Ann-Britt Bohlin

Renal transplantation in children less than two years old.

Twenty-one infants, 2 years old or younger, received 21 renal transplants between 1983 and 1995. Six of the transplantations were performed from 1983 to 1989, and the remaining 15 were performed from 1990 to 1995. The median age at transplantation was 16.0 months and the median body weight was 9.0 kg. Living-related donor kidneys were used in 15 cases, an adult cadaveric donor kidney was used in one case, and pediatric cadaveric donor kidneys were used in five cases. All grafts were placed intra-abdominally. The immunosuppressive therapy consisted of cyclosporine, azathioprine, and prednisolone. No prophylactic antithymocyte globulins were used. Five infants have died, one with a functioning graft and four after loss of graft function. All graft losses and deaths occurred during the first 6 months after transplantation. The 5-year patient survival and graft survival rates were 87% for recipients of living donor grafts and 44% for recipients of cadaveric grafts. The median height SD score increased from -3.7 before operation to -1.9 at 1 year, -0.7 at 3 years, and -1.1 at 5 years. The glomerular filtration rate in absolute values remained stable in all infants, whereas a reduction in glomerular filtration rate related to body surface area was seen at follow-up, 5 years after transplantation. We conclude that renal transplantation can be performed with good long-term results in children less than 2 years old.

Renal biopsy in children: indications, technique and efficacy in 119 consecutive cases.

Consecutive renal biopsies were performed on native kidneys in 109 children and adolescents, aged 0.1–19.8 (mean 9.9) years (119 biopsies). Bleeding diatheses were excluded or treated pre-operatively with intravenous desmopressin acetate. Biopsies were performed by a radiologist under ultrasound imaging, using an automated spring-loaded device allowing selection of the length of the needle movement and score size. Diagnostically adequate tissue was retrieved in 118 of 119 (99.2%) biopsy procedures; 24-h post-biopsy ultrasonography disclosed a small haematoma of the biopsied kidney in 26% of the cases. No correlation was seen between the occurrence of haematoma and (treated) prolonged bleeding time or a decrease in the haemoglobin level. No major complications occurred. Newly developed macroscopic haematuria was reported by 7% and micturition pain by 7% of patients. Painful body movements were reported by 37%. We conclude that the use of ultrasound imaging and an automated gunshot technique is a safe and efficient method for performing renal biopsies in paediatric patients.

Renal function following kidney transplantation in children treated with cyclosporine

The study was performed to evaluate the longterm renal function of children treated with cyclosporine after kidney transplantation. Renal function was determined with clearances of inulin and aminohippurate sodium for evaluating glomerular filtration rate (GFR) and effective renal plasma flow (ERPF). Thirty-six children aged 0.4–16.2 (median 6.9) years at transplantation were examined within 5 months of transplantation and then yearly over 0.3–7.1 years. Twenty-five children and young adults, 1.5–20 (median 7.7) years of age, with solitary kidneys because of renal agenesis or nephrectomy, served as controls. The GFR and ERPF within 1 year of transplantation were significantly lower than those of controls (65±19 and 345±88 vs 96±12 and 474±91 ml/min per 1.73 m2, respectively). GFR remained constant 4 years after transplantation, but ERPF decreased significantly. Significant inverse correlations were found between GFR within 5 months of transplantation and the mean cyclosporine concentration and the number of rejection episodes. The frequency of hypertension decreased from 82% within 5 months of transplantation to 0% after 4 years. The absolute GFR increased during follow-up. In conclusion, kidney transplantation results in a reduced renal function compared with that of solitary native kidneys. The reduction in renal function correlated with the number of rejection episodes and the cyclosporine load. The increase in absolute GFR during follow-up suggests a remaining capacity for growth and/or compensatory hypertrophy.

Screening for HIV in pregnant women: a study of maternal opinion.

