Doaa M. Salah

Surgical complications and graft function following live-donor extraperitoneal renal transplantation in children 20 kg or less

OBJECTIVES To evaluate the effect of patient, surgical, and medical factors on surgical complications and graft function following renal transplantation (Tx) in children weighing ≤ 20 kg, because the number of this challenging group of children is increasing. PATIENTS AND METHODS Between June 2009 and October 2013, 26 patients received living donor renal allotransplant using the extraperitoneal approach (EPA). The immunosuppression regimen was composed of prednisolone, mycophenolate mofetil, and ciclosporin or tacrolimus. RESULTS The mean weight was 16.46 ± 2.61 kg. Mean cold ischemia time was 53.85 ± 12.35 min. The graft survival rate (GSR) and patient survival rate (PSR) were 96% at 3 years. Acute rejection episodes (AREs) occurred in eight patients (30%). Postoperative surgical complications were ureteral leakage (3), vesicoureteric reflux (2), and renal vein thrombosis (2) (with one graft nephrectomy). Mean follow-up was 37.5 ± 7.4 months. CONCLUSION Excellent PSR and GSR can be achieved in low weight (<20 kg) recipients. Even in very low weight patients, the EPA was used. No cases were reported with primary graft non-function due to use of living donors, increasing pre-Tx body weight to at least 10 kg and maintaining adequate filling pressure before graft reperfusion. The presence of related donors and use of induction therapy and tacrolimus decreased the rate of ARE while the presence of pre-Tx lower urinary tract surgical interventions increased the rate of ureteric complications, but this was statistically insignificant.

Outcomes of living donor renal transplantation in children with lower urinary tract dysfunction: a comparative retrospective study.

To compare outcomes of renal transplantation (RTx) in children with end‐stage renal disease (ESRD) resulting from lower urinary tract dysfunction (LUTD) vs other causes.

Risk factors for urological complications following living donor renal transplantation in children

The aim of this study was to detect possible risk factors for UC and UTI following pediatric renal Tx and effect of these complications on outcome. One hundred and eight children who underwent living donor Tx between 2009 and 2015 were retrospectively included. Extraperitoneal approach was used with stented tunneled extravesical procedure. Mean recipient age was 9.89 ± 3.46 years while mean weight was 25.22 ± 10.43 kg. Seventy‐three (67.6%) recipients were boys while 92 (85.2%) were related to donors. Urological causes of ESRD were present in 33 (30.6%) recipients (14 [13%] posterior urethral valve, 16 [14.8%] VUR, and 3 [2.8%] neurogenic bladder). Augmentation ileocystoplasty was performed in 9 (8.3%) patients. Mean follow‐up was 39.3 ± 17.33 months. UC were detected in 10 (9.3%) children (leakage 4 [3.7%], obstruction 3 [2.8%], and VUR 3 [2.8%]) while UTIs were reported in 40 (37%) children. After logistic regression analysis, UC were significantly higher in children with cystoplasty (44.4% vs 6.1%; P = .001). UTIs were significantly higher in girls (51.4% vs 30.1%; P = .001) and in children with urological causes of ESRD (51.5% vs 30.7%; P = .049). UC and UTI were not significantly associated with increased graft loss or mortality. UC were significantly higher in children with cystoplasty while UTIs were significantly higher in girls and children with urological causes of ESRD. Presence of UC did not affect the rate of graft loss or mortality due to its early detection and proper management.

