Biomedical subjects

E K Sullivan

Publications and source records attributed to E K Sullivan.

At least 37 records · Page 2Linked to original sources

PubMed1998

Chronic renal insufficiency in children and adolescents: the 1996 annual report of NAPRTCS. North American Pediatric Renal Transplant Cooperative Study.

The 1996 annual report of the Chronic Renal Insufficiency Arm of the North American Pediatric Renal Transplant Cooperative Study (NAPRTCS) summarizes descriptive data and highlights important features on 1,725 patients from 130 centers. This database contains information on patients with an estimated glomerular filtration rate (GFR) < or = 75 ml/min per 1.73 m2 as calculated by the Schwartz formula, who were treated on or after 1 January 1994. Thus this report reflects 2 years of data entry. Analysis of the data revealed that nearly two-thirds of patients registered had a structural anomaly. On average, patients were 1.5 standard deviations below age- and sex-specific norms for height, and 0.6 standard deviations below weight norms. Mean serum creatinine for the entire group was 2.4 mg/dl and 68% of patients had a baseline GFR of at least 25 ml/min per 1.73 m2. The mean hematocrit for all children at registration was 33.3 +/- 6.3%, and did not vary among age groups. Overall, 30.9% of patients had a hematocrit < 30%. Only 12.8% of patients were receiving Epoetin therapy. Although still in infancy, the Chronic Renal Insufficiency Arm of the NAPRTCS database in providing important insights into this disorder.

Adolescent↗

PubMed1998

Renal transplantation in children with sickle cell disease: a report of the North American Pediatric Renal Transplant Cooperative Study (NAPRTCS).

Sickle cell disease is a rare cause of end-stage renal disease (ES-RD) in pediatrics accounting for only 0.5% and 0.2% of the patients registered in the dialysis and transplant arms of the NAPRTCS database, respectively. Accordingly, the single-center experience with this disorder is extremely rare, and little information on patient and graft outcome is available. Between 1989-1995, 9 patients with sickle cell nephropathy (5 male and 4 female) received 10 transplants [7 cadaver (CAD) and 3 living-related donor (LRD)]. The mean age at the time of the first transplant was 16.0 +/- 1.6 years. Prior to transplantation, all patients received maintenance dialysis (4 HD, 4 PD, 1 HD/PD) for 21.4 +/- 16.1 months (range 3-47 months), and all had received > 5 lifetime random blood transfusions. There was a mean 15.9 consecutive days of hospitalization from transplantation to discharge. Initial immunosuppression consisted of methyl predinsolone/prednisone (9 patients) cyclosporine (7 patients) and azathioprine (8 patients). ATG/ALG or OKT3 were used in 3 CAD transplants. There have been 21 acute rejection episodes in 7 of the 9 patients. Two patients had no rejections and 2 patients had 6 rejections each. Six of the 21 rejection episodes occurred within the first 100 days post-transplant. Nine (43%) of the rejections were completely reversed, the reversal rate varying from 71% for first rejections to 29% for second and subsequent rejections. Four (40%) of the 10 grafts have failed. Graft survival at 12 and 24 months post-transplant is 0.89 +/- 0.11 and 0.71 +/- 0.18, respectively. Patient survival is 89%. The present experience suggests that renal transplantation is a viable option for the adolescent patient with sickle cell nephropathy and ESRD.

Adolescent↗

PubMed1998

Living-unrelated renal transplantation in children: a report of the North American Pediatric Renal Transplant Cooperative Study (NAPRTCS)

