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PubMed2004

Benefit and timing of second transplantations in multiple myeloma: clinical findings and methodological limitations in a European Group for Blood and Marrow Transplantation registry study.

PURPOSE: To use European Group for Blood and Marrow Transplantation registry data to assess the benefit and optimal timing of a double-autologous transplantation strategy for patients with myeloma. PATIENTS AND METHODS: 7,452 transplantation patients described as being either in a multiple graft program ("planned") or not, were analyzed on an intention-to-treat basis. Subsequent multivariate analyses concentrated on the real occurrence of second transplantation, survival, relapse, and transplant-related mortality. RESULTS: Although the transplantation rate in the planned group failed to reach 60%, the median survival from transplantation is 60 months for the planned, compared with 51 months for the remainder group. While the hazard ratio of the planned group is 0.89 (95% CI, 0.79 to 1.00; P =.05) before approximately 70 months, this "effect" is reversed after 70 months, with the hazard ratio estimated as 3.01 (95% CI, 1.07 to 8.46; P =.04). A time-dependent multivariate Cox analysis shows that, taking patients without a second transplantation as a reference group, those receiving a second transplantation in first remission (ie, before relapse) show an increased probability of transplant-related mortality, especially if the transplantation is performed more than 12 months after the first, and the reduction of the risk of relapse is less than when the transplantation is performed earlier. Performing a second transplantation after relapse does not seem to prolong survival, though a second transplantation before relapse is associated with a higher probability of mortality. CONCLUSION: To improve survival of tandem autologous transplantation in multiple myeloma, the second transplantation should preferably be performed before relapse and within 6 to 12 months of the first transplantation.

Female↗
PubMedDate not supplied

Kaposi's sarcoma in organ transplant recipients. The Collaborative Transplantation Research Group of Ile de France.

OBJECTIVES: Kaposi's Sarcoma (KS) is a tumour of multicentric origin with increased frequency after organ transplantation. To date, only North American data from the Cincinnati Transplant Tumor Registry have given some information about this disease in organ transplant recipients, but its true prevalence still has to be determined. In order to analyze Kaposi's sarcoma after kidney, liver and heart transplantation, we performed a retrospective study using the oldest registry of organ transplant recipients in Europe. METHODS: Among all 7923 organ transplant recipients recorded in the Groupe Collaboratif de Recherche en Transplantation de l'Ile de France (GCIF) registry from 1968 to 1990, we analyzed the prevalence and the clinical characteristics of Kaposi's sarcoma in 6229 kidney, 727 liver and 967 heart transplant recipients. In the subgroup of kidney transplant recipients, we assessed the role of cyclosporine on disease evolution. RESULTS: Overall prevalence of Kaposi's sarcoma after organ transplantation was 0.52%, but it was significantly higher among liver (1.24%) than among kidney (0.45%) and heart (0.41%) transplant recipients. Chronic hepatitis B surface antigen carriers were more frequent in liver than in kidney transplant recipients who developed Kaposi's sarcoma (66% vs 21%, p < 0.03). Following kidney transplantation, Kaposi's sarcoma was more severe in patients receiving cyclosporine (n = 16) when compared with those under conventional immunosuppression (n = 12). CONCLUSION: True prevalence of Kaposi's sarcoma among European transplant recipients is high (0.52%) and appeared significantly higher in liver compared with other organ transplant recipients. Cyclosporine seems to increase severity of the disease among kidney transplant recipient.

Adult↗
PubMed2001

Post-transplant lymphoproliferative syndrome in the pediatric liver transplant population.