Pregnant women residing in the metropolitan area of Stockholm were screened for HIV in a 12-month pilot programme. The acceptance rate was 99.3%. Three HIV-antibody-positive women (0.04%) were identified. The screening was followed up by a study designed to ascertain the attitudes of the women towards the test. The vast majority had a positive attitude to HIV screening out of consideration for the health of the expected child. One out of seven felt uneasy while awaiting the test result. Significantly more women among those who thought repeatedly about the test had already considered having an HIV test before pregnancy. Once the women found out that their HIV test was negative it did not affect their subsequent experience of pregnancy.

Influence of donor and recipient ages and sex on graft function after pediatric renal transplantation.

BACKGROUNDnAdult donor grafts adapt to the smaller size of the child recipient by reducing their absolute glomerular filtration rate (GFR) (ml/min). The question arises whether these grafts can increase the absolute GFR when the child recipient grows or whether a child donor graft can better increase its function. The aim of this study was to evaluate the influence of donor and recipient ages and sex on renal function.nnnMETHODSnEighty-five children and adolescents, aged 0.4-20.5 years at transplantation, were monitored annually, by GFR and effective renal plasma flow (ERPF), determined by clearances of inulin and para-aminohippuric acid. The patients received 90 grafts from donors aged 3-67 years. Follow-up time was around 5 years.nnnRESULTSnAbsolute GFR and ERPF (ml/min) of grafts from donors <20 years of age (all cadaveric donor grafts) increased during follow-up, resulting in a constant relative GFR and ERPF (ml/min/1.73 m2), whereas absolute GFR and ERPF of grafts from donors >20 years of age remained constant during follow-up, resulting in a significant decrease in relative values. Relative GFR and ERPF fell during follow-up in young recipients (<12 years of age), but remained constant in older recipients (>12 years). Donor and recipient sex did not influence renal function.nnnCONCLUSIONSnChild donor grafts seem better able to increase their function with the growth of the child recipient than adult grafts. However, the limited access to pediatric grafts and the fact that pediatric cadaveric grafts might involve technical problems in connection with grafting restrict their use.

Ten years' experience of renal transplantation in children in the cyclosporine era

Sixty renal transplantations were performed in 53 children, 0.4-16.0 years of age during the last 10 years. Fifty-five percent of the children were < or = 7 years at transplantation and 23% were < or = 2 years. Congenital nephropathies were the primary disease in 79%. Preemptive transplantation was performed in 24 first transplantations. Forty-two grafts came from living related donors and 18 came from cadaveric donors. The 1- and 5-year patient survival rates in the 0- to 7.0-year age group were 83% and 83%, respectively, and in the 7.1- to 16.0-year age group, 100% and 93%. The 1- and 5-year graft survival rates were 77% and 77% and 90% and 74% in the two groups, respectively. In children < or = 2 years old at transplantation, the 1- and 5-year patient and graft survival rates were the same, 86% and 86% in living related donors recipients, whereas they were 40% and 40% in cadaveric donors recipients. Six patients died, 3 with functioning grafts. An additional 7 grafts were lost in 6 patients, all of whom were subsequently retransplanted. The median height SD scores at transplantation was -2.98 SD in children with congenital diseases and -0.48 SD in children with acquired diseases. The median height SD scores of the 22 children followed for 3 years after transplantation was -1.06 SD. It is concluded that the survival rates obtained are satisfactory, despite the fact that the majority of the children were transplanted at a comparatively young age because of a high frequency of congenital renal disorders.

Prognosis of children admitted to institutional care during infancy

The present study has investigated the prognosis of infants admitted to institutional care. The follow-up was made after five and ten years. Three groups of children were studied: those who were in adoptive homes, foster homes and biological homes, respectively, at the time of the investigation. Approximately 50% of the total population was treated in hospital after the neonatal period. More children in foster and biological homes were hospitalized because of trauma. At 4 years of age the psychomotor development was considered normal in 77% of the adopted children compared to approximately 55% in the other two groups. Furthermore, the children in foster and biological homes demonstrated a higher rate of psychological or behavioral disturbances. The children who were in foster homes had experienced more separations and 39% of them had been subjected to 6 or more placements. The experiences of institutional care per se in infancy do not predispose the child to health and behavioral problems. The determining factor for optimal development seems to be permanency of care and parenting capability.

