[Bacterial pathogens, resistance patterns and treatment options in community acquired pediatric urinary tract infection]

BACKGROUND

Epidemiology and resistance patterns of bacterial pathogens in pediatric UTI show large interregional variability and rates of bacterial resistances are changing due to different antibiotic treatment. We intended to evaluate data from northern Germany.

PATIENTS AND METHODS

In 100 children (53 female, 47 male, mean age 4.4 +/- 4.2 years) with community acquired UTI, who presented in the emergency department of our medical school from 2000 - 2002, urine cultures were performed. Inclusion criteria were: acute voiding symptoms, significant bacteriuria with growth of at least 10 (5) colony-forming units/ml urine, leukocyturia > 50/ micro l. Exclusion criteria were underlying renal diseases, anatomic abnormalities of the urinary tract, age < 2 months and recurrent UTI.

RESULTS

Patients presented with a mean rectal temperature of 38.6 +/- 1.3 degrees C, mean CRP of 66 +/- 68 mg/dl, mean WBC 13 500 +/- 5 600/ micro l and mean urinary leukocytes of 425 +/- 363/ micro l. In urine cultures E. coli was found in 47 % of the cases, Enterococcus faecalis 23 %, Proteus mirabilis 8 %, Klebsiella oxytoca 4 %, Pseudomonas aeruginosa 5 % and others 13 %. In 76 % one and in 24 % two different bacterial species (60 % Enterococcus faecalis) were cultured. Mean resistance rates were in all bacteria (in E. coli): Ampicillin 53 % (69 %), Ampicillin and Sulbactam 51 % (61 %), Cefalosporin 1 (st) generation (Cefaclor) 48 % (24 %), Cefalosporin 2 (nd) generation (Cefuroxim) 40 % (3 %), Cefalosporin 3 (rd) generation (Cefuroxim) 33 % (0 %), Tobramycin 30 % (2 %), Ciprofloxacine 0 %, Cotrimoxazole 40 % (42 %), Nitrofurantoin 12 % (0 %).

CONCLUSION

The resistance rates to Ampicillin (+/- Sulbactam) did not increase as compared to previous analyses (1990 - 1995), however, resistance rates to Cotrimoxazole and 1 (st) generation Cefalosporines increased about 20 %. We conclude that the policies for treatment of UTI in children should be re-evaluated every 5 years according to local resistance rates.

Morbidity of schistosomiasis mansoni in the highlands of Madagascar and comparison of current sonographical classification systems

To study the morbidity of schistosomiasis mansoni in the highlands of Madagascar, a cross-sectional study examined the extent to which liver fibrosis occurred in a rural community. The Managil and the Cairo classification systems were used. A second purpose was to investigate the effect of the measurements of 2 different branches of the portal vein (either segmental or sub-segmental branches) on the resulting staging of morbidity using the Cairo classification system. In a rice farmer village, 656 inhabitants (95% of the total population) were parasitologically examined; 561 patients underwent sonographic work-up based on the Managil scoring system, and in 307 randomized patients the outer to outer diameters of both the segmental and the sub-segmental branches of the portal vein were measured and scored by the Cairo classification system. Overall prevalence of schistosomiasis mansoni in the study area in 1994 was 68.3%. Upon sonographic examination and scoring by the Managil system 23.4% of the population showed liver changes (Managil degree I/II/III, 20%/2.5%/0.9%). Measuring the sub-segmental branches only and scoring by the Cairo classification, 19% of the study population were found to have liver changes, none with severe fibrosis. By contrast, 82% were found to have liver changes (Cairo degree 1/2/3, 70%/11%/2%) when the segmental branches were measured. The diameters of the sub-segmental branches were about two-thirds of those of the segmental branches. Both the Cairo- and the Managil-examination protocols have pitfalls. Using the Cairo classification, a considerable systematic error in classifying morbidity is created by measuring different branches of the portal vein.

Perioperative management of central diabetes insipidus in kidney transplantation

Central diabetes insipidus is clinically masked in dialysis patients. We report a 12-year-old girl receiving a living-related donor graft for renal failure from Alport syndrome, in whom a craniopharyngioma had been resected 6 months before transplantation. Pretransplant evaluation had documented central hypothyroidism, growth hormone deficiency, and presumptive hypogonadotropic hypogonadism. The corticotropin-releasing factor test had been normal. Four hours after transplantation, urine output exceeded 1,000 ml/h without diuretic therapy. Serum sodium concentration was 155 mmol/l, serum osmolality 333 mmol/kg, and plasma antidiuretic hormone 4.9 ng/l, while urine osmolality was 233 mmol/kg. Desmopressin acetate was started by continuous intravenous infusion at 1 microgram/day. Serum electrolytes rapidly normalized, urine output stabilized at 2 l/day. The patient was discharged 4 weeks after transplantation with good allograft function, receiving intranasal desmopressin acetate 10 micrograms twice daily. Pre-existing central diabetes insipidus is unmasked after successful kidney transplantation, leading to rapid dehydration and hypernatremia, which can be prevented by prompt institution of desmopressin therapy.

A meta-analysis of cytotoxic treatment for frequently relapsing nephrotic syndrome in children

For over 30 years cyclophosphamide (CYC) and chlorambucil (CHL) have been used to treat children with relapsing steroid-sensitive nephrotic syndrome (SSNS). A meta-analysis on treatment protocols, efficacy, and side effects of CYC and CHL was performed from the literature. Thirty-eight studies comprising 1,504 children and 1,573 courses of cytotoxic drug therapy were systematically evaluated. Relapse-free survival rates increased with the cumulative dosage of CHL and CYC and were higher in children with frequently relapsing than steroid-dependent NS. The fatality rate of the treatment was approximately 1%. Leukopenia occurred in one-third of patients treated with either drug. Severe bacterial infections developed in 1.5% of the patients under CYC and in 6.8% under CHL. Seizures were observed in 3.6% of children treated with CHL. Malignancies were observed in 14 children after high doses of either drug. Females rarely developed permanent gonadal damage. However, no safe threshold for a cumulative amount of CYC was found in males, but there was a marked increase in the risk of oligo- or azoospermia with higher cumulative doses. From this meta-analysis we recommend CYC 2-3 mg/kg body weight for 8-12 weeks as the standard scheme. CHL has higher rates of severe side effects and should be considered a second-line drug.