Post-transplant lymphoproliferative disease remains a complication with a high morbidity and mortality. The present study examined 291 pediatric liver transplants performed in 263 children from October 1984 to December 1999. Post-transplant lymphoproliferative disease has an overall incidence of 12%. Tacrolimus and cyclosporine had a similar incidence of post-transplant lymphoproliferative disease. Fifty-six per cent of patients who developed post-transplant lymphoproliferative disease were Epstein-Barr virus negative at the time of transplantation. Mean time of conversion to Epstein-Barr virus positivity was 1.1 years after liver transplantation. Ten per cent of those who developed post-transplant lymphoproliferative disease never had Epstein-Barr virus detected. Mean time from Epstein-Barr virus positivity to detection of post-transplant lymphoproliferative disease was 2.68 years, and 3.13 years from liver transplantation (OLTx) to post-transplant lymphoproliferative disease. There was a 35% incidence of mortality. Deaths occurred a mean of 0.76 years after diagnosis of post-transplant lymphoproliferative disease. Most cases of post-transplant lymphoproliferative disease had extranodal location. There was one recurrence in 10% of patients, and two in 3%. All recurrent cases were seen in recipients who became Epstein-Barr virus positive after transplantation. There has been a decrease in the incidence of post-transplant lymphoproliferative disease from 15% to 9% to 4%. Post-transplant lymphoproliferative disease should be diagnosed promptly and treated aggressively. The best treatment, however, seems to be prevention, starting in the immediate postoperative period. Survivors should be monitored for both recurrence of post-transplant lymphoproliferative disease and acute cellular rejection.

Adolescent↗
PubMed1999

Analyses of pancreas transplant outcomes for United States cases reported to the United Network for Organ Sharing (UNOS) and non-US cases reported to the International Pancreas Transplant Registry (IPTR).

As of September 1999, almost 13,000 pancreas transplants had been reported to the IPTR, > 9,000 in the US and > 3,000 outside the US. An era analysis of US cases from 1987 to 1997 showed a progressive improvement in outcome (p < 0.04), with pancreas transplant graft survival rates (GSRs) going from 74% to 85% at one year for SPK cases, from 56% to 75% for PAK cases, and from 50% to 69% for PTA cases. The improvements were due both to decreases in technical failure (TF) rates (overall from 16% to 8%) and immunological failure rates (going from 6% to 2% for SPK, from 23% to 7% for PAK, and from 35% to 9% for PTA cases). The proportion of recipients > 44 years old increased from 5% to 24%, and the improved outcomes encompassed the older patients as well. In patients > 44 years old, SPK pancreas GSRs at one year increased from 69% for 1987-89 cases to 79% for 1996-97 cases (p < 0.03). Pancreas GSRs were also similar for recipients reported to have Type I or Type II diabetes (at 1 year, 84% and 81%, respectively, for 1994-99 SPK transplants), the latter designated in 3% of the recipients. Contemporary pancreas transplant outcomes were calculated separately for 1996-99 US and non-US cases. US patient survival rates at one year were > or = 95% in each recipient category, with one year pancreas GSRs of 84% for SPK (n = 2,502), 76% for PAK (n = 404), and 72% for PTA (n = 176) (p = 0.0001). The immunological graft failure rates for 1996-99 US SPK, PAK and PTA cases were 2%, 6%, and 10% at one year (p = 0.001). There was a progressive increase in the use of ED (as opposed to BD) for duct management, up to nearly 60% of US pancreas transplants by 1998. Approximately 18% of SPK ED transplants had venous drainage via the portal system. Pancreas GSRs were not significantly different for 1996-99 ED (n = 1,170) and BD (n = 1,203) US SPK transplants (84% and 85%, respectively, at 1 year), nor was there any difference in pancreas GSRs for systemic (n = 437) versus portal (n = 194) venous drained ED SPK transplants (84% and 83%, respectively, at 1 year). Interestingly, kidney GSRs were significantly higher for ED versus BD US SPK cases, 93% versus 84% at one year (p = 0.003). Duct management did matter for solitary (PAK and PTA) pancreas transplants. PAK pancreas GSRs were 80% at one year for BD (n = 238) versus 68% for ED (n = 156) US transplants. PTA pancreas GSRs were 78% at one year for BD (n = 98) versus 63% for ED (n = 73) US transplants. However, BD transplants were associated with a 12% conversion rate to ED by 2 years after transplantation. Analyses of outcome by immunosuppression for US cases showed pancreas GSRs to be higher in SPK recipients given MMF (87% at 1 year) than in those who were not (76% at 1 year). For PAK and PTA recipients, those given anti-T cell for induction and TAC and MMF for maintenance immunosuppression had the highest GSRs: 86% and 83%, respectively, at one year for BD pancreas transplants; not significantly different from the pancreas GSR (87% at 1 year) in BD SPK recipients also given anti-T cell for induction and TAC and MMF for maintenance immunosuppression. Analyses of US pancreas transplant outcome according to HLA matching showed no effect at all in the SPK category, while for PAK and PTA transplants an effect was seen at the A and B loci, strongest at the B loci. Matching for at least one antigen at both loci was associated with one-year pancreas GSRs of 85% for PAK and 74% for PTA, versus 70% and 60%, respectively, at one year for those who were not matched for at least one antigen at both the A and B loci. In regard to non-US cases, the overwhelming majority were in the SPK category (n = 528 for 1996-99), with one-year pancreas GSR of 79%, not significantly different from US cases. Approximately 40% of non-US SPK cases were ED (n = 204), and, as in the US, the pancreas GSRs were similar for ED and BD transplants in this category. (ABSTRACT TRUNCATED)