Clinical Course and Renal Function in Minimal Change Nephrotic Syndrome

Thirteen unselected children with the minimal change nephrotic syndrome were followed for 11 months‐7.5 years, during which time 32 renal function tests were performed. Glomerular filtration rate (GFR) was determined as clearance of inulin using a standard clearance technique. The children had between zero and 34 relapses and three developed steroid resistance. Three patients had severe but reversible complications related to the corticosteroid therapy. Chlorambucil was given to four patients, of whom three with steroid resistance had lasting remissions, whereas one patient with frequent relapses had only transient improvement. The GFR was decreased at the first episode in six patients, whose clinical course did not differ from that of the others. None had a decreased GFR later in the course of the disease. It is concluded that reduced GFR at the onset of the minimal change nephrotic syndrome is reversible and does not imply an unfavourable outcome.

Pregnancy in HIV-infected women Counseling and care - 12 years' experiences and results

BACKGROUNDnA specialized antenatal care unit was set up for counseling and care of HIV-infected pregnant women. The team consisted of gynecologists, a midwife, a social worker and pediatricians.nnnMETHODSnThe women were referred from departments of infectious diseases, venereology or institutions for drug addicts, antenatal care units and abortion clinics, or applied themselves. Women identified in the pregnancy HIV screening program were informed primarily by the team. The women were counseled along with their partners and cared for during abortion or the antenatal period, delivery and post partum. Contraceptive services were offered and psychosocial support was given.nnnRESULTSnBetween April 1985 and March 1997, 95 HIV-infected women with 122 pregnancies attended. Twenty-one per cent were or had been drug users, 2% had been infected by transfused blood and 77% were classified as having been sexually infected, two thirds of whom were Africans. The mean age was 27.8 years. In 54 of 93 pregnancies (58%) in which the woman could make an informed decision, she elected abortion -- in 37 cases for HIV related reasons. Significantly more women with an uninfected steady partner, compared to women without a steady partner, chose to continue the pregnancy, as did women in a relatively stable social situation. Of the partners, 68 were HIV-negative, 36 HIV-positive and 18 not tested. No severe HIV-related complications occurred during pregnancy. Seven of 40 (18%) children with a known infection status were infected. During the course of follow-up, nine mothers, two fathers and three children have died. Seventeen children were at risk of being orphaned, and another five were placed in foster care.nnnCONCLUSIONnAlthough it is possible to reduce mother-to-infant transmission by zidovudine therapy, the negative consequences of HIV and childbearing are still substantial. Therefore HIV screening during pregnancy and pre-pregnancy counseling are important issues for the health care system.

Renal function and albumin excretion during exercise in children during remission of the minimal change nephrotic syndrome.

ABSTRACT. Six patients with the minimal change nephrotic syndrome in remission and seven healthy controls were investigated with regard to renal haemodynamics and albumin excretion before, during and after exercise. The glomerular filtration rate and effective renal plasma flow were determined by a standard clearance method, employing continuous infusion of inulin and para‐aminohippuric acid. Microalbuminuria was measured by an immunoturbidimetric method. The work load was standardized at 70% of the maximal working capacity and was applied for 20 min. During exercise there was a significant fall in the glomerular filtration rate and effective renal plasma flow and a significant rise in the filtration fraction. The pattern of renal haemodynamic changes did not differ between the groups. Nor was there any statistically significant difference in urinary albumin excretion, although the exercise‐induced increase in albumin excretion of the controls did not reach statistical significance. It is concluded that the renal haemodynamics and urinary albumin excretion of children having long remissions of the minimal change nephrotic syndrome are normal at rest as well as during and after a submaximal exercise test.