Ellis, D

Gilboa, N

Hakala, TR

Hopp, L

Irish, W

Jordan, ML

Mitchell, S

Scantlebury, VP

Shapiro, R

Simmons, RL

Starzi, TE

Tzakis, A

Vivas, C

PubMed

Starzl, TE

Name not available

Pediatric kidney transplantation at the University of Pittsburgh

D-Scholarship@Pitt

Pediatric Kidney Transplantation at the University of Pittsburgh V.P. Scantlebury, R. Shapiro, A. Tzakis, M.L. Jordan, C. Vivas, D. Ellis, N. Gilboa, L. Hopp, W. Irish, S. Mitchell, T.R. Hakala, R.L. Simmons, and T.E. Starzl THE RESULTS of pediatric kidney transplantation have varied over the years, with .outcomes ranging from fair to excellent. I The majority of centers performing pediatric kidney transplantation in the United States have shown patient and graft survival rates of 92% to 96% and 74% to 89%, respectively.2 We describe here our own results with cadaveric and living related pediatric renal transplant recipients over a 5·year period. MATERIALS Sixty·three consecutive kidney transplants were performed in 62 patients at Children's Hospital of Pittsburgh between Jan I. 1988. and Jan I. 1993 (Table I). Children with previous or simultaneous liver transplants were excluded. Thirty·five (56%) patients had living donors. while 28 (44%) received cadaveric kidneys. The mean age was 9.8 :!: 4.8 years (range, 0.8 to 17.4 years). Primary transplants were performed in 47 patients (75%). while 16 (25%) underwent retransplantatton. Only 9 patients (14%) had panel· reactive antibody levels of >40%. Thirty-three patients (52%) received cyclosporine as their main Immunosuppression. while 30 patients (48%) received FK 506 (Table I). Living related transplants performed with cyclosporine (20 patients) initially received induction Minnesota antiJymphoblast globulin (MALG), 20 mglkgld for 2 weeks along with azathioprine and prednisone. Cyclesporine was introduced at 5 mglkg twice a day starting at day 7. For cadaveric transplants performed with cyclosporine (\3 patients), 4 patients received induction OKT 3 at 5 mgld for 2 weeks and I patient received induction MALG. Azathiopnne was also used in II patients on cyclosporine ther· apy. Thirty patients (15 living donors and 15 cadaveric) received FK 506 and this was gIven at 0.1 mglkgld as a continuous infusion foHowed by a 0.30 mglkgld oral dose in two divided doses. Twelve patients (40%) receIved azathioprine Initially with FK 506, and aU patients received steroids. RESULTS The median follow-up was 38 months (range, 6 to 67 months). The 1- and 4-year actuarial patient survival rates Table 1. University of Pittsburgh Pediatric Kidney Transplantation (Jan 1, 1988, to Jan 1, 1993): Number 01 patients Number 01 grafts Living donor CadaveriC donor Mean reaplent age Primary transplants Retransplantation Recipient Characteristics Panel·reactive antibodies >40% Cyclosponne FK 506 62 63 35 (56%) 28 (44%) 9.8 :!: 4.8 years 47 (75%) 16(25%) 9 (14"10) 33 (52%) 30 (48%) Table 2. University of Pittsburgh Pediatric Kidney Transplantation (Jan 1,1988, to Jan 1, 1993): Survival Rates Patient Survival Graft Survival 1 Year 4 Years 1 Year 4 Years Overall 100% 98% 98% 86% Cadaveric donor 100% 96% 96% 76% Living related donor 100% 100% 100% 95% Cyclosporine 100% 97% 100% 85% FK506 100% 100'Yo· 96% 89%· ·Three years rather than 4. were 100% and 98%, respectively. The 1- and 4-year actuarial graft survival rates were 98% and 86% (Table 2). When cadaveric and living related patients were separated, patient survival rates were not significantly different at 1 and 4 years (100% and 96% vs 100% and 100%, respec-tively). Graft survival was shown to be a bit better for living related transplant recipients at I year and at 4 years when compared to cadaveric transplant recipients. Patient survival was essentially the same for cyclosporine-treated patients and FK 506-treated patients. There was also little difference in graft survival at 1 and 4 years with cyclospo-rine (100% and 85%) vs 1 and 3 years with FK 506 (96% and 89%). One patient died, 1.5 years after his second cadaveric transplant, with a functioning graft. This patient had been treated with cyclosporine and died of cardiac abnormali-ties. Five other patients lost their grafts: 2 to noncompli-ance at 1.5 and 3 years after transplantation (with cYclo-sporine), and 3 to recurrent disease (hemolytic uremic syndrome, focal segmental glomerulosclerosis, and mem-brane proliferative glomerulonephritis) at 1 week