Adult↗
PubMed2000

Liver transplantation in the United States: a report from the Organ Procurement and Transplantation Network.

UNLABELLED: TRANSPLANTS AND CENTERS: Between 1988-1999 the number of annual liver transplants performed in the United States more than doubled, from 1,713 to 4,689; the number of centers increased from 59 to 117. The number of living donor, segmental, and multiple organ transplants also increased over time, particularly between 1997-1999. The rate of increase in the number of centers has slowed over the last few years. OUTCOMES: Survival among pediatric recipients The one- and 10-year graft survival rates for pediatric recipients were 76% and 63%, respectively. The one- and 10-year patient survival rates were 85% and 78%. Patient survival did not decrease much after the first 2 years and graft survival stabilized after 5 years. Some of the factors associated with increased odds of graft failure and patient death at 6 months after transplantation included having a previous transplant; being hospitalized, in the ICU, or on life support at the time of transplant; a creatinine level > 2 mg/dl; donor race/ethnicity; and transplant type. Factors associated with decreased odds of graft failure or patient death were recipient gender, having a metabolic disease, and a shorter than average cold ischemia time. Among grafts, recipients surviving the first 6 months after transplantation, recipient and donor race/ethnicity, primary liver disease, and having a previous transplant were associated with a greater relative risk of graft failure and mortality. The risk of graft failure was reduced for recipients in the ICU at the time of transplant and for those receiving organs from younger donors. Survival among adult recipients The one- and 10-year graft survival rates among adult recipients were 79% and 51%, respectively. The one- and 10-year patient survival rates were 85% and 59%. Survival rates decreased steadily at all time points following transplantation. Some of the factors associated with increased odds of graft failure and mortality at 6 months were increasing recipient and donor age; recipient and donor race/ethnicity; primary liver disease; having a previous transplant; being hospitalized, in the ICU, or on life support at the time of transplant; longer cold ischemia time; having a non-identical recipient/donor blood type match; transplant type; and year of transplant. Younger recipient and donor ages, having cholestatic liver disease/cirrhosis, shorter cold ischemia times, and matching male recipients with male donors were associated with decreased odds of graft failure and mortality. Many of these characteristics also affected grafts and patients surviving the first 6 months, including recipient and donor age, recipient and donor race/ethnicity, primary liver disease, previous transplant, and year of transplant.

Adolescent↗
PubMed1997

The UNOS Scientific Renal Transplant Registry--ten years of kidney transplants.