Analysis of cognitive and motor functioning during pubertal development: a new approach

We investigated cognitive-motor abilities in 303 (156 female) school children from Zagreb, Croatia, in the age span 10 to 14 years using a newly developed chronometrical reactionmeter system (CRD). The following tests were applied: CRD-311 (simple visual discrimination of signal location), CRD-324 (short-term memory actualisation), CRD-21 (simple convergent visual orientation), and CRD-11 (arithmetically conceptualised/operationalised convergent thinking). In both gender a statistically significant age related improvement of the performance for time related parameters (minimum time of test item solving (MT), total ballast (TB), and total time of test solving (TT) was observed. In contrast, the number of errors (NE), which was the only non-time related parameter tested, did not significantly change with age. Significant differences between boys and girls were observed for the time related parameters TB and MT. TB was significantly lower in girls, whereas boys tended to be faster in MT measurements. In TT as a composed measure of the mentioned parameters, no major differences were observed. We conclude that the CRD system is a new useful tool for investigating the complexity of cognitive-motor abilities in children. Our cross-sectional study demonstrated that the time-related parameters were significantly affected by age and gender during puberty.

Does growth hormone therapy harmonize distorted morphology and body composition in chronic renal failure?

Recombinant human growth hormone (rhGH) therapy of growth retardation in chronic renal failure (CRF) has become well established. While there are ample data about its effectiveness in restoring longitudinal growth delay, data on complex anthropometry are scarce. Twenty-three children with CRF (6 after renal transplantation) were investigated using 24 different parameters. The analysis revealed disproportionate growth in CRF. While parameters of the trunk and transverse dimension of the head were preserved, the extremities were affected more severely. Bone dimensions of the legs and arms as well as muscle mass were affected the most. RhGH therapy was effective in restoring impaired longitudinal dimensions of the body in CRF. The restoration of growth retardation occurred predominantly in the extremities. This was accompanied by an increase in transversal dimensions, circumferences and soft tissue of the extremities, as well as an increase in bone and muscle volume, indicating harmonization of the total body shape. The dimensions of trunk, forehead diameter and morphological face height remained within the normal range. There was no evidence of acromegaly in children with CRF and rhGH therapy. We conclude that rhGH therapy at a dose of 28 iU/m2/week is effective in restoring previously disproportional body structure and shape in children with CRF.

Interleukin-2 receptor antibody-induced alterations of ciclosporin dose requirements in paediatric transplant recipients

In a retrospective analysis of paediatric renal-transplant recipients receiving basiliximab, we noted significantly increased blood concentrations of cyclosporin, early cyclosporin toxicity, and a lower dose requirement within the first 10 days compared with controls. As the CD25 saturation fades at days 28-50, cyclosporin concentrations decline and 20% higher doses are required to maintain adequate trough concentrations. We suggest that an interleukin-2 receptor-mediated alteration of the cytochrome P450 system causes this systemic drug interaction and propose that the initial ciclosporin dose should be limited to 400 mg/m2 if used in combination with basiliximab.

Improvement of growth after growth hormone treatment in children who undergo liver transplantation

BACKGROUND

Chronic liver insufficiency in children is frequently associated with growth retardation. Growth resumes after successful orthotopic liver transplantation in the majority of children with previous chronic liver failure. However, a subgroup of children demonstrates stunted growth even after orthotopic liver transplantation. The current study was conducted to determine whether administration of recombinant human growth hormone might benefit these patients.

METHODS

Ten children were identified who met the criteria of growth failure despite normal transplant function in a cohort of 60 transplantation patients: height standard deviation score (hSDS) for chronological age less than -2, and growth velocity SDS (gvSDS) for chronological age equaling 0. Seven of these patients were treated with subcutaneous injections of recombinant human growth hormone at 4.0 U/m2 body surface area per day for at least 1 year. Two patients in this group showed insufficient growth hormone response to stimulation (arginine, clonidine) before therapy. Treatment was begun after a median time of 4.6 years after liver transplantation (2.55-8.4 years). Five children were treated with cyclosporin A and prednisolone and two with tacrolimus and prednisolone for maintenance immunosuppression.

RESULTS

Within 3 months of treatment, median serum levels of insulin-like growth factor (IGF)-I increased from 0.05 to 0.71 (P < 0.02). Within 1 year, median hSDS improved from -2.7 (range, -5.6 to -2.3) to -2.1 (-4.5 to -1.4; P < 0.03). Median annual growth rate increased from 3.9 cm/year (range, 3-6) in the year before treatment to 8.2 cm/year (range, 6.1-10.4; P < 0.02) after the beginning of recombinant human growth hormone therapy. All patients tolerated treatment without side effects. During the cumulative treatment time of 14 years no rejection episode was observed.

CONCLUSIONS

Short-statured prepubertal liver transplant recipients who do not show sufficient compensatory growth after transplantation benefit from treatment with recombinant human growth hormone. Treatment with the hormone was safe without any side effects.

Treatment of FSGS with plasma exchange and immunadsorption

In primary focal and segmental glomerulosclerosis (FSGS) renal prognosis is poor if no remission of proteinuria can be achieved with treatment. Currently, most children with FSGS are treated with cyclosporine and steroids after establishing steroid resistance, and approximately 60% of patients benefit from this therapy. For the remaining 40%, no generally approved therapeutic recommendations exist for children. We treated nine children with cyclosporine-resistant primary FSGS with plasma exchange (PE), two with relapsing FSGS after renal transplantation and seven with FSGS in their native kidneys. Three patients did not respond to PE, but five came into complete remission and one patient achieved partial remission. Three patients relapsed between 6 weeks and 2 years following cessation of PE, and were subsequently treated with plasma immunadsorption (PIA), which also reliably reduced proteinuria. The patients without response to PE tended to have a longer duration of the disease. We conclude that PE and PIA are a useful option for treatment of steroid- and cyclosporine-resistant FSGS, particularly if applied early in the course of the disease. Although more demanding on supportive resources, PIA seems preferable to PE, since there is no necessity for additional albumin or fresh-frozen plasma, as with PE.

Glucose tolerance and insulin secretion in children before and during recombinant growth hormone treatment

This study evaluates glucose metabolism and insulin secretion in children with Ullrich-Turner syndrome (UTS), chronic renal failure (CRF) and kidney transplantation (KTx) with rh GH therapy using an intravenous glucose infusion test. Before treatment, glucose AUC was significantly increased in all patient groups when compared to normal controls. Both the early and second phases of insulin secretion were not altered. During treatment, elevated glucose AUC showed a further increase in patients with KTx but not in patients with CRF or UTS. Both the early and second insulin secretion phases rose significantly in UTS and were transiently elevated after 6 and 12 months of therapy in patients with CRF and KTx. We conclude that growth hormone therapy aggravates alteration of glucose metabolism in patients with KTx and not in children with CRF and UTS. Progressive hyperinsulinemia occurred only in patients with UTS.

