Vesicoureteral reflux after kidney transplantation in children.

BACKGROUND: The prevalence and significance of vesicoureteral reflux (VUR) after kidney transplantation in adults varies between authors and there have been few reports in children. METHODS: We conducted a retrospective study in a single-centre paediatric cohort. Fifty-five of the 84 children who underwent kidney transplantation over a 5-year period were checked with routine cystography after a median of 8 months post-transplantation. Graft function and urinary-tract infections were assessed during the first 6 years after transplantation. RESULTS: VUR into the graft was present in 58% of the patients. Graft function and incidence of urinary-tract infections were similar in the two groups, independent of VUR. After having excluded infections attributed to the presence of a catheter, actuarial survival rates without pyelonephritis and without pyelonephritis following a first lower urinary-tract infection were worse in patients with VUR (P:=0.017 and P:=0.0039 respectively). None of the eight patients with VUR treated with antibiotic prophylaxis after a first acute pyelonephritis (APN) episode presented subsequent APN after 4.4+/-3.3 years on therapy. CONCLUSIONS: VUR to the graft occurred in more than half paediatric renal transplant recipients. This condition was associated with an increased risk of APN. Long-term antibiotic prophylaxis seems to be able to prevent APN in transplanted children with VUR.

[Graft function following renal transplantation in children]. / Evolution de la fonction du greffon après transplantation rénale chez l'enfant.

BACKGROUND: Since renal transplantation is known to be the best choice for the growing child with end-stage renal failure, we prospectively evaluated early and late graft function in transplanted children. POPULATION AND METHODS: The study included 78 children (32 girls, 46 boys) 10.4 +/- 0.6 years at the time of transplantation. Renal investigations were performed at 3, 6 and 12 months post-transplantation and yearly thereafter. Inulin clearance was used to evaluate the glomerular filtration rate (GFR), and the reabsorption rates of Na, P and Ca were measured concomitantly. RESULTS: The overall adjusted GFR was approximately 70 mL/min/1.73 m2 and remained unchanged during the first 5 years post-transplantation. In the mean time the absolute GFR increased significantly, suggesting a remaining capacity for compensatory hypertrophy of the transplanted kidney. Renal function was significantly influenced by the number of rejection episodes during the first 2 years post-transplantation but no correlation was found between GFR and the number of HLA mismatches or the use of preemptive transplantation.

Role of the donor in post-transplant renal function.

BACKGROUND: The donor, i.e. adult or paediatric, might influence the outcome of the graft function. METHODS: The glomerular filtration rate (GFR) of 120 transplanted children (47 girls) aged 10.4+/-4.6 years (0.7-17.2) was prospectively assessed over a 5-year period. The patients were divided into two groups according to the age of donor: adult (donor age > 18 years; n=33) and paediatric (donor age < 18 years; n=87). GFR was assessed by inulin clearance at 3, 6 and 12 months and yearly thereafter. RESULTS: The average GFR was stable in the range of 70 ml/min/1.73 m2 for the whole follow-up period. The adjusted GFR in adult graft recipients was significantly higher at 3 months post-transplantation: 80.6+/-36.9 vs 65.1+/-22.0, P=0.02. However, from the second year post-transplantation, the adjusted GFR in paediatric graft recipients became significantly higher than that of adult graft recipients. Such results could be due to an improvement in the absolute GFR (ml/min) of paediatric graft recipients with time (P=0.0001) whereas that of the adult graft recipients remained stable despite the children's growth. CONCLUSIONS: The adjusted GFR of adult graft recipients was significantly higher than that of paediatric graft recipients in the early post-transplant period. In the long-term, a progressive decrease in adjusted GFR was noted in adult graft recipients. On the one hand, this may be due to a functional adaptation and/or inadequate compensatory growth of the graft. On the other hand, the absolute GFR of paediatric graft recipients increased, suggesting an ongoing capacity for growth and/or compensatory hypertrophy after child-to-child renal transplantation.

Outcome of preemptive renal transplantation and pretransplantation dialysis in children.