1. The number of kidney transplants reported to the UNOS Scientific Renal Transplant Registry (excluding multiorgan transplants) increased from 8,831 in 1988 to 10,204 in 1996, mainly due to increased donation by living donors (1,812-3,149 during the same period). 2. Overall projected 10-year primary graft survival rates were 73% for 3,515 recipients of HLA-identical sibling grafts, 55% for 16,160 recipients of other living donor transplants or 3,940 HLA-matched cadaveric grafts and 39% for 50,900 recipients of HLA-mismatched cadaver donor kidneys. 3. One-year first cadaver graft survival rates improved from 77% in 1988 to 87% in 1997 and graft half-lives improved from 7.6 years for 1988 transplants to 11.6 years for 1994 transplants. 4. Improving graft survival rates were associated with a modest 2% increase in one-year patient survival and a projected 13% increase at 10 years. Better patient survival may contribute to rising long-term graft survival rates. 5. Immunosuppression has also played an important role as the incidence of rejection episodes within the first 6 months decreased from 52% in 1988 to 24% in 1996 and immunological graft failures declined in 1995 and 1996 accounting for less than 30% of first year graft losses. The majority of first year graft losses were due to patient deaths for the first time in 1995. 6. A major change in maintenance immunosuppression occurred in 1996 when about 60% of first cadaver transplant recipients received Neoral, MMF and prednisone (NMP) at the time of hospital discharge. Preliminary results show a 90% one-year graft survival rate with NMP compared with 87% for CsA- and FK-based immunosuppression. Improved long-term graft survival that had been previously noted in patients treated with FK506 was not apparent in the 1994-96 cohort analyzed. The use of induction with OKT3 or ALG reduced rejection episodes during the initial transplant hospitalization but did not affect one-year or long-term graft survival. 7. There has been a significant improvement in immunological high-risk patients. The results of second transplants trailed those of primary grafts by only 3% in the 1994-96 period compared with a 6% difference in 1988-90 and recently retransplanted patients who were not broadly sensitized had the same graft survival rate as unsensitized first transplant recipients. Recipients of poorly HLA-matched kidneys also had significantly improved survival rates during 1994-96. The 3-year survival difference between recipients of kidneys with only one or 2 HLA mismatches and those with 5-6 mismatches was 4% compared with 8% for comparably matched recipients transplanted in 1988-90. 8. The 3-year graft survival rate for Black recipients was 57% in 1988-90 and 67% in 1994-96. The gap between Blacks and Whites narrowed from a 9% 2-year survival rate difference in the early cohort to 5% in the more recent transplants. Asians transplanted in 1994-96 had a superior graft survival rate of 90% at one year with an 18-year half-life. 9. Despite a substantial increase in the number of living donor transplants performed in recent years, graft survival rates were still superior to all but the best HLA-matched cadaver transplants. Most of the additional living donor activity has involved HLA-mismatched pairs with a 3-fold increase in the number of completely HLA-mismatched transplants (513 in 1988-90 vs 1,583 in 1994-96). The one-year graft survival rates were 96%, 93% and 92% for HLA-identical, one- and 2-HLA haplotype disparate transplants, respectively.

Cadaver↗
PubMed2003

Restorative potential of cholinergic rich transplants in cholchicine induced lesioned rats: a comparative study of single and multiple micro-transplantation approach.

Restorative potential of fetal neural transplantation in colchicine induced neurodegeneration was studied in rats; where colchicine (2.5mg per site) was administered bilaterally into the hippocampus followed by bilateral infusions of fetal neural cell suspension rich in cholinergic neurons as single macro- or multiple micro-transplants in the hippocampal region 3 weeks post-colchicine (2.5mg per site) lesion. Animals were studied for neuro behavioural and neurochemical recovery at 4 and 24 weeks post-transplantation and electrophysiological (single cell recording) and immunohistochemical parameters, choline acetyl transferase (ChAT) expression was studied in hippocampus at 24 weeks post-transplantation. Colchicine lesioned rats receiving single macro- or multiple micro-transplants exhibited significant restoration in cognitive dysfunction caused by colchicine after 4 weeks of transplantation which remain persistent in multiple micro-transplanted group upto 24 weeks post-transplantation, whereas, single macro-transplanted animals did not exhibit any significant recovery. Neurochemical studies revealed significant restoration in acetylcholine esterase activity and cholinergic (muscarinic) receptor binding after 24 weeks post-transplantation as compared to 4 weeks post-transplantation in multiple micro-transplanted group. Single cell recording studied at 24 weeks post-transplantation exhibited significant restoration in firing rates when compared with lesioned group. The viability of cholinergic fibre at transplanted sites has further been confirmed by increase in ChAT immuno positivity in hippocampal region using monoclonal antibody and quantified using image analyser Leica Qwin 500 software. The results suggest that intra-hippocampal multiple site cholinergic rich transplants provide better and long term restoration in the cholinergic deficits induced by colchicine lesion as compared to single site macro-transplantation.

Action Potentials↗
PubMed2001

Worldwide thoracic organ transplantation: a report from the UNOS/ISHLT international registry for thoracic organ transplantation.