Obstructive airway disease caused by Moraxella catarrhalis after renal transplantation

We report a case of severe acute obstructive airway disease 2 months after renal transplantation in a 16-year-old patient with Biedl-Bardet syndrome who was transplanted for end-stage renal failure secondary to cystic kidney disease. Symptoms of severe obstructive airway disease developed 2 months after transplantation under immunosuppression with prednisone, azathioprine, and tacrolimus. The patient did not develop signs of infection; progressive shortness of breath remained the only symptom for several weeks. After extensive diagnostic evaluation, bronchoalveolar lavage revealed Moraxella catarrhalis as the single infectious agent. After 3 weeks of appropriate antibiotic therapy, symptoms of obstructive airway disease were completely relieved. This atypical presentation of Moraxella infection in an immunocompromised host represents a rare complication of renal transplantation, especially in young patients. Special aspects such as frequency, diagnosis, differential diagnosis, and management of this rare complication of renal transplantation in a pediatric patient are discussed.

Does treatment of renal anemia with recombinant erythropoietin influence oxidative stress in hemodialysis patients?

Patients with chronic renal failure (CRF) undergoing hemodialysis (HD) are exposed to constant oxidative stress, as shown by elevated malondialdehyde (MDA) plasma concentrations in HD patients. The aim of our study was to investigate the role of renal anemia in oxidative stress. To this end, MDA and 4-hydroxynonenal (HNE) were measured in three groups of patients. Group I comprised 8 patients with hemoglobin (Hb) < 10 g/dl (mean Hb 8.1 +/- 1.3 g/dl) and group II 8 patients with Hb > 10 g/dl (mean Hb 12.4 +/- 1.9 g/dl). None of these 16 patients had been previously treated with recombinant erythropoietin (rhEPO). Group III comprised 27 patients with mean Hb 10.5 +/- 1.6 g/dl after long-term treatment with rhEPO. The plasma concentrations of both MDA and HNE in all 43 HD patients were significantly higher (p < 0.0001) than in 20 healthy controls (MDA 2.85 +/- 0.25 vs 0.37 +/- 0.03 microM, HNE 0.32 +/- 0.03 versus 0.10 +/- 0.01 microM). Comparison between the three groups showed that the HD patients with Hb < 10 g/dl had significantly higher plasma concentrations of lipid peroxidation products (MDA 3.81 +/- 0.86 microM, HNE 0.45 +/- 0.07 microM) than either HD patients with Hb > 10 g/dl (MDA 2.77 +/- 0.58 microM, HNE 0.25 +/- 0.05 microM) or HD patients treated with rhEPO (MDA 2.50 +/- 0.12 microM, HNE 0.29 micro 0.03 microM). An inverse correlation was also demonstrated between plasma HNE and Hb (r= 0.62, p < 0.0001). It follows that a substantial part of the oxidative stress is due to renal anemia. Treatment with rhEPO can therefore effectively reduce oxidative stress in HD patients.

Manifestations and treatment of Schimke immuno-osseous dysplasia: 14 new cases and a review of the literature

Schimke immuno-osseous dysplasia (SIOD) is a rare autosomal recessive spondylo-epiphyseal dysplasia. The characteristic features of SIOD include 1) short stature with hyperpigmented macules and an unusual facies, 2) proteinuria with progressive renal failure, 3) lymphopenia with recurrent infections, and 4) cerebral ischaemia. Although 25 patients have been reported with this disorder, the clinical course and phenotype of SIOD are not well characterized. This report summarizes the clinical findings, course and treatment of reported patients and includes 14 additional patients with SIOD. We emphasize the high incidence of cerebral ischaemia and ocular abnormalities, define the high incidence of thyroid dysfunction and blood cytopenia, and confirm the absence of effective and durable medical therapies.

CONCLUSION

Schimke immuno-osseous dysplasia is a multi-system autosomal recessive disorder with variable expression that affects the skeletal, renal, immune, vascular, and haematopoietic systems. Medical therapy is limited especially for more severely affected individuals.

Cystatin C and creatinine after successful kidney transplantation in children

BACKGROUND

Serum creatinine is commonly used for the monitoring of allograft function following renal transplantation (RTX). Due to lower muscle mass, creatinine production rate is reduced in children, thus decreasing its sensitivity for the detection of allograft dysfunction. In children, the serum concentration of cystatin C, a low molecular weight protein of 13.3 kDa, reflects glomerular filtration rate independent of age, height and body composition. We, therefore, sought to assess the potential of cystatin C as a marker of allograft function in children.

METHODS

Cystatin C and creatinine were measured in parallel at least daily in 24 children (14 boys, 10 girls; mean age 10.5+/-5.1 years) during hospitalization after successful RTX. Cystatin was determined immunoturbidimetrically, creatinine enzymatically.

RESULTS

Within one hour after RTX, cystatin C (mean+/-SE) almost halved from 6.69+/-0.45 mg/l to 3.69+/-0.38 mg/l while creatinine declined from 862 +/-65.4 to 633+/-62.9 micromol/l. Following a nadir of 1.82+/-0.18 mg/l on day 2, there was a secondary increase in cystatin C concentrations to 2.69+/-0.35 mg/l on day 10. Creatinine concentrations continued to decline until day 9 reaching 80.5+/-13.1 micromol/l. Day-to-day variation at steady-state was comparable. In the course of 9 acute rejection episodes, both parameters rose in parallel, the increase in creatinine concentration being much greater.

CONCLUSION

Cystatin C was an early indicator of allograft function following successful RTX in children. It did not prove superior to creatinine for the recognition of acute allograft dysfunction, however.

Sonomorphologic evaluation of goiter in an iodine deficiency area in the Ivory Coast

OBJECTIVES

This study evaluated the extent of thyroid abnormalities in a remote iodine-deficient area of the Ivory Coast.

METHODS

Ultrasonography was used in detecting the presence of goiter.

RESULTS

The overall prevalence rates of goiter were 64.7% among females and 53.3% among males. In children aged 6 to 15 years (n = 314), the prevalence of goiter was 62% regardless of sex. Thyroid volume increased steadily with age, with significantly larger goiters in women 25 years and older. Frequency of cysts and calcifications did not correlate with sex.

CONCLUSIONS

Especially in developing countries, prophylaxis of iodine deficiency disorders must be improved in iodine-deficient areas to prevent substantial morbidity, which is more severe in women and elderly persons.