The shortage of cadaver kidneys available for organ donation compared to growing demand has led to an increase in the use of living-unrelated donors (LURD) for renal transplantation (Tx). Results from trials in adults show that 1-year graft survival rates in LURD are similar to living-related donor (LRD) rates and superior to those of cadaver renal donor (CAD) transplants. We report our experience with 38 LURD transplants for children enrolled in NAPRTCS that were performed between 1987 and 1997. Ages of recipients at Tx were 0-5 years (n=8), 6-12 (n=10), and >12 years (n=20). Twenty nine were primary Tx, seven were second Tx, and two were third Tx. HLA antigen data showed that the number of 2-antigen mismatches for each locus was 44.7% for HLA-A, 71.1% for HLA-B, and 55.3% for HLA-DR. There were 7 donor/recipient pairs with a 6-antigen mismatch, 12 pairs with a 5-antigen mismatch, while there were 6 pairs with a 3-antigen match of which 3 pairs had at least one match at each of the A, B, and DR loci. A total of 38 acute rejection episodes occurred in 25 LURD recipients. Among primary grafts the incidence of first acute rejection at 30 d post-Tx was 46% in LURD vs. 29% in LRD and 37% in CAD recipients; at 1 year post-Tx it was 76% in LURD vs. 48% in LRD and 62% in CAD recipients. Acute tubular necrosis (ATN) was reported in four or 10.5% of LURD transplants compared with 5.4% in LRD and 19.0% in CAD recipients. There were 12 LURD graft failures, due to vascular thrombosis (3), acute rejection (2), recurrence of original disease (1), infection (3), and patient death (3). Estimated primary graft survival probabilities (+/- SE) at 12 months post-Tx are 0.825 +/- 0.071 for LURD, compared to 0.911 +/- 0.006 for LRD, and 0.815 +/- 0.009 for CAD. We conclude that data from this study show that LURD Tx in children have a low rate of ATN that is similar to that of LRD Tx. However, LURD Tx have a high incidence of acute rejection, and the graft survival at 12 and 24 months post-Tx is inferior to LRD Tx. There is a high frequency of graft loss due to causes other than rejection, and these may be related to adverse recipient selection criteria.

Adult↗

PubMed1998

The impact of donor source, recipient age, pre-operative immunotherapy and induction therapy on early and late acute rejections in children: a report of the North American Pediatric Renal Transplant Cooperative Study (NAPRTCS).

Acute rejection is a frequent event in pediatric transplantation. In addition to graft loss, acute rejection episodes stimulate the development of chronic rejection and inhibit growth in children post-transplantation. In this study, we analyzed our data from 1987 through 1996 to identify acute rejection episodes in children. In 2,520 living donor (LD) transplants there were 2,540 rejection episodes (rejection ratio: 1.1), and in 2,579 cadaver donor (CD) transplants 3,653 episodes were observed (rejection ratio: 1.32). For LD recipients the first rejection occurred sooner when there was at least one HLA-DR mismatch (RR=1.6, p<0.001) and prophylactic T-cell antibody was not used (RR=1.4, p<0.001). For CD transplants absence of prophylactic T-cell antibody (RR=1.2, p<0.001) and donor age below five years were risk factors (RR=1.5, p<0.001). Late initial acute rejections were seen in 327 of 1,471 patients (22.2%) who were rejection free at one year. At risk for the development of late rejections were children over the age of six years at transplantation (RR=1.7, p<0.001) and children of non-white origin (RR=1.5, p <0.002). For LD transplant recipients in the age range of 0-5 years, irreversible rejection was observed in 8.7% compared to 4.1% for older children (RR=1.46, p<0.001). Similar results for CD transplants were 12.6% versus 6.6% (RR=1.5, p<0.00). The high frequency of rejection episodes in children and the greater irreversibility in younger children suggest pediatric patients may have a more robust immune response. Current ongoing studies in the molecular mechanisms of the pathogenesis of rejection in surveillance biopsies of children may help determine if this hypothesis is valid.

Acute Disease↗

PubMed1998

Renal transplantation in Down syndrome: a report of the North American Pediatric Renal Transplant Cooperative Study.

