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Biomedical subjects

A Tejani

Publications and source records attributed to A Tejani.

At least 55 records · Page 3Linked to original sources
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↗
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

Clinical correlates of chronic rejection in pediatric renal transplantation. A report of the North American Pediatric Renal Transplant Cooperative Study.

A total of 1699 patients with living donor transplants and 1795 patients with cadaver donor transplants entered between January 1987 and November 1994 in the North American Pediatric Renal Transplant Cooperative Study registry form the cohort for this report. Failure from chronic rejection occurred in 76 (4.5%) of living donor transplants and 149 (8.3%) of cadaver transplants. Chronic rejection is the leading cause of graft failure, with 27% of living donor and 26.7% of cadaver donor graft failures attributed to chronic rejection. Univariate and multivariate analyses of various risk factors revealed acute rejection (relative risk [RR]=3.1, P<0.001) and greater than two acute rejections (RR=4.3, P<0.001)to be the most common correlates of chronic rejection. Additionally, late initial acute rejection (>365 days; RR=2.3, P<0.001) was also correlated. Cadaver donor source (RR=1.6, P=0.001) and African-American race (RR=1.6, P<0.003) were weaker but significant risk factors. An analysis of cyclosporine dosing revealed tht a dose of <5mg/kg/day at day 30 was also a risk factor (RR=1.5, P=0.027). Our study concludes that acute rejection is the single most critical element in the genesis of chronic rejection. Thus, measures to prevent the first episode of acute rejection could ameliorate the incidence of chronic rejection.

Adolescent↗
PubMed1996

The 1994 annual report of the North American Pediatric Renal Transplant Cooperative Study.

The North American Pediatric Renal Transplant Cooperative Study (NAPRTCS) is a research effort that was organized and initiated in 1987. The following manuscript is the 1994 NAPRTCS annual report which has summarized data that has been voluntarily contributed by 83 centers. The report includes data on 3,183 patients who have undergone a total of 3,445 renal transplants between 1 January 1987 and 18 February 1994 when the data set was closed. The report also contains data on 1,611 independent courses of dialysis which were initiated between 1 January 1992 and 18 February 1994. This report is meant to update the previous NAPRTCS annual reports as well as demonstrate how the NAPRTCS database has changed clinical practice since its inception. There have been 855 graft failures among the 3,438 transplants. Due to the maturing of the database, chronic rejection now accounts for 34% of graft failures which have occurred over the last year. Graft failure was increased in recipients if the recipients were < 2 years of age, of the black race, or had received five or more prior transfusions. Early treatment with antithymocyte globulin/antilymphocyte globulin/OKT3 was associated with increased graft survival. Catch-up growth post transplant was only seen in the youngest patients (< 6 years of age). Those patients > 6 years did not have catch-up growth post transplant. Overall graft survival has improved markedly since the inception of this study. The dialysis database is just maturing and the data confirm that growth on dialysis continues to be very poor. The 1994 annual report of NAPRTCS extends previous findings of this valuable database. It is gratifying to know that early findings of NAPRTCS have led to changes in therapy which have led to improvement in the care of these very special children.

Adolescent↗
PubMed1996

Hyperlipidemia in children: the role of uremia, steroids and cyclosporine therapy.

At present, there are very few studies that look at the effect of uremia, prednisone and cyclosporine therapy on the lipid profiles of children. This effect is important because of the potential association of hyperlipidemia and increased risk of cardiovascular morbidity and mortality and glomerulosclerosis. We measured fasting lipid profiles in 73 children. There were 21 controls, 18 patients treated with cyclosporine and prednisone, 9 patients treated with cyclosporine alone and 25 dialysis patients. Lipoprotein (a) levels were measured using direct binding 'sandwich' ELISA. Uremic children had higher levels of triglycerides and very-low-density lipoprotein as compared with the control group. Children receiving combination of cyclosporine and prednisone also had higher total cholesterol, triglycerides, low-density lipoprotein, very-low-density lipoprotein as compared to the control group. However, children receiving cyclosporine monotherapy had lipid profiles similar to the control group. Patients receiving cyclosporine and prednisone had higher total cholesterol, high-density lipoprotein and low-density lipoprotein as compared with the dialysis group. Evaluating lipoprotein (a) levels, children on cyclosporine monotherapy had lower lipoprotein (a) levels as compared with children on dialysis and those receiving both combination therapy. The total cholesterol/high-density lipoprotein-cholesterol ratio (TC/HDL) was similar among the study groups. In summary, uremic children and children receiving steroids with cyclosporine have elevated lipid levels. However, the increased risk for atherosclerosis is not evident because of similar levels of lipoprotein (a) and TC/HDL ratios among the study groups.