Evaluation of pediatric nephropathies by a computerized Urine Protein Expert System (UPES)

A computerized Urine Protein Expert System (UPES) measuring creatinine, total protein, albumin, IgG, alpha(1)-microglobulin, alpha(2)-macroglobulin, and N-acetyl-beta-D-glucosaminidase, together with urine dipstick testing for granulocyte esterase and hemoglobin pseudoperoxidase, and measurement of serum creatinine had been found to be useful in adults for differentiating between renal disorders. The objective of this study was to investigate UPES for identifying the different types of proteinuria and their underlying prerenal, glomerular, tubular, and postrenal causes in 146 children characterized by routine and invasive nephrological investigations. UPES proved to be a useful tool in pediatric renal patients after refinements were implemented in the program. Comparing UPES with the pediatric nephrologist's interpretation of all available clinical and laboratory data, UPES diagnosed glomerulopathies in 46 (75%) of 61 patients. In a further 23% it suggested glomerular involvement by indicating either a disturbed glomerular permeability or increased excretion of albumin. Tubular proteinuria was correctly described by UPES in 23 (100%) patients with different tubulopathies. UPES revealed normal kidney function in all healthy children and all children with remission of renal disorders. Therefore, UPES can be regarded as a useful tool in the automated differentiation of renal diseases in children.

Long-term prognosis of hemolytic uremic syndrome and effective renal plasma flow

The long-term prognosis of diarrhea-associated hemolytic uremic syndrome (D+ HUS) was evaluated in a cohort of 127 of 149 children who had survived the acute phase. Glomerular filtration rate (GFR) and effective renal plasma flow (ERPF) were estimated by serial (51)Cr-EDTA and (123)iodine-hippurate clearances. All children had acute renal failure during the initial phase and 74% of patients were dialyzed. During the 1st year, mean GFR and ERPF increased continuously until a plateau was reached. In the 2nd year after the diagnosis of HUS, GFR was below 80 and ERPF below 515 ml/min per 1. 73 m(2) in 16% and 47% of patients, respectively. At the end of a median follow-up of 5.0 (range 2.0-13.2) years, the proportion of children with renal sequelae such as proteinuria >/=300 mg/l, hypertension, or a GFR <80 ml/min per 1.73 m(2) was 23%. Anuria of more than 7 days' duration and hypertension during the acute phase were statistically significant risk factors for an unfavorable outcome. A reduced ERPF in the 2nd year was found in 93% of patients with sequelae. Mean filtration fraction (SD) in these patients was 0. 26 (+/-0.07) versus 0.19 (+/-0.05) in patients without sequelae (P<0. 0001). These data suggest that loss of nephrons during the acute phase may implicate hyperfiltration in the residual functioning kidney mass leading to progressive renal disease. ERPF in the 2nd year after D+ HUS may serve as an excellent parameter to detect patients with a high risk of an unfavorable long-term outcome.

Renal involvement in Gambian children with cerebral or mild malaria

Kidney function was studied in 80 Gambian children with cerebral malaria, 73 children with mild malaria, and in 19 children with other febrile illnesses. Serum creatinine was measured, and the excretion in urine of immunoglobulin G, transferrin, albumin and alpha 1 microglobulin was determined. Twenty-five percent of children with cerebral malaria, and 4% of children with mild malaria had an elevated serum creatinine above 62 mumol/l. Increased urinary protein excretion was frequent: 53% of children with cerebral malaria had a glomerulo-tubular pattern of protein excretion, and 46% a tubular pattern. Median albuminuria was 68 mg/l in children with cerebral malaria, 18 mg/l in children with mild malaria, and 9 mg/l in febrile children with other diseases (P < 0.0001). There was no significant association between the proteinuria and height of fever or the degree of parasitaemia, and there was no significant association between death and signs of renal impairment. Renal involvement is common in children with malaria in The Gambia, with prerenal, glomerular, and tubulo-interstitial factors contributing. It is more pronounced in children with cerebral malaria than in those with mild malaria. However, renal dysfunction is relatively mild and does not indicate a worse prognosis.

Kidney transplanted children come of age

BACKGROUND

The aim of renal replacement therapy in children is to restore their potential for normal growth and development in order to reach mature adulthood. Because pediatric kidney transplantation started in the late 1960s, it is now possible to document the progress and outcome of these patients from transplantation in childhood to survival into adulthood.

METHODS

In this single-center study, all 150 children born before December 1977 and having received a kidney transplant between 1970 and 1993 were selected for long-term follow-up. The mean age at transplantation was 12.1 years (range 3.2 to 16.7), and the mean follow-up was 13.1 years (range 2.0 to 25.0). In December 1995, 124 grown-up patients with a mean age of 25.4 years (range 18.4 to 40.3) were alive, 89 with a functioning graft. Fifty had the first graft functioning longer than 10 years. The fate of all patients was traced, and those living were analyzed in regard to their somatic and socioeconomic states.

RESULTS

The actuarial 25-year survival rate for the patients was 81%, and for the first graft it was 31%. The best graft survival rates were observed after living related donation, preemptive transplantation, and immunosuppression with cyclosporine. The latter benefit, however, vanished after eight years. The mean creatinine clearance declined over the years from 76 to 45 ml/min/1.73 m2, and the incidence of hypertension increased to more than 80% of the patients. Malignancies occurred in 2.6%. Final height was stunted in 44% of noncystinotic patients, whereas all patients with cystinosis were extremely growth retarded. Twenty-seven percent suffered from additional disabilities. A majority of adult patients were rehabilitated in regard to education and socioeconomic status, and 14% were unemployed.

CONCLUSIONS

The results indicate that renal transplantation in children leads to a high degree of rehabilitation in adulthood. The life of a kidney transplant, however, is limited, which points out the need for more specific immunosuppression with fewer side-effects in order to reach the goal of lifelong graft function.

Renal involvement in children with malignancies

Renal complications in children with malignancies primarily arise from renal parenchymal tumors, "tumor lysis syndrome," and malignant infiltration or obstruction of the urinary tract. Therapy-associated renal side effects may develop following surgical and cytostatic treatment or be induced by radiotherapy. Clinically, both acute renal failure, for example following cisplatin, or chronic dysfunction, following ifosfamide and resulting in growth failure, are observed. Frequencies of renal impairment in these patients are, however, not well established, but terminal renal failure is a rare event: pediatric malignancies account for only 0.9% of patients on renal replacement therapy; the majority of these patients had been treated for a bilateral nephroblastoma. Since potentially serious long-term renal sequelae may evolve following both single measures and additive nephrotoxic effects, long-term monitoring of growth, blood pressure, and renal function is mandatory for a great proportion of former pediatric oncology patients. Future research should prospectively address frequencies of long-term renal impairment in these patients and should establish the prognosis of renal dysfunction. Only these data will ultimately allow risk-adopted use of potentially nephrotoxic treatment modalities and adequate counselling of patients.

Abbreviated cyclosporine AUCs on Neoral--the search continues!