There are few published reports on renal transplantation in patients with Down syndrome and renal failure. By means of a questionnaire sent to participating renal centers of the North American Pediatric Renal Transplant Cooperative Study, this study identified 14 Down syndrome patients who received renal transplants between January 1987 and November 1995. There were 6 males and 8 females between the ages of 6 and 21 years. Of the group, 8 patients were Caucasian and 6 were of African American ethnicity. Four patients had a primary diagnosis of obstructive uropathy, two had hypoplastic/dysplastic renal disease, two had focal segmental glomerulosclerosis, two had a diagnosis of chronic glomerulonephritis and four patients had unspecified diagnoses. Eight patients received cadaver kidneys whilst the other six had a living related transplant from a parent or sibling. Only one patient had received a prior kidney transplant, ten patients were on dialysis at the time they were transplanted and 4 patients were preemptively transplanted. Standard immunosuppression with Cyclosporine, Imuran and Prednisone was used. In addition, nine patients received induction therapy at the time of transplantation. Follow-up data revealed that 5 grafts (35.7%) had failed, two as a result of rejection and three due to patient death. At the time of data cutoff there were 3 deaths, one due to viral infection and the other two secondary to cardio-pulmonary complications.

Adolescent↗

PubMed1998

ABO-mismatched renal transplantation in children: a report of the North American Pediatric Renal Transplant Cooperative Study (NAPRTCS) and the Midwest Organ Bank (MOB).

Successful ABO-mismatched renal transplantation (RT) (blood group A2 donor to blood group B or O recipient) has occurred in adults in the setting of a low titer (< or =4) natural isoagglutinin (anti-A) level in the recipient of the mismatched organ. Similar experiences have rarely occurred in children. Between 1986-1996, 11 pediatric patients (6 male and 5 female) received 11 ABO-mismatched kidneys [7 cadaveric (CAD) and 4 living related donor (LRD)]. There were 8 O recipients/A2 donor pairs, 2 B recipients/A2 donor pairs and 1 B recipient/A2B donor pair. Recipient age at the time of RT was 14.7+/-3.0 yr (mean +/- SD). Prior to RT, 2 recipients underwent splenectomy and none received donor-specific transfusions. Induction and early maintenance immunosuppression consisted of corticosteroids (11 pts), ALG/ATG (6 pts), OKT3 (3 pts), azathioprine (11 pts) and cyclosporine (8 pts). The mean 30-d cyclosporine dosage was 10.6+/-4.0 mg/kg/d. Eight patients suffered > or =1 acute rejection episodes, the initial episode occurring within the first 31 d post-transplant in 7 of them. Five grafts (45.4%) failed secondary to vascular thrombosis (1), acute rejection (2) and chronic rejection (2). The remaining grafts (54.5%) all functioned for >1000 d (range: 1023-3746 d). The pre-transplant anti-A titer was determined in 6 pts; in 4 it was low (2) and in 2 it was high (8). Graft survival in all but one of these patients (whose titer was 8 and who suffered a non-rejection-related vascular thrombosis) was > or =2 yr. In summary, ABO-mismatched RT in pediatric patients is an uncommon practice. However, the adult experience and our preliminary pediatric experience suggests that evaluation of recipient isoagglutinin levels in this setting may be helpful in the selection of donor/recipient pairs in whom mismatched transplantation can be successful.

ABO Blood-Group System↗

PubMed1997

Renal transplantation, chronic dialysis, and chronic renal insufficiency in children and adolescents. The 1995 Annual Report of the North American Pediatric Renal Transplant Cooperative Study.

