and familial primary hyperparathyroidism target the coding sequence but spare the promoter region

Germ line mutations of the multiple endocrine neoplasia type 1 (MEN1) tumour suppressor gene cause MEN1, a rare familial tumour syndrome associated with parathyroid hyperplasia, adenoma and hyperparathyroidism (HP). Here we investigated the role of the MEN1 gene in isolated sporadic and familial HP. Using RT-PCR single-strand conformational polymorphism screening, somatic (but not germ line) mutations of the MEN1 coding sequence were identified in 6 of 31 (19.3%) adenomas from patients with sporadic primary HP, but none in patients (n=16) with secondary HP due to chronic renal failure. MEN1 mutations were accompanied by a loss of heterozygosity (LOH) for the MEN1 locus on chromosome 11q13 in the adenomas as detected by microsatellite analysis. No DNA sequence divergence within the 5' region of the MEN1 gene, containing the putative MEN1 promoter, was detectable in HP adenomas. Clinical characteristics were not different in HP patients with or without MEN1 mutation. Heterozygous MEN1 gene polymorphisms were identified in 9.6% and 25% of patients with primary and secondary HP respectively. In a large kindred with familial isolated familial HP, MEN1 germ line mutation 249 del4 and LOH was associated with the HP phenotype and a predisposition to non-endocrine malignancies. We suggest that the bi-allelic somatic loss of MEN1 wild-type gene expression is involved in the pathogenesis of a clinically yet undefined subset of sporadic primary HP adenomas. MEN1 genotyping may further help define the familial hyperparathyroidism-MEN1 disease complex, but it seems dispensable in sporadic primary HP.

Measurement of the hydrogen 1S- 2S transition frequency by phase coherent comparison with a microwave cesium fountain clock

We report on an absolute frequency measurement of the hydrogen 1S-2S two-photon transition in a cold atomic beam with an accuracy of 1.8 parts in 10(14). Our experimental result of 2 466 061 413 187 103(46) Hz has been obtained by phase coherent comparison of the hydrogen transition frequency with an atomic cesium fountain clock. Both frequencies are linked with a comb of laser frequencies emitted by a mode locked laser.

Phase coherent vacuum-ultraviolet to radio frequency comparison with a mode-locked laser

We demonstrate a versatile new technique that provides a phase coherent link between optical frequencies and the radio frequency domain. The regularly spaced comb of modes of a mode-locked femtosecond laser is used as a precise ruler to measure a large frequency gap between two different multiples (harmonics or subharmonics) of a laser frequency. In this way, we have determined a new value of the hydrogen 1S-2S two-photon resonance, f(1S-2S) = 2 466 061 413 187.29(37) kHz, representing now the most accurate measurement of an optical frequency.

Choledochocele imaged with magnetic resonance cholangiography

Choledochal cysts are rare developmental malformations of the biliary tree. Percutaneous and endoscopic ultrasound, as well as endoscopic retrograde cholangiopancreatography, are recommended diagnostic tools. Magnetic resonance cholangiography may also contribute to the workup and treatment plan of patients with choledochal cysts. We report a 25-yr-old white woman with episodic nausea and moderate epigastric discomfort. Magnetic resonance cholangiography showed a rather spherical, cyst-like, fluid-filled structure in continuity with the prepapillary segment of the common bile duct, thus making a choledochocele (type III choledochal cyst) likely. The patient was treated by endoscopic sphincterotomy and, after a 6-month follow-up, is without complaints.

A prospective evaluation of magnetic resonance cholangiopancreatography in patients with suspected bile duct obstruction

BACKGROUND

The value of magnetic resonance cholangiopancreatography (MRCP) is under debate.

AIMS

To assess the diagnostic accuracy of MRCP and endoscopic retrograde cholangiopancreatography (ERCP) and to determine whether MRCP may help to prevent unnecessary interventional procedures.

METHODS

Eighty six patients with suspected common bile duct obstruction who presented between January and December 1996 were enrolled. Twenty six were excluded due to anatomical reasons or because MRCP or ERCP could not be performed successfully. Results of MRCP were interpreted by two radiologists and a gastroenterologist unaware of clinical diagnosis. Final diagnosis was determined by ERCP and histopathological findings or a follow up of at least 12 months.

RESULTS

MRCP images of diagnostic quality were obtained in all 60 patients. Thirteen patients had a clear bile duct. Sensitivity and specificity for the detection of any abnormality (n=47) were 89% and 92%, and for the detection of malignancy (n=27) 81% and 100%, respectively. These results were equivalent to the respective figures of ERCP (91% and 92% for any abnormality, and 93% and 94% for malignant diseases).

CONCLUSIONS

MRCP is as sensitive as ERCP in the evaluation of bilary tract diseases. As the specificity of this non-invasive technique is close to 100%, MRCP may prevent inappropriate invasive explorations of the common bile duct and pancreatic duct.

Phase-coherent light pulses for atom optics and interferometry

We have developed a novel source for the generation of powerful phase-coherent light pulses. Our setup uses an acousto-optic modulator (AOM) inside an external high-finesse resonator. By applying a short rf pulse to the AOM, we dump the cavity and extract a large part of the stored and enhanced power within a short optical pulse and with a controllable optical phase. In preliminary experiments we reached 100 W of peak power in a 15-ns optical pulse. The mutual phase coherence of successive light pulses is demonstrated with a molecular iodine interferometer experiment in a cell.

Value of magnetic-resonance cholangio-pancreatography (MRCP) after unsuccessful endoscopic-retrograde cholangio-pancreatography (ERCP)

BACKGROUND AND STUDY AIMS

The present study tries to evaluate the success rate of MRCP when two attempts by experts to perform ERCP in a center failed.

PATIENTS AND METHODS

From March 1996 to December 1996 thirteen patients fulfilled the inclusion criteria. The MR cholangiopancreatograms were acquired using commercially available software in a clinical MR scanner (Magnetom Expert 1 T-Scanner, Siemens, Erlangen, Germany). MRCP utilized heavily T2-weighted turbo-spin echo sequences with fat supression (HASTE). Maximum intensity projection (MIP) of the pancreatic duct and biliary tree was then carried out. Additionally, T1-weighted sequences were obtained using the breath-hold technique.

RESULTS

The MRCP images were of diagnostic quality in all 13 patients. In five cases the diagnoses detected by MRCP were followed by an interventional procedure. One patient showed a pancreatic pseudocyst, that was percutaneously drained using ultrasound guidance. In three cases we found benign bile duct obstruction, all of which were successfully treated by percutaneous transhepatic drainage. In one patient choledocholithiasis was diagnosed, the stone was successfully managed by percutaneous transhepatic extraction.

CONCLUSION

MRCP is the method of choice in cases where ERCP is incomplete or where duct cannulation is not possible. A further advantage of MR imaging is the fact that it may provide complementary information about the whole region of interest, thus detecting the cause of duct pathology in many cases.