Cyclosporine is a powerful immunosuppressant with a narrow therapeutic window and considerable inter- and intrapatient variability. The pre-dose trough concentration (C(min)) is commonly used for therapeutic drug monitoring. With the new microemulsion (Neoral), intrapatient variability was reduced. However, the usefulness of Neoral C(min) was questioned. Firstly, because of the improved and more-rapid absorption, accidental intake before blood sampling has a greater impact on C(min) than with classic cyclosporine. Secondly, C(min) may be low despite high drug exposure, due to rapid clearance in children. A full pharmacokinetic (PK) profile with determination of the area under the curve (AUC) is expensive and cumbersome, and therefore a search for an abbreviated AUC began. Here, we present a retrospective analysis of 84 PK profiles from 78 pediatric renal transplant recipients. By analysis of rejection episodes and toxicity, we estimated a target AUC above 5,000 ng x h/ml in the early post-transplant period and 3,900 ng x h/ml beyond 100 days. The abbreviated AUC using the 2- and 6-h concentrations (C2 and C6) and a simple estimate derived from the 3-h concentration (C3) were equally well correlated with the AUC. From our data, we recommend a target C3 at approximately 800 ng/ml early after transplantation and 450-550 ng/ml beyond 100 days.

Oxidative stress in hemodialysis patients treated with a dialysis membrane which has alpha-tocopherol bonded to its surface

BACKGROUND

MDA, a major product of LPO, was shown to be increased in plasma of patients with end-stage renal failure (ESRF) undergoing hemodialysis (HD). Elevated oxidative stress in ESRF patients is a result of multiple pathogenetic factors. HD treatment has been shown to be one important cause of accelerated radical generation. The aim of our study was to examine whether treatment with a dialysis membrane which has alpha-tocopherol hydrophobically bonded to its surface (Excebrane by Terumo, Japan) can decrease oxidative stress due to HD.

METHODS

10 ESRF patients undergoing HD three times weekly were examined. First, analysis was done when patients were still dialysed with the membranes used before the study. Thereafter, samples were taken when patients were dialysed first time with the Excebrane membrane, and six weeks after Excebrane treatment. Samples were collected always before and after HD session. A method with HPLC-separation and flourimetric detection was used to measure plasma concentration of MDA.

RESULTS

After HD with the regularly used membranes MDA was found significantly increased (before HD 1.92 [1.81-2.02] microM (median and interquartile ranges) vs. after HD 2.26 [2.02-2.60] microM, p < 0.05) suggesting that MDA was produced during HD. The first time Excebrane was used MDA was decreased significantly (before HD 2.04 [1.95-2.88] microM vs. after HD 1.35 [1.19-1.92] microM, p < 0.05). After six weeks of Excebrane treatment, plasma MDA did not change significantly during HD (before HD 2.01 [1.69-2.62] microM vs. after HD 1.95 [1.42-2.20] microM).

CONCLUSION

Oxidative stress due to HD might be significantly decreased by the Excebrane membrane. However, after six weeks of treatment with Excebrane no effect was seen on the initial plasma concentration of MDA compared to the time before.

Effect of a silver device in preventing catheter-related infections in peritoneal dialysis patients: silver ring prophylaxis at the catheter exit study

Catheter-related infections remain a significant cause of method failure in chronic peritoneal dialysis (PD) therapy. Given the increasing antibiotic resistance, such nonpharmacological strategies as local silver devices attract more interest. To establish whether a silver ring device (designed by Grosse-Siestrup in 1992) mounted onto the PD catheter and placed at the exit site at skin level is effective in preventing exit-site and other catheter-related infections, a prospective 12-month, multicenter, controlled study stratified by diabetes status was conducted. The study subjects were assessed by an extensive structured inventory, including a broad spectrum of control variables, such as age, body mass index (BMI), Staphylococcus aureus carrier status, catheter features, mode and quality of PD therapy, comorbidity, and psychosocial rehabilitation. Ten experienced German outpatient dialysis centers (seven adult, three pediatric) participated in the trial. All eligible patients (n=195) from the study area without catheter-related infections during the ascertainment period were included (incidental subjects undergoing PD therapy for at least 3 months). The main outcome measures were the occurrence of first exit-site infections (primary study end point), sinus tract/tunnel infection, and peritonitis. Ninety-seven patients were assigned to the silver ring and 98 patients to the control group. Baseline characteristics of age, sex, proportion of pediatric and incidental patients, S aureus carrier status, and other variables were similar in both groups. The incidence of infections in the silver ring group versus the control group was as follows: 23 of 97 versus 16 of 98 patients had exit-site infections, 12 of 97 versus 12 of 98 patients had sinus tract/tunnel infections, 16 of 97 versus 18 of 98 patients had peritonitis, respectively. Kaplan-Meier analysis for the probability of an infection-free interval showed no statistical difference (log-rank test) between the two groups. Displacement of the silver ring contributed to study termination in 6% of the study group patients, including two patients with catheter loss. Univariate analysis and multiple logistic regression identified younger age (<50 years), low serum albumin level (<35 g/L), number of previously placed PD catheters, short cuff-exit distance (<2 cm), and S aureus nasal carriage as risk factors for the development of exit-site infections. In conclusion, our study does not show any benefit of the silver ring in preventing catheter-related infections in PD patients. Thus, prevention of infection-related method failure in PD still has to rely on conventional antibiotic treatment strategies and less so on alternative methods.

Non-compliance following renal transplantation in children and adolescents

Reported frequencies of non-compliance in children with end-stage renal disease range from 8% to 70% with a mean around 40%. Sequelae amount to momentous emotional and financial burdens, including the loss of 7% of transplanted organs. Reasons for non-compliance have too often been attributed selectively to the patients (e.g., emotional, mental, social, or communication problems). Compared with general compliance research, this selective attribution appears to be too simplistic. Selective attribution neglects the patients' experiences within the context of disease and treatment and prevents open communication about non-compliance. Research on personal reasons for non-compliance is scarce. In psychological interviews, a third of our 85 patients with end-stage renal disease (34 boys, 51 girls, mean age 12.7 years, range 7.4-19.3 years) communicated psychologically meaningful reasons for non-compliance, frequently related to interrelational and systemic treatment conditions. Patients indirectly asked for more communication about their subjective reasons for non-compliance.

Does long-term treatment of renal anaemia with recombinant erythropoietin influence oxidative stress in haemodialysed patients?

BACKGROUND

Patients with end-stage renal failure undergoing haemodialysis (HD) are exposed to oxidative stress. Increased levels of malondialdehyde (MDA) were demonstrated in plasma of uraemic patients, indicating accelerated lipid peroxidation (LPO) as a consequence of multiple pathogenetic factors. The aim of our investigation was to examine the role of renal anaemia in oxidative stress in HD patients.