The 1995 Annual Report of the North American Pediatric Renal Transplant Cooperative Study summarizes data voluntarily collected from 123 centers on 5,197 children and adolescents grouped into three cohorts: (1) patients who received renal transplants on or after 1 January 1987 (n = 3,066), (2) patients who were maintained on peritoneal dialysis (PD) or hemodialysis (HD) on or after 1 January 1992 (n = 1,488), and (3) patients treated for chronic renal insufficiency (CRI) on or after 1 January 1994 (n = 643). The transplant and dialysis information update previous registry data whereas the CRI information reflects 1st-year registry data. Three-year graft survival rates were 83% and 66% for living donor grafts and cadaver donor (CD) grafts, respectively. Triple drug maintenance therapy with prednisone, cyclosporine, and azathioprine was used by > 70% of all transplant recipients through 5 years of follow-up. The 2-year CD survival has steadily improved from 65% in 1987 to 82% in 1992. Fifty malignancies have been reported, the majority of which are lymphoproliferative disorders. The 2-year patient survival posttransplantation is 95%. Mortality rates for the youngest patients have drastically improved over the past 2 years. Approximately two-thirds of patients in the dialysis cohort are maintained on PD; automated PD remains the preferred modality. Overall, the peritonitis rate is one infection every 13.3 patient months, the frequency of infection being greatest in the youngest patients. Whereas the primary reason for dialysis modality termination is transplantation approximately 40% of the entire dialysis cohort (PD at HD) were not considered active transplant candidate Baseline CRI data revealed the most common primary diagnoses to be obstructive uropathy (24%) and aplastic/hypoplastic/dysplastic kidneys (19%). The standardized height deficit in the CRI cohort was greatest in the younger patients and those with the most impaired renal function.

Adolescent↗

PubMed1997

Immunization practices in children with renal disease: a report of the North American Pediatric Renal Transplant Cooperative Study.

To determine the current immunization recommendations of practicing pediatric nephrologists, a questionnaire was sent to the members of the North American Pediatric Renal Transplant Cooperative Society. Sixty-two percent of the centers responded. The results of the survey suggest that although consensus for approaching immunization does exist, recommendations do vary from center to center. Virtually all centers recommend standard vaccines [DTP, oral poliovirus (OPV), hepatitis B (Hep B), and Haemophilus influenzae B (Hib)] for their renal insufficiency and dialysis patients. Despite the fact that they are not infectious, standard killed vaccines (DTP, Hep B, Hib) are recommended less frequently for transplanted patients (86%) than their renal insufficiency (98%) and dialysis (near 100%) counterparts. Additionally, OPV and measles/mumps/rubella (MMR), both live viral vaccines, are rarely recommended post transplant. Almost 90% of centers recommend the use of influenza vaccine, while only 60% of centers recommend pneumococcal vaccine for children with renal disease. Over 70% of centers recommend the newly licensed varicella vaccine for patients on dialysis and those with renal insufficiency. Between 5% and 12% of centers recommend live viral vaccines, including OPV, MMR, and varicella vaccine, for immunosuppressed patients post renal transplant.

Child↗

PubMed1997

Cytomegalovirus infections following renal transplantation--effects on antiviral prophylaxis: a report of the North American Pediatric Renal Transplant Cooperative Study.

Post-transplant cytomegalovirus (CMV) infections are a source of significant morbidity. However, the extent of the problem and the benefits of various antiviral prophylactic therapies remain incompletely understood. The North American Pediatric Renal Transplant Cooperative Study registry was screened to identify patients hospitalized for CMV infections during the 1st post-renal transplant year between 1987 and 1993. Using a control group of transplant recipients, we performed a retrospective analysis of risk factors for CMV disease among these hospitalized patients and studied the effects of various viral prophylactic strategies on CMV risk, clinical manifestations, and outcome. We identified 142 patients hospitalized with CMV infections, the majority of which included major organ involvement. A CMV-positive kidney donor was the most significant risk factor for hospitalization [odds ratio (OR) = 5.2, P<0.0001] irrespective of recipient age or CMV immune status. As opposed to antiviral agents (acyclovir, ganciclovir) or pooled IgG, prophylaxis with enriched anti-CMV IgG significantly reduced the risk of CMV hospitalization (OR = 0.31, P = 0.03). The prophylactic use of antiviral agents was associated with a decreased risk of major organ involvement during the CMV infection (OR = 0.34, P<0.005). Among the patients with CMV, the 3-year graft survival was significantly better for those who received any form of prophylaxis compared with those who received none (88% vs. 52%, P<0.001). Our findings suggest a role for combined CMV-enriched IgG and antiviral agent prophylaxis for post-transplant CMV disease. Such an approach could diminish the incidence and severity of CMV infection and appears to have an independent favorable effect on graft outcome.