Klotho G-395A gene polymorphism: impact on progression of end-stage renal disease and development of cardiovascular complications in children on dialysis

BackgroundKlotho G-395-A gene polymorphism may impact children with end-stage renal disease (ESRD). We investigated the relevance of Klotho G-395-A on ESRD development and progression, and its relationship with evolution of cardiovascular complications in pediatric dialysis patients.MethodsFifty-five children with chronic kidney disease (CKD) and seventy healthy children were genotyped for Klotho G-395A.ResultsIncidence of GA/AA genotypes and A allele were higher in ESRD patients compared with controls (54.5 vs. 7.1%, P < 0.001; 30.9 vs. 13.6%, P = 0.001, respectively). Also, children with GA/AA genotypes were 15.6 times more likely to develop ESRD than with GG genotype (95% CI 5.4–44.7, P < 0.001). A allele carriers have 2.8 times higher risk of developing ESRD than those with G allele (95% CI 1.5–5.35, P = 0.001). Also, the A allele could be considered a predictor of cardiovascular disease (CVD), as carriers have 161 times higher risk of cardiovascular complications than non-carriers (95% CI 21–1233, P < 0.001). All ESRD patients with CVD presented with left ventricular hypertrophy (LVH) and the frequency of A allele was significantly higher among ESRD children with LVH, whereas G allele frequency was significantly higher among ESRD children without LVH.ConclusionsThe A allele of the G-395A Klotho gene polymorphism shows a significantly higher frequency among children with CKD and those with CVD and LVH. This mutant allele could be used as a risk marker for the development of ESRD as well as a predictor of CVD in these children.

Serum Soluble Interleukin 2 Receptor Level as a Marker of Acute Rejection in Pediatric Kidney Transplant Recipients

Background: Despite advances in immunosuppression, acute allograft rejection remains one of the key factors affecting patient and graft survival in pediatric kidney transplantation. The aim of the study is to evaluate the role of serum soluble IL2 receptor (sIL2R) level as a noninvasive assessment parameter of acute rejection (AR). Method: Serum sIL2R level was measured (using enzyme-linked immune-sorbent assay technique) in 60 pediatric kidney transplant recipients (30 recipients with AR and 30 transplant recipients with stable graft function). Results: The mean values of sIL2R level in patients experiencing AR (14.8 ± 6.54) ng/mL were significantly higher than that in patients with stable graft functions (6.44 ±1.95) ng/mL (p = 0.0001). In addition; patients with AR proved by graft biopsy had their mean values of sIL2R level (16.19 ± 7.48) ng/mL significantly higher than that of other recipients in the study population (p = 0.032). Conclusion: Serum sIL2R level may serve as a noninvasive diagnostic indicator in pediatric kidney transplant recipients experiencing AR.

Visfatin versus Flow-Mediated Dilatation as a Marker of Endothelial Dysfunction in Pediatric Renal Transplant Recipients

BACKGROUND: Renal transplantation (RTx) is the treatment of choice for paediatric end-stage renal disease (ESRD). A major cause of morbidity and mortality after RTx is cardiovascular disease. Independent predictors of cardiovascular events were shown to constitute an endothelial dysfunction (ED). This study aims to evaluate Visfatin serum level in comparison to brachial artery flow-mediated dilatation (FMD) as a marker of endothelial dysfunction in paediatric RTx recipients. METHODS: Visfatin serum level has been evaluated in 30 patients on regular hemodialysis (HD), 36 patients post-RTx and 30 controls as a measure for ED, and has been compared to brachial artery FMD. RESULTS: Visfatin level in transplant recipients was significantly lower than the hemodialysis group as well as FMD was better in transplant recipients. In spite of marked improvement of FMD and marked reduction of visfatin in post-RTx no direct statistical correlation was found between serum Visfatin level and flow-mediated dilatation. CONCLUSION: Pediatric RTx recipients show lower serum Visfatin level and better FMD than those on regular hemodialysis, reflecting less endothelial dysfunction (ED) and less cardiovascular risk. FMD in kidney transplant recipients tends to be less than normal subjects while visfatin level of the same group is similar to controls. Pediatric RTx appears to have a positive impact on the growth development of children with ESRD.

Renal ultrasound and Doppler parameters as markers of renal function and histopathological damage in children with CKD: Renal Doppler parameters as markers of renal function and histopathological damage

Doppler ultrasonography can be used to assess the progression of vascular (arterial sclerosis) and parenchymal (glomerular sclerosis and crescents) renal damage. The aim of this study was to evaluate the significance of some sonographic and Doppler parameters as non‐invasive markers of glomerular filtration rate (GFR) and renal histopathological damage in children.