METHODS

MDA and 4-hydroxynonenal (HNE) were measured in three groups of patients undergoing HD: group I comprised eight patients with a blood haemoglobin (Hb) < 10 g/dl (mean Hb = 8.1+/-1.3 g/dl), and group II were eight patients with a Hb > 10 g/dl (mean Hb=12.4+/-1.9g/dl); none of these 16 patients had been treated with human recombinant erythropoietin (rHuEpo). Group III comprised 27 patients with a mean Hb of 10.5+/-1.6 g/dl after long-term rHuEpo treatment.

RESULTS

Mean plasma concentrations of both MDA and HNE were significantly higher (P<0.0001) in all 43 HD patients than in 20 healthy controls (MDA 2.85+/-0.25 vs 0.37+/-0.03 microM, HNE 0.32+/-0.03 vs 0.10+/-0.01 microM). Comparing the three groups, it was shown that HD patients with a Hb <10 g/dl had significantly higher plasma levels of LPO products (MDA 3.81+/-0.86 microM, HNE 0.45+/-0.07 microM) than HD patients with a Hb >10g/dl (MDA 2.77+/-0.58 UM, HNE 0.25+/-0.05 microM), and than HD patients treated with rHuEpo (MDA 2.50+/-0.12 microM, HNE 0.29+/-0.03 microM). Furthermore, an inverse correlation between plasma concentration of LPO products and haemoglobin levels was seen (r=0.62, P<0.0001).

CONCLUSION

Radical generation in HD patients might be caused in part by renal anemia itself. Treatment with rHuEpo may decrease radical generation effectively in HD patients due to the increase in the number of red blood cells and blood haemoglobin concentration.

Slowly deteriorating insulin secretion and C-peptide production characterizes diabetes mellitus in infantile cystinosis

Infantile cystinosis, a rare lysosomal storage disease of cystine, leads to Fanconi syndrome and end-stage renal failure. After renal transplantation, no recurrence of the disease occurs in the graft, but other organ involvement becomes evident later in life. Diabetes mellitus has been associated with cystinosis, but the mechanisms of impaired glucose tolerance have not yet been characterized. Here, we studied glucose tolerance, glucose constant decay (k-values), insulin and C-peptide by intravenous glucose tolerance test (IVGTT) in eight patients with infantile cystinosis (three with impaired GFR (CRF) and five after kidney transplantation (KTX)). For comparison, 15 age-matched children with CRF and 15 age-matched KTX patients were analysed. Both early and second insulin secretion phases were diminished in patients with infantile cystinosis, whereas in CRF, k-values were no different from control patients. After renal transplantation, k-values were significantly lower in cystinotic patients with a markedly reduced early insulin secretion phase. There was a significant negative correlation between k-values and age in patients with cystinosis. Repetitive IVGTTs in these patients demonstrated progressive but rather slow loss of first phase insulin secretion and C-peptide production, suggesting a slowly reducing secretion potential of the beta cell due to cystine storage.

CONCLUSION

Unlike type I diabetes mellitus, glucose intolerance in patients with infantile cystinosis is characterized by a slow, progressive loss of insulin secretion and C-peptide production. For these patients, the data indicate a 50% risk of developing glucose intolerance by the age of 18 years. We recommend to perform intravenous glucose tolerance tests at 5-year intervals.

Clinical features of unilateral multicystic renal dysplasia in children

A clinical study of 204 patients with unilateral multicystic renal dysplasia referred to 30 nephrology departments was undertaken to assess the frequency of complications in children who underwent nephrectomy (n = 40) versus those who were treated conservatively (n = 164). Six patients required antihypertensive treatment, 30 (13% of girls, 17% of boys) had at least one episode of urinary tract infection. The number of clinical complications did not differ in patients who underwent nephrectomy in comparison to those who did not. The dysplastic kidney decreased in size in 65% of kidneys with repeated ultrasound values; no change occurred in 16%, while an increase in maximal diameter was observed in 19%. Contralateral kidney length of more than 2 standard deviation scores (SDS) was seen in 30% of patients. There is evidence for a slight impairment of renal function in the whole study group given by a median of serum creatinine level of 0.63 SDS in all patients available for analysis. Among those 35 patients with contralateral anomalies (mainly obstructive changes and vesico-ureteral reflux), all 3 patients with contralateral changes suggestive of hypoplasia and 22% with obstruction, but only 1/7 (14%) with reflux showed elevated serum creatinine level >2 SDS.

CONCLUSION

Renal function seems to be slightly impaired in patients with unilateral multicystic renal dysplasia. The apparent tendency to regression of the dysplastic kidney and no difference in the number of complications justify a conservative management rather than operative intervention.

Dosing of MMF in combination with tacrolimus for steroid-resistant vascular rejection in pediatric renal allografts

Steroid-resistant vascular rejection was treated in seven adolescent renal allograft recipients using the combination of mycophenolate mofetil (MMF) and tacrolimus (FK506). Since there are no published pediatric dose recommendations for MMF using this combination, trough concentrations and pharmacokinetic profiles were used for therapeutic drug monitoring. In order to keep the mycophenolic acid (MPA) concentrations between 2-5 micrograms/ml, mean MMF doses were reduced from 600 to 250 mg/m2 b.i.d. Apparent clearance of MPA decreased from 5 to 1 ml/min per kg within 2 weeks. Pharmacokinetic monitoring revealed substantial variability among patients of both MMF and FK506. The MPA dose ranged from 178 to 1008 mg/m2 per day to achieve an area under the curve (AUC) of 59.9 micrograms x h/ml +/- 10.5 SD (range 49-65 micrograms). FK506 dose ranged from 1.3 to 8.8 mg/m2 per day to achieve an AUC of 116 ng x h/ml +/- 27 SD (range 83-145). We recommend adjusting MMF doses using therapeutic drug monitoring.

Reversible diabetes mellitus during growth hormone therapy in chronic renal failure

A 12-year-old girl with short stature due to idiopathic Fanconi syndrome and chronic renal failure was treated with recombinant human growth hormone (rhGH). There was no family history of diabetes mellitus and the glucose tolerance before treatment was normal. Intravenous glucose tolerance tests were performed before, during and after treatment. Two months after starting rhGH the early phase of insulin secretion (1-+3-min values) was diminished, and the patient developed manifest diabetes mellitus with hyperglycemia and an elevated hemoglobin A1c. Following discontinuation of rhGH, glucose tolerance slowly returned to normal.