Adolescent↗

PubMed1997

Growth-hormone treatment of renal transplant recipients: the National Cooperative Growth Study experience--a report of the National Cooperative Growth Study and the North American Pediatric Renal Transplant Cooperative Study.

OBJECTIVE: To evaluate growth response and renal allograft measures after recombinant human growth-hormone (GH) treatment in pediatric renal transplant recipients. STUDY DESIGN: Data on GH-treated children in the National Cooperative Growth Study (NCGS) database were linked to the database of the North American Pediatric Renal Transplant Cooperative Study (NAPRTCS). Data were analyzed for growth rate, graft survival, graft function, acute rejection, and adverse events. Data on 2390 transplant recipients in the NAPRTCS who had at least 24 months of graft function were used in the comparisons. RESULTS: Fifty-nine patients were treated with GH after renal transplantation. One-year growth data were available for 42 of these; 2-year, for 31; and 3-year, for 13. Growth velocity increased from 2.47 +/- 1.83 cm/yr to 7.17 +/- 2.97 cm/yr after 1 year. Year-2 and -3 growth rates were 5.93 +/- 2.29 cm/yr and 6.31 +/- 2.32 cm/yr. Height standard deviation score immediately after transplantation was -3.26 +/- 1.44 and at the initiation of GH was -3.59 +/- 1.15; it increased to -3.18 +/- 1.06 at year 1 and to -3.16 +/- 0.92 at year 2 and was -3.31 +/- 1.00 at year 3. Five-year graft survival was 80% in the GH cohort and 85% in the NAPRTCS cohort. Acute rejection ratio was 1.44 and 1.43 episodes per patient in the GH and NAPRTCS cohorts, respectively. Calculated creatinine clearance at 6 years was 68 and 63 ml/min per 1.73 m2, respectively. CONCLUSIONS: Growth hormone increase growth velocity for up to 3 years without an apparent decrease in graft survival or renal function, and no relation between GH therapy and acute rejection is seen. A randomized, prospective study to evaluate further the safety and efficacy of this promising therapy is required.

Acute Disease↗

PubMed1997

Pre-transplant blood transfusion and renal allograft outcome: a report of the North American Pediatric Renal Transplant Cooperative Study.

Data from the North American Pediatric Renal Transplant Cooperative Study were analyzed to determine the effect of pre-transplant blood transfusions on graft survival and acute rejection for pediatric renal transplant recipients. Between January 1, 1987 and November 11, 1995, 4015 renal transplants in children <18 years of age (2007 living donor, 2008 cadaver) were registered in the study. Recipients were grouped by number of pre-transplant blood transfusions (0, n=1171; 1-5, n=1796; >5, n=1048). The risks of graft failure and acute rejection were related to number of pre-transplant transfusions by proportional hazards regression analysis. Models were adjusted for recipient age, sex, race, induction therapy, prior dialysis, prior transplant, HLA-DR mismatching, and transplant year. Additionally, the living donor (LD) model was adjusted for the use of donor-specific blood transfusion, and the cadaver donor (CAD) model was adjusted for donor age and cold storage time. The risk of graft failure was increased in LD (p<0.001) and CAD (p=0.001) recipients who received >5 pre-transplant transfusions. There was no significant difference in the causes of graft loss between groups. The risk of a first acute rejection decreased in LD recipients who received 1-5 blood transfusions compared with 0 (p=0.04) or >5 (p=0.003) and in CAD recipients who received 1-5 compared with 0 (p=0.05). We conclude that multiple (>5) pre-transplant blood transfusions are a risk factor for graft failure in pediatric recipients and should be avoided. However, limited blood transfusions (1-5) are associated with a decreased risk of acute rejection. Our data show that for pediatric recipients the number of pre-transplant blood transfusions is an important factor in transplant outcome.