and 3.5 and 2.5 years after their transplants. Rejection was seen in 46% of the patients. Eighteen cadaveric transplant patients experienced rejection (64%), while 11 (31%) living related transplant patients rejected their grafts (P = .01). Cyc!osporine-treated patients had From the Department of Surgery, Transplantation Institute, Division of Urologic Surgery, University of Pittsburgh School of Medicine, and the Veterans Administration Medical Center, Pitts-burgh, Pennsylvania. Supported by National Institutes of Health Grant OK 29961 and by the Veterans Administration. Address reprint requests to Velma P. Scantlebury, MD. Depart-ment 01 Surgery, Transplantation Institute, University of Pittsburg', 3601 Fifth Ave, 5C Falk Clinic, Pittsburgh, PA 15213. © 1994 by Appleton & Lange 0041-13451941$3.001 + 0 46 Transplantation Proceedings, Vol 26, No 1 (February), 1994: pp 46-47 PEDIATRIC KIDNEY TRANSPlANTS 39% rejection vs 53% for those patients who received FK 506 (P = .237). Eighteen (60%) patients treated with FK 506 had pred-nisone discontinued. No patient on cyclosporine was suc-cessfully taken off prednisone long term. Six patients (10%) developed cytomegalovirus (CMV) infections (3 cadaveric and 3 living related patients). Five of 6 (83%) patients received FK 506 (P = .07), and nearly all patients (5 of 6) were at high risk for CMV infection (seropositive kidneys to seronegative recipients). Posttransplant lymphoproliferative disease was seen in 6 patients (10%), 3 cadaveric and 3 living related. One patient had been treated with cyclosporine (3%), and 5 patients (17%) received FK 506 immunosuppression (P = .07). All patients were treated with cessation or diminution of their immunosuppression, along with intravenous acy-clovir or ganciclovir. No grafts were lost. and all patients recovered. Four patients were switched from cyclosporine to FK 506: 1 for rejection and 3 for proteinuria. The patient with rejection was successfully rescued and 1 patient with proteinuria had significant improvement in protein excre-tion with FK 506. The remaining 2 patients lost their grafts to recurrent disease. DISCUSSION Pediatric patient survival after kidney transplantation did not vary significantly regardless of donor source or type of immunosuppression. Results of graft survival at 4 years for cadaveric transplants, although above average, were not as good as for those patients who received a kidney from a living related donor (76% vs 95%). Likewise, more episodes of rejection were seen in the cadaveric patients 47 when compared to the living related patients. Although FK 506-treated patients had slightly more rejection episodes, 60% of this group had the ability to discontinue pred-nisone. For pediatric recipients. this allows for long-term growth and development after transplantation, and there are some preliminary data from this center suggesting that there is improvement in growth for those patients treated only with FK 506 in the long term.) The increased incidence of CMV infection and post-transplant lymphoproliferative disease seen with patients treated with FK 506 is significant when compared to that in the cyclosporine-treated patients. Fortunately, these com-plications all resolved without any significant sequelae or graft losses. These findings may represent a learning curve with the use of FK 506 in renal transplant recipients, as described in our own experience with adult patients.4 Overall, our data support the improved results of pedi-atric kidney transplants and suggest that newer agents such as FK 506, with the ability to discontinue the use. of steroids after transplantation can be very useful, especially for this population of patients. Further work to decrease the long-term side effects of chronic immunosuppression should still be a primary focus to optimize the long-term outcome of pediatric kidney transplantation. REFERENCES 1. Almond PSt Matas AJ. Gillingham K. et al: Transplantation 53:46.1992 2. Alexander SR. Arbus GS. Butt KMH. et al: Pediatr Nephro1 4:542,1990 3. Ellis D. Shapiro R. Gilboa N. et al: Pediatr Nephrol (in press) 4. Shapiro R. Jordan M. Scant1ebury V. et al: Transplant Proc 25:669. 1993 

http://d-scholarship.pitt.edu/5040/1/31735062125665.pdf

Pediatric kidney transplantation at the University of Pittsburgh

Abstract

Similar works

Full text

Available Versions

Name not available

D-Scholarship@Pitt

Name not available