The present study compares the outcome of 40 children (39%) transplanted without prior dialysis, i.e., preemptive transplantation (PET), with 63 children (61%) transplanted after a variable duration of dialysis, i.e., pretransplantation dialysis (PTD). The two groups were matched for recipient and donor age and for immunological risk factors. There was no statistical difference in the time to first acute rejection episode nor in the number of acute rejection episodes during the 1st year after renal transplantation. In the PET group, 78% of the recipients received blood transfusion versus 92.5% in the PTD group (P < 0.05), and the average number of blood units per patient was 3.2 and 7.8, respectively (P < 0.05). Arterial hypertension was found in 55% of the patients in the PET group versus 73% in the PTD group (P < 0.05). The number of functioning grafts at the end of the study period was 87.5% in the PET group and 73% in the PTD group (NS). The major cause of graft failure was vascular thrombosis in the PET group (3/5) and chronic allograft rejection in the PTD group (10/17). In the PET group, the actuarial graft survival rate was 100%, 84%, 81%, and 76% at 1, 3, 5, and 7 years, which was not statistically different from the PTD group at 1, 3, and 5 years (98%, 91%, and 73%, respectively) but there was a significantly lower graft survival (59%) after 7 years in the PTD (P < 0.05). The 7-year actuarial patient survival rate was 97% in the PET group and 90% in the PTD group (NS). In the PTD group, children on dialysis for less than 1 year (group 1, n = 25) were compared with those on dialysis for more than 1 year (group 2, n = 38). Arterial hypertension was noted in 40% of patients from group 1 and 65% from group 2 (P < 0.05); there was no significant difference in graft loss rate. In conclusion, these results confirm PET as the preferred approach rather than PTD in children who need renal replacement therapy.

[Bacterial complications of nephrotic syndrome in children]. / Complications bactériennes des néphroses chez l'enfant.

OBJECTIVES: Evaluate bacterial infection epidemiology and pathophysiology in children with nephrotic syndrome. METHODS: From January 1983 to December 1992, 399 children with the nephrotic syndrome were admitted in 3 University Pediatric wards (Paris Enfants Malades, Lyon Edouard Herriot, Lyon Debrousse). Severe bacterial infection was diagnosed when the patient's condition has justified an intravenous antibiotherapy. RESULTS: Forty-eight bacterial infections were noted in 32 patients (8%); the infection was the first symptom of the disease in 10 patients (31%); one patient died shortly after admission. Severe bacterial infection concerned steroid-resistant nephrotic syndrome in 13 cases (41%), but only 7 out of them received immunosuppressive agents at the time of the infection. Eleven children (34%) experienced recurrent infections (1 to 6 recurrences), several of which under antibioprophylaxy. Half of the infections involved peritonitis and 50% of the identified germs were S. pneumoniae. However, peritonitis was not always related to S. pneumoniae (1 H. influenzae among 9 identified germs). CONCLUSIONS: These data demonstrate the importance of microbiological sampling and justify a first-line antibiotherapy using a third generation cephalosporin. The presentation of severe bacterial infections show that it is less a iatrogenic event than a consequence of immunological disturbances induced by the nephrotic syndrome itself, as suggested by the acquired deficiency of factor I and B. Despite recent advances in antibiotic strategies responsible for a significant reduction in the severity of such infections (1 death among 32 patients), preventive treatments are quite disappointing.

Recurrent nephrotic syndrome after transplantation: early treatment with plasmaphaeresis and cyclophosphamide.