Based on data reported to the UNOS/ISHLT Thoracic and International Registry for Thoracic Organ Transplantation: 1. The number of heart transplant operations performed in the United States decreased between 1998-1999 and 17 (1%) more procedures were performed in 1999 (2,181) than in 2000 (2,198). Sixty-nine more lung transplants (an 8% increase) were reported in 2000 than in 1999. 2. Coronary artery disease and cardiomyopathy were the most frequently cited indications for heart transplantation in the US and have been reported at similar rates during the past 10 years. Combined, these diagnoses account for approximately 85% of all heart transplants. In 2000, half of all lung transplants were performed for emphysema/COPD or alpha-1 antitrypsin deficiency. The most frequently reported diagnoses for thoracic transplantation outside the US were: cardiomyopathy (49%) for heart, cystic fibrosis (30%) for double lung, emphysema/COPD (34%) for single lung and primary pulmonary hypertension (21%) for heart-lung transplants. 3. US heart transplant recipients were predominately male (76%), aged 50-64 (51%) and white (81%). US lung transplant recipients were also predominately between ages 50-64 (47%) and white (90%), but unlike heart recipients were more likely to be female (51%). No meaningful variance from the US recipient demographic profile was noted for the non-US recipients during the same time period. 4. Pediatric recipients (< 18 years of age) received 11% of the reported heart transplants and 6% of the reported lung transplants in the US. 5. Among US thoracic transplant recipients during 1999, the one-year survival rates were 84% for heart, 59% for heart-lung and 77% for lung. The 5-year survival rates for transplants performed during 1995 were: 71% for heart, 56% for heart-lung and 44% for lung transplants. 6. The long-term patient survival rates were: 23% at 19 years for heart, 16% at 11 years for lung and 23% at 14 years for heart-lung recipients. 7. During the first year after transplantation, 66% of heart recipients and 44% of lung recipients did not require rehospitalization. Among those recipients who were rehospitalized, the major cause was infection.

Age Distribution↗
PubMed1999

Worldwide thoracic organ transplantation: a report from the UNOS/ISHLT International Registry for Thoracic Organ Transplantation.

1. The number of heart transplant operations performed in the US has increased by 51 procedures between 1997 (2,294) and 1998 (2,345). The number of lung transplants decreased by 67 in 1998 (862). 2. The most frequently reported indication for heart transplantation in the US is coronary artery disease (44.6%). For other thoracic transplants, the most frequently reported indications include other/unknown (43.9%) for double lung, emphysema/COPD (53.5%) for single lung and other/unknown (53.2%) for heart-lung. The most frequently reported diagnoses for thoracic transplantation outside the US include cardiomyopathy (50.5%) for heart, cystic fibrosis (32.0%) for double lung, idiopathic pulmonary fibrosis (32.7%) for single lung and congenital heart disease (24.7%) for heart-lung. 3. US heart transplant recipients were predominately male (77%), between 50-64 years old (51.4%) and White (81.7%). In contrast, US lung transplant recipients are predominantly female (51.3%), between 50-64 years of age (44.7%) and White (89.7%). No meaningful variance from the US recipient demographic profile was noted for the non-US recipients during the same time period. 4. Pediatric recipients (< 18 years of age) received 10.9% of the reported heart transplants and 6.5% of reported lung transplants. 5. One-year survival for thoracic transplants performed in the US was 83.2% for heart, 70.6% for lung and 62.5%. Five-year survival for US thoracic transplants was 70% for heart and 49.1% for lung. 6. Long-term patient survival rates were: 22.3% at 18 years for heart, 20% at 9 years for lung and 25% at 12 years for heart-lung recipients. 7. The most important risk factor for mortality of US heart recipients at one month, one and 5 years after transplantation was receipt of a previous heart transplant. Significant short-term risk factors included donor age, recipient age and ischemic time. Substantial long-term risk factors include older donor age, donor race and recipient race. 8. The factors having the most significant impact on lung mortality at all time points were related to either the patient's medical condition (e.g., in the ICU prior to transplant, requiring mechanical ventilation) or diagnosis. 9. Mechanical ventilation and previous transplant had the largest impact on heart-lung mortality. 10. For heart and lung recipients, the major cause of hospitalization during the first posttransplant year was infection.

Adolescent↗
PubMed1982

Connectivity of neural transplants in adult rats: analysis of afferents and efferents of neocortical transplants in the cerebellar hemisphere.