Blood Transfusion↗

PubMed1997

Varicella in the first year after renal transplantation: a report of the North American Pediatric Renal Transplant Cooperative Study (NAPRTCS).

Prior reports document that children with renal transplants are at risk of severe varicella, with a 5-25% mortality rate. We have examined the current incidence and mortality of varicella requiring hospitalization in pediatric patients in the first year after kidney transplantation through a multi-center retrospective cohort study. Data from the North American Pediatric Renal Transplant Cooperative Study (NAPRTCS) for 2320 pediatric patients who received renal transplants between 1987 and 1993 and were followed until 1995 were examined. Varicella requiring hospitalization in the first post-transplant year occurred in 44 children. Characteristics of the patients who developed varicella were compared to the rest of the NAPRTCS cohort using chi-square analysis. Kaplan-Meier estimates of graft survival were used to compare graft survival in varicella patients and other NAPRTCS patients. Varicella patients tended to be younger (p=0.09) and more often male (p=0.07, chi-square) than other NAPRTCS patients. None of the 44 patients with varicella in their first post-transplant year died from this infection. The number of episodes of acute rejection per transplant and the time to first rejection was not different in patients with varicella compared to the other NAPRTCS patients. Five-year graft survival was not different for varicella cases when compared to other NAPRTCS patients with grafts surviving at least 6 months post-transplant. We conclude that the mortality rate of patients hospitalized with varicella in the first post-transplant year and the risk of subsequent graft dysfunction may be significantly lower than previously described. However, varicella remains a significant cause of potentially avoidable hospitalization in the first post-transplant year. Further study of the safety and efficacy of varicella vaccination in children with renal insufficiency and those post-transplant is warranted.

Adolescent↗

PubMed1997

Pediatric renal transplantation--the NAPRTCS experience.

The NAPRTCS has enrolled 4,329 children who have received an index renal transplant since 1987. Seventy-three percent of the transplant recipients were children above 6 years of age. In the age group below 6 years rejection episodes are not more frequent, however the first acute rejection episode is frequently irreversible leading to graft failure. Many of the renal disorders that lead to ESRD and transplantation in adults, such as diabetes and hypertension, are less often observed in the pediatric population. Developmental disorders, such as renal dysplasia and obstructive uropathy, are frequent diagnostic entities, and the most common glomerular disorder leading to transplantation in children is focal segmental glomerulosclerosis. In an attempt to overcome dialysis-associated growth retardation many pediatric renal centers resort to preemptive transplantation, thus 24% of the children receiving a transplant have never undergone dialysis. Graft survival in these children is similar to that observed in children receiving maintenance dialysis, however accelerated growth is not noted. Catch-up growth, defined as gain of 1 SDS, is observed in 47% of children below the age of 6 years and in only 22% of children over the age of 6 years. Infants (below 2 years) have a higher mortality rate following transplantation compared to older children. Long-term (5-year) graft survival for children receiving a cadaver donor graft is 60%, and for living donor kidney recipients the graft survival is 76%. Due to changes in practice patterns, such as a judicious use of cadaver donors, increased use of prophylactic T-cell antibody, and better maintenance immunosuppression, cadaver donor graft survival has improved each year since 1987. The cohorts of children with a cadaver donor transplant in the years 1991 and 1992 have a 2-year graft survival which is 10% better than that observed in the earlier years.

Adolescent↗

PubMed1996

Factors that impact on the outcome of second renal transplants in children.