Adolescent↗
PubMed1996

A randomized double-blind placebo-controlled trial of cyclosporine in steroid-resistant idiopathic focal segmental glomerulosclerosis in children.

There is no generally accepted treatment for primary focal segmental glomerulosclerosis (FSGS). Steroids alone and steroids plus cyclophosphamide can be expected to induce a remission of the proteinuria in only 27% of patients. Probably the majority of FSGS patients will reach ESRD over the extended course of their disease. In addition to the work presented in this study, there have been many reports of the potential effectiveness of cyclosporine (CSA) on reducing the proteinuria of FSGS. This study was undertaken to test the efficacy and safety of a 6-month course of CSA in a double-blinded, prospectively randomized, placebo-controlled trial in children with corticosteroid-resistant FSGS. The potential inhibitory effect of hypercholesterolemia on the proteinuria-reducing actions of CSA was also assessed. Twenty-five patients with FSGS were randomized to receive either placebo or CSA for 6 months. Twelve of the 12 patients that received CSA experienced a diminution of their proteinuria as opposed to only two of the 12 placebo-treated patients. Proteinuria was significantly reduced from 151.7 +/- 162.4 mg/kg per 24 h at Week 0 to 36.9 +/- 42.3 at the end of the study in the group that received CSA (P < 0.05). There was no significant change in the proteinuria of the patients in the placebo group. A significant correlation between the percentage change of proteinuria over the 6 months of the study and the prestudy serum cholesterol levels (r = 0.79, P < 0.05) was seen in the CSA group. A partial correlation analysis controlling for the effects of serum cholesterol uncovered a significant relationship between average CSA level and proteinuria change (r = -0.76, P < 0.05). The fractional decline in GFR over the course of the study was not significantly different between the CSA and placebo-treated groups. In conclusion, CSA reduces proteinuria, increases serum albumin levels, and can be expected, therefore, to reduce the symptoms of nephrotic syndrome. Hypercholesterolemia antagonizes this effect of CSA.

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

Lupus nephritis in children: a longitudinal study of prognostic factors and therapy.

There are only a few studies in the pediatric literature that have analyzed risk factors for renal failure in childhood lupus nephritis. This study reviewed the outcome of 56 children (4 to 18 yr of age) with lupus nephritis seen at the authors' institution over a 27-yr period (1965 to 1992), in relation to risk factors and therapy. All children underwent percutaneous renal biopsy before the institution of therapy. From 1965 to 1987, treatment for Class III and IV lupus nephritis consisted of high-dose pulse methylprednisolone, 500 mg daily for 10 days, followed by oral prednisone. From 1987 to 1992, IV cyclophosphamide was given monthly for 6 months and then every 3 months for a period of 3 yr for patients with Class III and Class IV disease. Of 56 children, 42% had Class IV and 21% had Class III histology at onset. The mean follow-up period was 4 yr and ranged from 0.5 to 20.3 yr. Life-table analysis showed that the cumulative proportion of patients surviving was 82.8% at 5 yr and 67.7% at 10 yr. Renal survival was 44.4% at 5 yr and 29% at 10 yr, after the initial diagnosis of lupus nephritis was made. Age at diagnosis, race, sex, initial serum creatinine level, and the presence of proteinuria, hypertension, and DNA antibody titers were reviewed with respect to disease progression, as was the histological class at diagnosis. The effect of the different therapies was also examined. Univariate analysis revealed a significant association of progression to ESRD with an elevated serum creatinine level (P = 0.021), decreased C3 complement (P = 0.024), hypertension (P = 0.053), and histological classification of Class IV lupus nephritis (P = 0.031). Multivariate analysis demonstrated that progression to ESRD was independently associated with an initial Class IV histology (relative risk, 1.78; P < 0.003), hypertension at presentation (relative risk, 1.67; P < 0.003), and a low C3 complement level in conjuction with a high creatinine level (relative risk, 1.52; P < 0.028). Among children with lupus nephritis, those with Class IV disease, hypertension, high creatinine levels, and low C3 complement levels at the time of diagnosis are at increased risk for ESRD. Initial histological classification of lupus nephritis was the most reliable prognostic factor for disease progression. This study was unable to detect a difference in outcome for the two treatment groups.