Embryonic neocortical tissue, 3.5 mm3 in volume, obtained from 17-day-old Long-Evans rat embryos, was transplanted into the intact cerebellar hemisphere of normal adult rat hosts. Transplants examined 90-160 days later had grown to a final volume of 27.24 mm3, which reflected nearly an 8-fold increase in the initial volume of tissue transplanted. The transplants were all intraparenchymal, having replaced large parts of the cerebellar hemisphere and occasionally portions of the vermis and paramedian lobule during their course of growth and differentiation. They retained a cellular and cytoarchitectural identity characteristic of neocortical tissue. Anterograde degeneration studies and retrograde tracing methods on the light microscopic level revealed that transplants had received afferent connections from the ponto-, olivo- and spinocerebellar projection systems. In addition to these major connections, afferents from other nuclei such as the locus coeruleus and the lateral reticular nucleus were also observed with the HRP method. Efferent outgrowth as studied with degeneration methods revealed projections to the nearby host cerebellum and to the ipsilateral deep cerebellar nuclei. All transplants had developed massive intratransplant connections. Findings on the nature and magnitude of connections were analyzed in terms of different characteristics of the interface between the transplant and the host brain tissue. The surface of cortical transplants was found to consist of 7 distinct components, 5 of which were interface regions. Two types of interface regions, those between the cerebellar medullary and granular layers and transplants, were readily related to the magnitude of extrinsic afferent ingrowth, and hence were effective sprouting surfaces. Using two correlated estimates of the magnitude of afferent ingrowth to cortical transplants, volume of degeneration and surface area of degeneration of transplants resulting from lesions of host brain structures, the pontine system was found to provide more afferents to transplants than the olivary or spinal systems. Generally, extrinsic fibers were located nearer to transplant-host brain interface regions than deep within transplants. A positive correlation existed between the available effective sprouting surface area of transplants (an estimate of interactive host fibers with a suitable trajectory) and the magnitude of innervation of cortical transplants by extrinsic afferents.

Afferent Pathways↗
PubMed1989

Embryonic entorhinal transplants project selectively to the deafferented entorhinal zone of adult mouse hippocampi, as demonstrated by the use of Thy-1 allelic immunohistochemistry. Effect of timing of transplantation in relation to deafferentation.

The mouse Thy-1.1/Thy-1.2 allelic marking system is used to show that transplanted embryonic entorhinal cortex can reinnervate adult host hippocampi. The projection is limited to the appropriate terminal zones--viz. the outer two-thirds of the stratum moleculare of the dentate gyrus, and the stratum lacunosum-moleculare of the hippocampus--and extends for up to about 2 mm into the denervated host terminal field. The reconstruction of the entorhinal projections to the host requires direct contact between the embryonic donor tissue and the denervated adult host terminal field, and is dependent upon removal of the ipsilateral host entorhinal area. In the absence of an overall deafferenting host entorhinal lesion the transplanted entorhinal area forms only small local projections which are confined to areas which would have been locally deafferented as a result of direct damage to the host entorhinal afferents (i.e. during their intrahippocampal course) by the hippocampal lesion caused at the time when the transplant was inserted. The correct relative timing of deafferentation and transplantation is vital for the formation of the transplant-to-host projection. The host dendrites can be made receptive to entorhinal transplant projections by removal of the host entorhinal area at the time of transplantation. When deafferentation is performed first and transplantation is delayed, it is found that the deafferented host dendrites retain this receptivity even when deafferentation has been performed as much as two months before transplantation. Reversing the order of transplantation and deafferentation, however, shows that the transplants have only a transient ability to project to the deafferented host territory. Thus, transplants inserted and allowed to become established for one week before host deafferentation make very much reduced projections to the host, and from two weeks onwards are incapable of any detectable response to subsequent removal of the host entorhinal area. Coextensive with the formation of transplant-to-host entorhinodentate projections, the host entorhinal lesion also induces an intensification of the acetylcholinesterase staining of the host septodentate afferents in the denervated outer dentate stratum moleculare. The findings demonstrate the accurate reconstruction of a lost projection in adult brain by transplanting the appropriate type of embryonic tissue, but the results of altering the relative timing of deafferentation and transplantation raise currently unsolved questions about the nature of the competitive interactions between transplant and host axons.(ABSTRACT TRUNCATED AT 400 WORDS)

Animals↗
PubMed2002

European best practice guidelines for renal transplantation. Section IV: Long-term management of the transplant recipient. IV.11 Paediatrics (specific problems).