Steroid-resistant nephrotic syndrome (NS) with focal glomerulosclerosis (FGS) and its recurrence after transplantation are mainly seen in children. The recurrence rate approximates 30% and the graft loss is about half this. Several therapeutic regimens have been proposed, giving conflicting results. In an attempt to remove a putative circulating factor and inhibit its production by lymphocytes, three patients with biopsy-proven FGS in the native kidney were included in a prospective uncontrolled trial using early plasmaphaeresis followed by substitutive immunoglobulins in association with methylprednisolone pulses and cyclophosphamide instead of azathioprine over a 2-month period. The patients were girls, aged 6.5, 13.3 and 15.8 years, who received a cadaveric transplant; concomitant immunosuppression included prednisone and cyclosporine A. All three patients exhibited early recurrence of the NS and were treated 5-10 days after the onset of proteinuria. Rapid and sustained remission was achieved in all patients within 12-24 days on therapy. One patient experienced a late acute but steroid-sensitive rejection episode; another suffered from septic ankle arthritis as a complication of reinforced immunosuppression. The latter girl had a second late recurrence of proteinuria that was controlled within 7 weeks. With a 18- to 27-month follow-up, all three patients have normal renal function, normal blood pressure and no proteinuria. We conclude that intensive therapy using plasmaphaeresis, steroid pulses and cyclophosphamide over a 2-month period can induce complete remission in children with early recurrence of NS after transplantation.

[Effectiveness of and tolerance to human recombinant erythropoietin in the treatment of kidney failure anemia in children undergoing continuous peritoneal dialysis. Multicenter study]. / Efficacité et tolérance de l'érythropoïétine recombinante humaine dans le traitement de l'anémie de l'insuffisance rénale des enfants en dialyse péritonéale continue. Etude multicentrique.

Eight young children with renal failure, undergoing continuous peritoneal dialysis (CDP) and presenting an anemia (hemoglobin level [Hb] 57 to 89 g/l) were treated by subcutaneous recombinant human erythropoietin (rHu EPO) twice weekly. The initial dose of 75 U/kg was adjusted to induce progressive increase of Hb with a target level of 100-120 g/l. Treatment duration was 24 weeks in five of these children and 10 to 13 weeks in the three others. In seven cases out of eight, anemia was corrected. The target Hb level was reached in 3 to 21 weeks with rHu EPO doses of 150 to 300 U/kg/w (mean: 200 U/kg/w) for four children without recent transfusion; then the median maintenance dose was 135 U/kg/w (range: 50-300 U/kg/w). In only one patient, Hb never reached a level higher than 77 g/l despite weekly dose of 350 U/kg, a reticulocytosis of 5.6%, rHu EPO treatment lasting up to 24 weeks and the absence of iron deficiency. In any case, no transfusion was necessary after the first day of rHu EPO treatment. In three patients, the increase of a preexisting hypertension required the adaptation of antihypertensive treatments. One patient presented a marked thrombocytosis. In conclusion, twice-a-week subcutaneous injections of 75 to 150 U/kg of rHu EPO appear to be well tolerated and effective in the treatment of anemia of CPD children.

[Rheumatoid purpura and Berger's disease in the same patient. 2 cases]. / Purpura rhumatoïde et maladie de Berger chez un même patient. Deux observations.

The two patients reported experienced initially typical Henoch Schönlein purpura, and Berger disease some years later. Same cases are described in the literature pleading for the relationship between the two entities; Berger disease may be considered as a symptomatic form of anaphylactoïd purpura.

[Nephrotic syndrome, pancreatitis, hepatitis B. Report of a case]. / Syndrome néphrotique, pancréatite, virus de l'hépatite B. Une observation.

We report on a case of acute pancreatitis in a 9 year-old girl suffering from steroid resistant nephrotic syndrome. Acute abdominal pains revealed pancreatitis whose outcome was favorable after 5 days of total parenteral nutrition. None of the usual causes of pancreatitis was recognized. A serologic profile of hepatitis B, compatible with a chronic carriage of the virus B was found. The possible relationships between pancreatitis, viral hepatitis and the nephrotic syndrome are discussed.

Acute renal failure in a child after chewing of match heads.

A few days after ingestion of 40 match heads, a 3-year-old boy was admitted to hospital with oliguric acute renal failure (ARF) requiring peritoneal dialysis during 9 days. A renal biopsy showed acute tubulointerstitial nephritis; the outcome was rapidly favorable and the child recovered normal GFR. It seems to be the first published case of ARF after match poisoning, probably because of the presence of potassium bichromate.

