Ramzi Ben-Youssef

Comparison of outcomes with low-dose anti-thymocyte globulin, basiliximab or no induction therapy in pediatric kidney transplant recipients: a retrospective study.

Abstract: It is unclear which induction therapy yields the best outcomes in pediatric kidney transplantation. Retrospective data of 88 children receiving a renal allograft between November 1996 and October 2003 were analyzed. Patients received ATGI (n = 12), BI (n = 29), or NAI (n = 47). The mean ATG dose was 5.1 ± 2.1 mg/kg. At 12 months, graft survival rates were 91.7%, 100%, and 97.9% for ATGI, BI, and NAI groups, respectively. Acute rejection rates at 12 months were 0 (ATGI), 20.6% (BI), and 10.7% (NAI). The mean GFR for ATGI (42.4 ± 25.9 mL/min) was lower than for BI (78.3 ± 27.2 mL/min), and NAI (66 ± 28.3 mL/min) at 12 months (p < 0.05). One ATGI patient developed CMV pneumonia but none developed post‐transplant lymphoproliferative disorder. Although there was no renal allograft survival benefit with either ATGI or BI, relative to NAI, the absence of acute rejection and equivalent rates of viral infections in the higher‐risk ATGI recipient group suggests that the treatment strategy is promising. A large prospective study is needed to better define the role of ATGI in pediatric kidney transplantation.

The impact of intercurrent EBV infection on ATP levels in CD4+ T cells of pediatric kidney transplant recipients

Abstract:  ImmuKnow® measures ATP (ng/mL) in PHA‐activated CD4+ T cells from patient’s whole blood. According to published reports, median ImmuKnow® is 258 ng/mL in stable pediatric kidney transplant (PKT) recipients ≥12 yr, and 165 ng/mL in those <12 yr. However, data on the effect of infection or AR on ImmuKnow® are scarce. We studied the effect of Epstein‐Barr virus (EBV) viremia on ImmuKnow® in PKT with GD. Twenty‐eight PKT with GD were reviewed. Group 1 has 19 PKT ≥12 yr, and group 2 has nine PKT <12 yr. Mean follow‐up was 19.4 ± 12 months. All ImmuKnow® values discussed in this study were measured during GD ± fever. None had ImmuKnow® pretransplant. EBV DNA was isolated from patient blood by real‐time PCR. Group 1 has eight boys and 11 girls (mean age = 16.6 ± 2.4 yr). Group 2 has two boys and seven girls (mean age = 6 ± 3.1 yr). Median ImmuKnow® was 292 ng/mL in group 1, and 370 ng/mL in group 2. Nine children developed EBV viremia: two in group1 (median ImmuKnow® = 273 ng/mL), and seven in group 2 (median ImmuKnow® = 475 ng/mL). Overall mean ImmuKnow® in the nine EBV viremic patients was higher than that in the 19 non‐viremic ones (422 ± 176 ng/mL, and 302 ± 113 ng/mL, respectively, unequal variance t‐test, p = 0.08). Eight children developed AR (all in G1, median ImmuKnow® = 272 ng/mL). In group 1, one patient developed concurrent EBV viremia and rejection, while another patient developed EBV viremia six months following a rejection episode. In group 2, none developed simultaneous AR, CMV, or BK virus infection with EBV viremia. None developed post‐transplant lymphoproliferative disease. In summary, EBV viremia was paradoxically associated with high ImmuKnow® in PKT <12 yr. This suggests strong co‐stimulation of PHA‐activated CD4+ T cells by EBV‐transformed B cells.