We have reviewed the incidence, demography, and outcome of children who have received a repeat transplant in the North American Pediatric Renal Transplant Cooperative Study registry. From 1987 through 1994, 3290 primary and 573 first repeat transplants were performed on North American children. Living donor grafts were used in 52% of primary and 23% of first repeat transplants. Of primary transplants, 23.7% were among children under the age of 6 years. For repeat transplants, the percentage was 15% for the same category. The percentage of 2-DR mismatches was 27% for primary and 40% for repeat transplants (P < 0.01). Graft survival rates for primary transplants at 6, 12, 24, 36, and 60 months were 88%, 85%, 80%, 76%, and 69%, respectively, compared with 81%, 77%, 71%, 64%, and 52% for repeat transplants at the same time periods (P < 0.05). For cadaver donor source transplants, graft survival rates were 83%, 79%, 74%, 69%, and 62%, compared with 79%, 74%, 68%, 60%, and 47% for the repeat transplants (P < 0.01). However, for living related repeat transplants, the rates of 88%, 86%, 81%, 78%, and 72% were not significantly different from the rates of 93%, 91%, 87%, 83%, and 76% for primary transplants. A proportional hazards model for cadaver donor source repeat transplants evaluated donor age, recipient age, race, use of T-cell induction therapy, number of HLA-DR mismatches, year of transplantation, and cold storage time. Only the use of kidneys from cadaver donors less than 6 years of age was predictive of graft failure. Graft survival rates at 12 and 24 months were 77% and 70%, respectively, for donors > 6 years of age, and 58% and 54% for donors < 6 years of age (P < 0.007). We conclude that avoiding the use of younger aged cadaver donors would assure better graft survival for repeat transplants and negate the ethical dilemma facing the issue of retransplantation.

Child↗

PubMed1996

Alternate-day steroid dosing improves growth without adversely affecting graft survival or long-term graft function. A report of the North American Pediatric Renal Transplant Cooperative Study.

Data from the North American Pediatric Renal Transplant Cooperative Study were analyzed to determine the effects of alternate-day (QOD) steroid dosing on growth, graft survival, and graft function in children with functioning grafts 12 months after transplantation. At 12 months after transplantation, 16.8% (337/2001) of transplant recipients were receiving QOD dosing. The basis for the selection of a steroid dosing regimen cannot be determined from registry data; however, the frequency of QOD dosing differed by donor source, race, age at transplant, and the occurrence of rejection episodes in the first year. The effect of the steroid dosing pattern on growth was evaluated in children continuously on either QOD or daily (QD) steroid dosing. The mean change in the standardized height scores from 1 month to 24 months after transplantation was significantly greater in those on QOD dosing (+0.5 +/- 0.06) than in those on QD dosing (+0.1 +/- 0.03). Using multiple regression analyses, better growth was associated with QOD dosing, recipient age less than 13 years, lower total steroid dose over 48 hr, and lower serum creatinine (all P < 0.001). Graft survival did not differ on the basis of the steroid dosing pattern. In a proportional hazards model for survival of living donor grafts after 12 months, graft survival was negatively associated with the use of QD dosing, black race, rejection episodes in the first year, and a higher serum creatinine at 12 months. The survival of cadaver grafts was negatively associated with the use of QD steroid dosing, recipient age less than 2 years, rejection episodes in the first year, and a higher serum creatinine at 12 months. In addition, the decline in graft function did not differ between those on QOD steroid therapy and those on QD therapy. We conclude that selected pediatric renal transplant recipients receiving QOD dosing have better growth than those receiving QD dosing without compromising allograft survival or function.

Adolescent↗

PubMed1996

Higher maintenance cyclosporine dose decreases the risk of graft failure in North American children: a report of the North American Pediatric Renal Transplant Cooperative Study.