Sonographic measurements of the portal vein and its intrahepatic branches in children

Dilatation of the portal vein is a leading sonographic sign in portal hypertension. Enlargement of its intrahepatic branches is found in various liver diseases such as cystic fibrosis and hepatic schistosomiasis. However, body height dependent values for pathological portal vein diameters on ultrasound have been published for adults only and reference values for intrahepatic portal vein branches have to be established. Diameters of the portal vein and of peripheral portal vein branches were investigated in 130 healthy European children and adolescents by ultrasound. The findings correlated significantly with age and body height. Thus, height related diameter values should be used to define pathological enlargement of the portal vein and its intrahepatic branches in children. Our reference data may contribute to improve sonographical investigation of portal hypertension and periportal fibrosis.

Prophylactic oral ganciclovir after renal transplantation-dosing and pharmacokinetics

Ganciclovir alone or in combination with hyperimmunoglobulin is replacing other treatment modalities for the prophylactic treatment of cytomegalovirus (CMV) infections. No dose recommendations are available for oral ganciclovir therapy in children with impaired renal function after renal transplantation of a kidney from a CMV IgG-positive donor. We undertook a pharmacokinetic study in 14 pediatric renal transplant recipients who were CMV IgG negative and had received a graft from a CMV IgG-positive donor. We estimated the daily dosage of oral ganciclovir in relation to the glomerular filtration rate (GFR). Oral ganciclovir was administered at a starting dose of 3 x 1 g for children with a weight above 50 kg, 3 x 750 mg for children between 50 and 37.5 kg, and 3 x 500 mg for children between 37.5 and 24 kg. The starting dose was reduced by 50% for GFR values < or = 50 ml/min per 1.73 m2 and by 75% for GFR values < or = 25 ml/min per 1.73 m2. The daily dose was divided into three daily doses unless GFR was < 40 ml/ min per 1.73 m2, when only two daily doses were given. Doses were adjusted according to the measured plasma trough concentrations (c) using the simple formula: c(ganciclovir)(measured)/c(ganciclovir)(desired) = dosage rate(used)/dosage rate(adjusted). Mean stable plasma trough concentration was 0.91 +/- 0.68 microg/ml. The dosage rate, adjusted to a trough concentration of 1.0 microg/ml, correlated with the GFR. The dose per day could be calculated according to a simple equation for a GFR < 100 ml/min per 1.73 m2: dosage per day (mg/kg per day) = GFR. No CMV disease developed in any of the patients during oral ganciclovir, but 1 patient developed an acute rejection episode and a positive pp65 antigen 5 weeks after discontinuation of ganciclovir. The drug was well tolerated and without side effects.

Twenty-four-hour ambulatory blood pressure monitoring in young children

Twenty-four-hour ambulatory blood pressure monitoring (ABPM) has many advantages for the diagnosis and follow-up of hypertension at all ages. This technique has so far not been documented as applicable to the very young. We studied the feasibility of ABPM in 61 healthy children and in 40 patients with renal diseases and/or hypertension, aged less than 6 years. A satisfactory ABPM profile (recording time = 24 h and > 30 good recordings) was obtained in 77% of the healthy children. The mean number of good blood pressure (BP) measurements per 24 h increased with age from 46 (3-4 years) to 58 (6 years). The mean (+/- SD) systolic and diastolic BPs of healthy 3- to 6-year-old children (n = 47) were 110 +/- 5/67 +/- 5 mmHg during the day-time and 100 +/- 5/58 +/- 5 mmHg at night. In addition to the nocturnal decrease in BP, ABPM detected a second, day-time dip in BP during bed rest after lunch. Ninety percent of patients with renal disease and/or hypertension had successful ABPM recordings for 24 h, with an age-dependent increase in the mean number of reliable readings from 34 (< 2 years) to 48 (4 years). In 5 of 10 children with hypertensive results obtained by casual BP measurements, elevated BP was not confirmed by ABPM. We conclude that ABPM is a useful tool for the diagnosis and evaluation of hypertension in children under 6 years of age.

Renal transplantation from donors aged < 6 years into children yields equal graft survival when compared to older donors

Several articles have shown inferior renal allograft survival in patients receiving kidneys from young cadaver donors. We therefore assessed the survival and function of the first cadaveric graft from donors aged under 6 years of age, transplanted after 1983. The results were compared with the outcome of children receiving kidneys from older donors. Graft survival and serum creatinine were analyzed retrospectively at various time intervals after first cadaveric transplantation in 35 pediatric recipients of renal transplants grafted between 1983 and 1996 from donors < 6 years of age. Their data were compared with those of 167 pediatric recipients of renal transplants grafted from older donors. The proportion of young donors remained constant throughout the observation period. Mean recipient age was 10.4 years (range 3.2-17.5 years) in the patients grafted from donors < 6 years of age, not much different from the mean age of the donors in the 6+ years group (12.5 years, range 2.3-18.6 years). Five-year patient survival did not differ between the two groups (89 vs. 90%). In 1983-1996, graft survival rate of kidneys from donors aged < 6 years after one year was 77% (donors aged 6+ years=76%), after 2 years 66% (donors aged 6+ years=68%), after 3 years 62% (donors aged 6+ years=66%), and after 5 years 55% (donors aged 6+ years=60%, n.s., Log-rank test). In 1994-1996, 2-year graft survival was 88% (controls 91%, n.s.). In children receiving a cadaveric graft from a donor aged < 6 years, mean serum creatinine fell from 132+/-101 (SD) micromol/l after 3 months to 101+/-66 micromol/l after 12 months, and was 110+/-52 micromol/l after 5 years. This compared with a serum creatinine of 131+/-108 micromol/l after 3 months, 132+/-97 micromol/l after 12 months and 143+/-81 micromol/l after 5 years in children receiving grafts from older donors. When transplanting renal allografts from young donors into children, there was no significant difference in graft survival between donors aged < 6 years and older donors or in graft function. We conclude that good results from young donors can be obtained in a specialized center, and therefore the restriction of kidney selection to donors aged > 6 years may not be justified.

Urinary tract morbidity due to Schistosoma haematobium infection in Mali

A total of 824 Malian villagers in a region endemic for Schistosoma (S.) haematobium were examined clinically, parasitologically and by abdominal ultrasound. Systematic schistosomicidal treatment had never been applied to this population. Prevalence of S. haematobium infection ranged from 77% in adolescents to 51% in adults older than 40 years. Intensity of infection was generally mild, 91% of all patients excreting less than 100 ova/10 ml urine. Bladder wall enlargement and irregularities, bladder masses, pseudopolyps and dilation of the upper urinary tract were found ultrasonographically in about one third of infected individuals. Bladder lesions were more frequent in children than in adults and correlated with the intensity of infection in younger age groups only. Hydronephrosis was rare (7 of 824) and never seen in uninfected individuals. Prevalence of urinary tract pathology dropped significantly with age (P < 0.001) and was lowest in patients older than 40 years. Logistical regression identified age and infection as independent parameters affecting the prevalence of urinary tract pathology (P < 0.001). We conclude that Schistosoma haematobium infection causes substantial morbidity in children and younger adults. The reduction of urinary tract morbidity with age despite a considerable prevalence of infection in older age groups suggests spontaneous resolution during adulthood in most cases.