Morbidity of 200 Consecutive Cases of Hand-Assisted Laparoscopic Living Donor Nephrectomies: A Single-Center Experience

Background. Recipients of laparoscopically procured kidneys have been reported to have delayed graft function, a slower creatinine nadir, and potential significant complications. As the technique has evolved laparoscopic donor nephrectomy technique is becoming the gold standard for living donation. Study Design. We retrospectively reviewed the data of the first 200 hand-assisted laparoscopic living donor nephrectomies performed between January 2003 and February 2009. The initial 41 donors and their recipients (Group 1) were compared to the next 159 donors and their recipients (Group 2). The estimated blood loss, serum creatinine at discharge and 6 months, and the incidence of delayed graft function and perioperative complications were analyzed. Results. The median donor serum creatinine at discharge and 6 months was 1.2 mg/dL in each group. None of the laparoscopic procedures required conversion to an open procedure, and none of the donors required perioperative blood transfusion. The median recipient serum creatinine at 6 months after transplant was 1.2 mg/dL for each group. No ischemic ureteral complications related to the laparoscopic technique were seen. Conclusions. HALDN with meticulous surgical technique allows kidney procurement with very low morbidity and no mortality. This improved safety and decreased invasiveness from laparoscopic approach may further decrease morbidity of the procedure and increase organ donation.

Simultaneous pediatric kidney transplantation and ureterocystoplasty in a 20-month-old boy

Abstract:  Kidney transplantation (KT) in children with end‐stage renal disease and an abnormal bladder poses a complex management challenge. Ureterocystoplasty (UC) has been previously reported in older children with non‐compliant bladders, but the timing and technique of repair are controversial. This case reports the youngest patient, a 20‐month‐old boy to undergo successful single‐stage UC and living‐related KT. UC was performed because of a fibrotic, non‐compliant bladder. A temporary vesicostomy was placed to provide adequate drainage in the presence of urethral stenosis. The patient developed a single episode of pyelonephritis within the first six months post‐operatively, but there were no other urologic complications. At 13 months, the renal function is excellent with a mean glomerular filtration rate of 100 mL/min/1.73 m2 and no clinical evidence of rejection. This case demonstrates that simultaneous UC and KT can be safely performed even in infants with non‐compliant bladders and renal failure.

Poster 429: Transverse Myelitis With Atypical Findings: A Case Report

Disclosures: P. Q. Tien, None. Patients or Programs: 48-year-old woman diagnosed with transverse myelitis (TM). Program Description: This patient gradually developed bilateral leg weakness over 2 weeks. At presentation, she had bowel and bladder incontinence with abdominal pain. On examination, she had sensory impairment below the level of T4, intact sacral segments S4-S5, bowel and bladder incontinence. She also had features of acute pyelonephritis and was treated with IV antibiotics. Initial MRI of the spine showed enlargement of the spinal cord at C5-T4, and brain MRI showed left optic neuritis but no other features of multiple sclerosis. Lumbar puncture had no oligoclonal bands. She was treated with high-dose steroid and azathioprine once the diagnosis of TM was established. Setting: Acute rehabilitation hospital. Results: She was transferred to the acute inpatient rehabilitation program. Steroid was continued throughout her rehabilitation course. Her progress showed steady functional gains of activities of daily living and wheelchair mobility. She accomplished self-intermittent catheterization and managed bowel program daily with manual evacuation. Follow-up MRI of the spine showed resolution of the TM and no evidence of cord swelling. Her immunological profile revealed positive autoantibodies: ANA, SS-A, and SS-B suggestive of connective tissue disorder. Discussion: TM is a rare inflammatory syndrome affecting the spinal cord. Approximately 4-8 new cases per million per year that affects people of all ages with a bimodal distribution between the ages of 10-19 and 30-39. TM can be idiopathic or associated with a specific disease such as antiphospholipid antibody syndrome, Sjogren syndrome, or systemic lupus erythematous. Most TM cases are monophasic, while up to 20% will have recurrent episodes. There are data suggesting an association between anti-Ro antibodies and recurrent TM. Conclusions: TM is a syndrome without a clear single etiology. One theory is that TM is an autoimmune disorder affecting the spinal cord involving interleukin-6. Patients presenting with TM should be thoroughly investigated for the presence of systemic inflammatory disease. Laboratory studies should include complete blood count and smear, autoantibodies (eg, ANA, SS-A), and complement level.