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↗
PubMed1995

Analysis of rejection outcomes and implications--a report of the North American Pediatric Renal Transplant Cooperative Study.

For this study, we analyzed the role of rejection in graft failure in children. Rejection results were examined after 3004 pediatric renal transplants (1367 living donor, 1637 cadaver source). A total of 3453 (1298 living donor, 2155 cadaver source) rejection episodes have occurred, for rejection ratios of .95 for living donor and 1.32 for cadaver source transplants, with a constant difference of 18% points after four months, in the percentage of patients ever experiencing a rejection. Rejection results were examined by patient age (0-1 vs. 2-5 vs. 6-12 vs. > or = 13). Rejection ratios, annualized rejection frequency, time to first rejection, and mean number of rejections for patients with rejection were not elevated in the younger patients. However, for the initial rejection episode, recipients less than six years of age had significantly (P < .001) poorer outcome from the rejection episode with an increased risk of graft failure in both donor source groups. This age effect on rejection outcome is only seen with the first rejection episode and is not observed with subsequent rejection episodes.

Adolescent↗
PubMed1995

Renal transplantation and chronic dialysis in children and adolescents: the 1993 annual report of the North American Pediatric Renal Transplant Cooperative Study.

The 1993 North American Pediatric Renal Transplant Cooperative Study annual report summarizes data voluntarily contributed by 82 participating centers on 3,223 pediatric patients who received 2,819 renal transplants from January 1987 through January 1993 and 999 independent courses of dialysis from January 1992 through January 1993. In addition to updating information regarding trends and outcomes in pediatric renal transplantation presented in previous annual reports, 1st-year registry data are presented regarding current practices and trends in chronic dialysis therapy for children and adolescents in North America. Living donor graft (LDG) survival rate was 90% at 1 year, 85% at 2 years and 75% at 5 years post transplant. Cadaver graft (CG) survival rates were 76%, 71% and 62% at 1, 2 and 5 years post transplant, respectively. Overall mortality post transplantation continues to be low (CG 6.8%, LDG 4%), mortality remains high in young infants. The dialysis cohort was generally younger than the transplantation cohort. In all age groups, peritoneal dialysis was utilized in the majority of pediatric patients and the overall incidence of peritonitis was 1 episode per 8.2 patients months. External percutaneous catheters were utilized as the predominant chronic hemodialysis access in the study, and access site infections ranged from 6.9% at 1 month to 13.5% at 6 months.

Adolescent↗
PubMed1995

An analytical review of growth hormone studies in children after renal transplantation.

With steady improvement in 1- and 5-year patient and graft survivals in the last decade, rehabilitation of the child is the major focus of the transplant physician. The notion that the elimination of the uremic milieu should enable children to grow has not been born out over time, and growth retardation continues to be a serious morbidity in many children despite a well-functioning renal allograft. In children with chronic renal failure prior to renal transplantation, recombinant human growth hormone (rhGH) has been recently shown in controlled trials to improve growth. The use of rhGH in children after renal transplantation is controversial, since uncontrolled studies have questioned its safety. Acute rejection and graft loss have been reported in children after the initiation of rhGH. This study analyzes the data regarding the safety and efficacy of rhGH in children after renal transplantation as presented in seven current published reports. The demographic characteristics of the patients, the dose and duration of rhGH therapy, the "growth" rates of the patients before and after rhGH therapy, renal function before and after rhGH therapy, and other possible complications are reviewed. Based on this analysis, suggestions for future studies are made.