Pharmacokinetics of tacrolimus (FK 506) in children and adolescents with renal transplants

BACKGROUND

Only few data exist on pharmacokinetics of tacrolimus in children.

PATIENTS

In 1995 and 1996, 14 children (mean age 13 years, range 5-23 years) received tacrolimus after renal transplantation; 10 of these after biopsy-proven steroid-resistant rejection (2 with vascular rejection), two for cyclosporin A (CsA)-induced severe nephrotoxicity, one for untreatable gingival hyperplasia on CsA, and one child was treated primarily after transplantation because of severe liver involvement in nephronophthisis. Pharmacokinetic investigations were performed after establishing a stable maintenance dose with trough levels in the desired window of 5-12 ng/ml.

RESULTS

Mean follow-up time was 6 months (range 3-25 months). Eleven patients are still on tacrolimus. Two were discontinued because of severe aggravation of chronic persistent hepatitis C (one of them also developed diabetes mellitus), and one patient was subsequently switched to conventional immunosuppression because of tacrolimus-associated nephrotoxicity. All tacrolimus levels were measured by a modified assay (MEIA, Tacrolimus, Abbott) with improved sensitivity. At the time of switch, median serum creatinine was 234 +/- 82 mumol/l and 6 months after switch 201 +/- 99 mumol/l. All grafts are still functioning. Mean FK-506 dose was 0.16 mg/kg body weight/day (range 0.036-0.30 mg/kg). Mean trough level was 7.1 +/- 2.6 ng/ml in the morning and 6.5 +/- 2.0 ng/ml in the evening. Median time of maximum concentration (tmax) was 120 min after application, and the mean maximum concentration (Cmax) was 15.2 +/- 6.7 ng/ml. Mean area under the curve (AUC) was 104 +/- 33 ng* h/ml, with a range from 65 yo 169 ng* h/ml. No patient had unsatisfactorily low trough levels during the study. There was only a weak but significant (P < 0.05) correlation between dose per kg body weight and AUC and, as expected, an excellent correlation (r2 = 0.73, P < 0.001) between AUC and trough level.

CONCLUSION

Because of interindividual variation between patients, therapeutic drug monitoring of tacrolimus is mandatory. In this study, a daily dose of 0.15 mg/kg was sufficient in most patients. We recommend the performance of at least one pharmacokinetic study after establishing stable FK 506 trough levels to ascertain a safe profile.

Schistosoma mansoni-related morbidity on Ukerewe Island, Tanzania: clinical, ultrasonographical and biochemical parameters

One thousand six hundred and ninety-five inhabitants of 3 rural villages on Ukerewe Island, Lake Victoria, Tanzania, were examined by clinical, parasitological, ultrasonographic and--in part--serological means to evaluate Schistosoma (S.) mansoni-related morbidity on a community level. Villagers frequently complained of typical colitis symptoms (abdominal pain 80.1%, bloody stools 43.1%, diarrhoea 35.1%); haematemesis, on the other hand, was rare (and reports doubtful in most cases). 16.9% of the population had been given praziquantel previously. Overall S. mansoni prevalence was 86.3%, with a median egg output of 176 eggs per gram (e.p.g.) and maximum output of 17,984 e.p.g. Children and adolescents were infected more severely than adults, men more severely than women. Pretreated individuals excreted significantly fewer ova (median 124 vs 192e.p.g., P < 0.001). Hepatomegaly (determined by ultrasonography) was present in 35%, splenomegaly in 80%. Organomegaly was significantly related to egg output. Pretreated persons had lower rates of splenomegaly and left lobe hepatomegaly. Low-degree periportal fibrosis was common, while severe grades of fibrosis (MANAGIL score II and III) were present in about 6%. About 10% had other abnormalities on liver sonography (irregular parenchymal texture and/or shape); these person passed significantly more S. mansoni ova than others. Clear sonographic signs of portal hypertension were seen in 2.1%. Serum procollagen-IV-peptide and gamma-glutamyl-transferase levels were increased in persons with severe periportal fibrosis, irregular liver texture of portofugal collateral vessels. Thus, S. mansoni infection in the western part of Ukerewe Island is frequent and often severe, leading to a high prevalence of gastrointestinal symptoms. Hepatosplenic involvement does occur, although symptomatic cases of portal hypertension were not identified beyond doubt. The overall level of schistosomal morbidity is thus considered intermediate. Serum procollagen-IV-peptide may be a promising marker of schistosomal liver disease. Our data suggest that S. mansoni infection may also be related to diffuse liver parenchyma alterations in this area.

Repeated successful pregnancies after kidney transplantation in 102 women (Report by the EDTA Registry)

BACKGROUND

Between 1967 and 1990, 820 successful pregnancies in 718 women on renal replacement therapy (RRT) were reported to the EDTA Registry.

METHODS

This study analyses data on repeated successful pregnancies in 102 of these women, of whom 99 had two and three had three pregnancies.

RESULTS

Primary renal diseases were mainly glomerulonephritis (41%), pyelonephritis (32%), and congenital malformations such as cystic diseases and hypoplasia or dysplasia (3%). Mean age at start of RRT was 21 years +/-5 SD. Ninety-four per cent of the women had the same transplant during the first and second pregnancies; 85% of these were alive with their first graft and 9% with a second graft; 4% were retransplanted after the first pregnancy and 2% were back on dialysis during the second pregnancy. Of the mothers with two successful pregnancies, two-thirds had a serum creatinine below 121 micromol/l after the first or after the second pregnancy. Six mothers lost their first graft after the first pregnancy. None of the mothers had died after delivery of the second or third baby. Several features of the first and the second pregnancy in these mothers were quite similar. Mean gestational age was 36 weeks+/-3SD during first and second pregnancy. Mean birth weight (height) of the first child was 2490 g+/-660 SD (48 cm+/-4 SD) and 2587 g+/-639 SD (50 cm+/-3 SD) of the second child (NS). Neonatal mortality was 4% after the first and second delivery; congenital abnormalities were found in five and three children respectively.

CONCLUSIONS

Fourteen per cent of mothers who had a successful pregnancy on RRT subsequently had a second baby. Repeated pregnancies should not adversely affect graft function and/or fetal development provided that graft function was well preserved at the time of conception.