GUIDELINES: A. Kidney transplantation should be the treatment of choice for end-stage renal disease (ESRD) in children (up to 16 years of age). Because the incidence rate of ESRD is very low, approximately 1-2 children per million general population or 4-6 children per million childhood population, kidney transplantation in children should be performed in specialized paediatric centres with multidisciplinary experts, i.e. transplant surgeons, anaesthetists and paediatric nephrologists, and optimally should be supported by psychologists, paediatric nurses and social workers. B. Due to the urgent need for transplantation, children should have priority in the allocation systems. In addition, pre-emptive transplantation from either live or cadaveric donors should be offered to all paediatric transplant candidates whenever possible. These protocols will reduce the time on dialysis, thus limiting the retardation of growth and development. C. Absolute contra-indications to renal transplantation in children are extremely rare but should be respected: uncontrollable malignancy, ABO incompatibility, the presence of a current positive cross-match or multi-organ failure. There are few relative or transient contra-indications: history of cancer (Wilms tumour), viral infection (HIV, HBV, EBV), very young age (<6 months), severe mental retardation and/or additional disabilities. D. In contrast to adult patients, primary renal diseases responsible for ESRD in children are mostly congenital and hereditary disorders (60%). Children with massive vesico-ureteric reflux or permanent urinary infection should undergo nephroureterectomy to avoid the development of sepsis. In children with ESRD not due to any urinary tract malformation, pre-transplant bilateral nephrectomy of the native kidney should be considered in the case of severe arterial hypertension, heavy proteinuria or risk of renal cancer. E. Psychosocial evaluation of future transplant recipients and their parents is necessary in assessing compliance with management of dialysis and after transplantation. Poor compliance worsens the outcome of paediatric renal transplantation. F. Routine childhood vaccination should be completed whenever possible prior to transplantation, in addition to vaccination against hepatitis B and varicella. G. The pharmacokinetics of immunosuppressive drugs often differ between adult and paediatric recipients. Therefore, drug monitoring is mandatory in order to find the correct drug dosage. H. Today the actuarial probability of graft survival at 1 year should exceed 90% in unselected renal transplant children, and the acute rejection rate should be lower than 30%. I. Special attention should be paid to specific risk factors in paediatric transplantation, such as thrombotic complications, EBV and CMV infections, post-transplant lymphoproliferative disease (PTLD) and recurrence of original renal disease, mainly in patients with focal segmental glomerulosclerosis (FSGS) or atypical haemolytic-uraemic syndrome (HUS).

Adolescent↗
PubMed2003

Dialysis, kidney transplantation, or pancreas transplantation for patients with diabetes mellitus and renal failure: a decision analysis of treatment options.

Patients with type 1 diabetes mellitus and end-stage renal disease may remain on dialysis or undergo cadaveric kidney transplantation, living kidney transplantation, sequential pancreas after living kidney transplantation, or simultaneous pancreas-kidney transplantation. It is unclear which of these options is most effective. The objective of this study was to determine the optimal treatment strategy for type 1 diabetic patients with renal failure using a decision analytic Markov model. Input data were obtained from the published medical literature, the United Network for Organ Sharing registry, and patient interviews. The outcome measures were life expectancy (in life-years [LY]) and quality-adjusted life expectancy (in quality-adjusted life-years [QALY]). Living kidney transplantation was associated with 18.30 LY and 10.29 QALY; pancreas after kidney transplantation, 17.21 LY and 10.00 QALY; simultaneous pancreas-kidney transplantation, 15.74 LY and 9.09 QALY; cadaveric kidney transplantation, 11.44 LY and 6.53 QALY; dialysis, 7.82 LY and 4.52 QALY. The results were sensitive to the value of several key variables. Simultaneous pancreas-kidney transplantation had the greatest life expectancy and quality-adjusted life expectancy when living kidney transplantation was excluded from the analysis. These data indicate that living kidney transplantation is associated with the greatest life expectancy and quality-adjusted life expectancy for type 1 diabetic patients with renal failure. Treatment strategies involving pancreas transplantation should be considered for patients with frequent metabolic complications of diabetes and for those patients who favor kidney-pancreas transplantation over kidney transplantation alone. For patients without a living donor, simultaneous pancreas-kidney transplantation is associated with the greatest life expectancy.

Adult↗