Localized Renal Graft Aspergillosis in a Child after Kidney Transplantation:Case Report and Review of Literature

Pediatric kidney transplant recipients are at special risk of infection with opportunistic fungi, such as Aspergillus spp., which is uncommon but can be fatal. We report a 16 year male renal transplant recipient, who suffered from acute graft dysfunction five months post transplantation. Imaging of the graft revealed sever back pressure and increased echogenic contents with a distinct pelviureteric ill-defined small mass. Percutaneous nephrostomy was done to relieve the obstruction and microscopic examination and fungal culture of the nephrostomy urine were done which revealed the organism (Aspergillus fumigatus). He developed initial improvement subsequent to relief of obstruction; graft function partially regained and received voriconazole for six months. His radiological finding gradually disappeared and graft function resumed to an acceptable level 4 weeks later. As of September 2016 (6 years later), despite the graft injuries, graft function had been conserved. This case serves to reinforce the concept that high index of suspicion of such infection and repeated examination with specific culture media are mandatory for transplant recipients particularly being potentially treatable and if neglected might be fatal infection.

Endothelial Dysfunction in Pediatric Renal Transplant Recipients

Background: Cardiovascular disease is a major cause of morbidity and mortality after kidney transplantation. Endothelial dysfunction was shown to constitute an independent predictor of cardiovascular events. This study aimed at detecting endothelial dysfunction in pediatric renal transplant recipients. Methods: This was a prospective cohort study of 36 pediatric renal transplant recipients during their first posttransplantation year (transplantation group), 30 patients with end stage renal disease (ESRD) on regular hemodialysis (HD) (dialysis group) and 30 normal subjects (control group). Doppler ultrasound was performed for assessment carotid artery intima-media thickness (IMT) and brachial artery flow-mediated dilatation (FMD). Results: Carotid artery IMT measurements in the transplantation group (mean ± SD = 0.43 ± 0.08 mm) were significantly (p=0.001) lower than the dialysis group (0.5 ± 0.1mm) and insignificantly higher than the control group (0.41 ± 0.07mm). FMD was significantly impaired in the dialysis group. The median (IQR) FMD of the transplantation group, 8.7% (2.5-20.4), tended to be higher than that of the dialysis group, 4.4% (2.6-10.8) and lower than that of normal controls, 14% (8.5-19.7); p=0.055 and 0.12 respectively. Conclusion: Pediatric renal transplant recipients tend to show evidence of endothelial dysfunction at an apparently lesser extent than those on regular hemodialysis.Children and young adults, who suffer from cancer, receive gonadotoxic therapy, which destroys their fertile abilities after survival. Ovarian cryopreservation and transplantation provide the promising solution to this problem, where the ovary can be removed before the gonadotoxic therapy and reimplanted after patients survival, where the ovary is to be cryopreserved during the period of the therapy. However, cryopreservation of the whole ovary is still facing great obstacles, namely the ischemic reperfusion injury and the defective cryopreservation related to the defective ability to universally deliver the cryopreservation/warming solutions through the ovarian vascular bed. Meanwhile, the currently applied technique of ovarian tissue cryopreservation provides limited follicular recovery because many follicles are lost until the development of revascularization post-transplantation. To solve the problems, an innovative system has been developed to insure immediate and universal delivery of the cryopreservation/warming solutions to the graft, in addition to keeping the graft under continuous perfusion before and after cryopreservation, minimizing any chance for microthrombi formation or ischemia-reperfusion. This innovative system can be applied in the following surgical and clinical interventions: 1) Allogeneic ovarian transplantation; 2) Preservation of fertility after systemic chemotherapy or bone marrow transplantation in young females, where the ovaries could be removed before the therapy and exposed to the adequate cryopreservation provided by the system till re-implantation after the patients survival; 3) The system is also suitable for the corresponding applications on the testicles.