Child↗
PubMed1995

Do children exhibit catch-up growth post transplant: North American Pediatric Renal Transplant Cooperative Study special study.

Changes in height deficit and standard deviation score (SDS) were evaluated in 524 recipients who were growth retarded at transplantation (SDS > -2.00) and were followed for at least 2 years post transplant. At 2 years the delta SDS was 0.32 +/- 0.04 and the delta height deficit was 0.75 +/- 0.23. Therefore despite improvement in the SDS at 2 years post transplant, the change in height deficit was < 1 cm. Change in height deficit may be a better indication of "catch-up" growth following transplantation.

Adolescent↗
PubMed1995

Renal allograft survival according to primary diagnosis: a report of the North American Pediatric Renal Transplant Cooperative Study.

The data base of the North American Pediatric Renal Transplant Cooperative Study (NAPRTCS) was used to examine the effect of primary diagnosis on the outcome of renal transplantation in children. The relative risk of graft failure for eight diagnostic groups was determined, with patients with congenital and structural anomalies of the urinary tract serving as the reference group. Covariate analysis was used to control for the effects of age, race and transfusion history in recipients of living-related donor kidneys, and for age, donor age, antilymphocyte prophylaxis, prior transplantation, prior dialysis and cold ischemia time in recipients of cadaver kidneys. In recipients of living-related donor kidneys, the lowest graft failure rates were associated with the diagnoses of cystinosis, familial nephritis and hemolytic uremic syndrome (HUS), while the highest failure rates were observed in patients with a primary diagnosis of congenital nephrotic syndrome (CNS) or focal segmental glomerulosclerosis (FSGS). In cadaver allograft recipients, the lowest graft failure rates were associated with primary diagnoses of glomerulonephritis, congenital/structural disease and cystinosis, while patients with FSGS, HUS and CNS had the highest graft failure rates. This study suggests that patients with a primary diagnosis of cystinosis have superior outcomes, while the diagnoses of FSGS and CNS carry with them the highest risks of graft failure.

Canada↗
PubMed1995

Steady improvement in renal allograft survival among North American children: a five year appraisal by the North American Pediatric Renal Transplant Cooperative Study.

From 1987 through 1994, the North American Pediatric Renal Transplant Cooperative Study (NAPRTCS) has enrolled 1641 cadaver donor transplants. For this study, we have analyzed one and two year graft survival by annual cohorts for the years 1987 through 1991. For the 1987 cohort one and two year graft survival was 72% and 65%, respectively, and for the 1991 cohort it was 83% and 78%, respectively. Using a proportional hazards model, and comparing the 1987 cohort to the 1991 cohort, the relative risk for graft failure was 1.40 (P = 0.02). Analysis of practice patterns revealed the following changes which may have been associated with this improved graft survival: (1) use of T cell induction antibody, 38% in 1987 and 67% in 1991 (P < or = 0.001); (2) the increased use of cyclosporine (CsA) post-transplant: in 1987, 87% were maintained on CsA at day 30 compared to 97% in 1991 (P < 0.001); (3) the mean higher daily maintenance CsA dose at 12 months post-transplant which in 1987 was 6.5 mg/kg compared to 7.5 mg/kg in 1991 (P = 0.03); (4) the decreased use of random transfusions, 54% receiving > 5 transfusions in 1987 compared to 37% in 1991 (P < 0.001); and (5) decreased use of younger cadaver donors between 1987 and 1991 (P < 0.001).

Antibodies, Monoclonal↗
PubMed1995

Focal segmental glomerulosclerosis in children.

Idiopathic focal segmental glomerulosclerosis is a histologic diagnosis that usually presents as the nephrotic syndrome but, unlike minimal change disease, often leads to renal failure in children. Standard therapies used to treat the proteinuria are often futile, and thus patients are at risk for the multiple complications resulting from persistent, severe proteinuria. Eventually, end-stage renal failure ensues, and the possibility of the disease recurring in the transplanted renal allograft is worrisome. This report reviews the clinical features and outcomes of idiopathic focal segmental glomerulosclerosis in children, the response to newer treatment options, and new insights into understanding what factors may be involved in causing the disorder.

Child↗