Because of changing cyclosporine dosing patterns over the years, maintenance doses in 1469 living donor and 1486 cadaver donor index renal transplants in patients who were 0 to 20 yr of age of the time of transplantation were reviewed. All grafts had at least 30 days' function. Eighty-nine percent of living donor patients and 95% of cadaver donor patients were maintained on cyclosporine for 12 months after transplantation. Among patients receiving cyclosporine, the maintenance 12-month dose in living donor graft recipients increased from 6.4 mg/kg per day for patients who had transplants done in 1987 to 7.9 mg/kg per day for patients who had transplants done in 1992 (P = 0.02). Among cadaver donor graft recipients, the mean 12-month maintenance dose increased from 6.4 mg/kg per day in 1987 to 7.8 mg/kg per day in 1992 (P = 0.01). At 6 months after transplantation, the maintenance cyclosporine dose in 1103 living donor graft recipients who retained graft function during the subsequent 6-month period was 7.1 mg/kg per day, compared with a 6-month dose of 3.9 mg/kg per day in 28 patients who lost their graft in the subsequent 6-month period. For 1041 recipients of cadaver donor grafts who retained graft function through 12 months after transplantation, the 6-month maintenance cyclosporine dose was 7.4 mg/kg per day, compared with 5.4 mg/kg per day in 59 patients whose graft failed in the subsequent 6 months. In patients who did not have an acute rejection episode during the first 12 months after transplantation, the rate of subsequent "late" rejections was 22% for patients with a 12-month maintenance cyclosporine dose < or = 4.0 mg/kg per day, and 16% for patients whose 12-month maintenance cyclosporine dose exceeded 8.6 mg/kg per day. A proportional hazards regression analysis, using cyclosporine dose as a time-dependent covariate, showed that the hazard of graft failure was reduced 5 to 6% for each incremental increase of 1 mg/kg maintenance dose of cyclosporine (within the dose range studied) for both living and cadaver donor source transplants.

Adolescent↗

PubMed1996

Lessons from the peritoneal dialysis patient database: a report of the North American Pediatric Renal Transplant Cooperative Study.

Data derived from 1383 independent courses of peritoneal dialysis have been recorded in the database of the North American Pediatric Renal Transplant Cooperative Study (NAPRTCS). Automated peritoneal dialysis (APD) continues to be the preferred modality. Peritoneal access is most commonly achieved with a Tenckhoff curled catheter with a single-cuff and straight tunnel. Overall, the peritonitis rate is 1 infection every 13.3 months, the frequency of infection being greatest in the youngest patients. Two-cuffed catheters and exit-sites directed down positively influence this rate. Excessive infection is the primary reason for modality termination in surviving patients not transplanted. A total of 64 deaths have occurred in the peritoneal dialysis population. The 12-month and 24-month mortality probabilities in children < two years of age are significantly greater than comparable data in the older children.

Adolescent↗

PubMed1996

A longitudinal study of the natural history of growth post-transplantation.

We have evaluated 587 patients with a functioning renal allograft for at least 54 months in whom baseline and continuous bi-annual height measurements were available. All height data were converted into SD score (SDS) or Z-score using normative tables. The results obtained in these patients were compared to our previous data collected at two years (N = 300) and three years (N = 412) post-transplantation. The demography of the study groups in the three time periods was similar. The height deficit in the first study was -2.41; it was -2.46 at the end of the second study period and was -2.29 at the end of the third study period. Children in the first study period had an improvement in height SDS (delta Z) of +0.18, of +0.16 in the second period, and of +0.11 at the end of the third study period. When improvement in height SD was evaluated by donor source, no differences were noted between living related and cadaver donor transplants. Analysis of height SDS by race revealed that, whereas for Caucasian children a steady improvement of 0.18 was noted during both second and third study periods, there was actual deceleration of growth for the African-American and Hispanic children at the end of the third study period (P < 0.02). Multivariate analysis showed that only initial height deficit and recipient age were independent predictors of improved height post-transplantation. Catch up growth, defined as an improvement of 1 SDS, was seen only in those with the greatest deficit or in children 0 to 1 year of age. Overall, catch up growth was seen in only 47% of 2 to 5 year olds. For children over the age of six years who form 72% of the total study cohort, little catch up growth was noted. Our long-term studies reveal that in the first years post-transplantation, when renal function is still stable, height acceleration does not occur in most of the children over the age of six years, and alternative strategies are necessary to improve the quality of life of these children.

Adolescent↗