[Membranous glomerulonephritis in children: 20 cases]. / Glomérulonéphrites extramembraneuses chez l'enfant: 20 observations.

Twenty cases of membranous glomerulonephritis have been diagnosed between 1978 and 1988 in children (13 girls, 7 boys) aged 4 to 15 years, observed for a 5.1 +/- 2.9 year period. The conditions of the diagnosis were: routine urinalysis in 10 cases, edema in eight, and the surveyance of a D-penicillamine treatment in two. All the patients had proteinuria (0.3 to 15 g/24 h) ranging to nephrotic syndrome in nine children. Microscopic hematuria was found in 16 children (80%). Elevated blood pressure was recorded in two cases at the time of diagnosis, and developed in two other cases during the follow-up. One child experienced renal failure at the onset of the disease. Most histological lesions consisted in stage II membranous glomerulonephritis. Immunofluorescence study (18 biopsies/20) always showed granulosus and intensive IgC deposits, associated with IgM and IgA deposits which were less marked; intensive extra-membranous C3 deposits were noted in 11 cases. As to the etiology, D-penicillamine was responsible for two cases (10%) and HBs antigen in one (5%); the nephropathy was considered as idiopathic in the 17 remaining cases (85%). Regarding the evolution: in eight cases (38%) proteinuria disappeared by 54 +/- 28 months; in 10 cases (55%), proteinuria persisted after 41 +/- 31 months; hematuria, which was present at onset, disappeared in most cases (13/17); in one case (5%), end-stage renal failure occurred within 3 years. The patient with initial renal failure has been last sight off.(ABSTRACT TRUNCATED AT 250 WORDS)

Aetiology of membranous glomerulonephritis: a prospective study of 82 adult patients.

Eighty-two consecutive Caucasian adults (52 males, 30 females, aged 17-86 years) with membranous glomerulonephritis were prospectively evaluated for possible aetiological factors 1-4 weeks after renal biopsy. Presumed causes were identified in 17 patients (21%) as follows: drugs in five (D-penicillamine 3, captopril 1, fenoprofen 1); malignancy in four; chronic thyroiditis in three; systemic lupus erythematosus (SLE) in two; secondary syphilis in one; hepatitis B virus (HBV) infection in one and non-insulin-dependent diabetes mellitus in one patient. Except for age (patients with secondary membranous glomerulonephritis were older), clinical presentation and histological stage distribution did not differ between the secondary and the primary groups. Ten out of the 17 patients with secondary membranous glomerulonephritis (59%) achieved complete clinical remission within 12 months. The incidence of associated conditions in adults with membranous glomerulonephritis in this study corresponds with that reported in the few previous series. Although membranous glomerulonephritis is deemed to be idiopathic in most cases, it seems warranted to search for medication, malignancy, SLE, HBV infection, syphilis and thyroiditis as possible aetiological factors. Further evaluation should be orientated by the clinical context. An improved outcome of membranous glomerulonephritis may be expected insofar as the underlying condition is controlled.

[Hypertrophic kidneys in utero and neonatal renal failure caused by diffuse mesangial sclerosis]. / Gros reins in utero et insuffisance rénale néonatale par sclérose mésangiale diffuse.

The authors report an unusual mode of onset of diffuse mesangial sclerosis in a newborn. Fatal neonatal renal failure, and not infantile nephrotic syndrome, was the main symptom after birth. In utero, ultrasonography revealed hypertrophy and hyperechogenicity of the kidneys associated with oligoamnios.

[Genetic heterogeneity of cystinuria. Study of 12 families]. / Hétérogénéité génétique de la cystinurie. Etude de 12 familles.

The authors attempted to predict the genotypes of 15 cystinuric children, from the results of oral lysine loads on the propositus and the urinary excretion rates of cystine, lysine, ornithine and arginine of their parents and siblings. Type I cystinuria is more common, as well in the homozygous state, as in combination to type II or III (compound heterozygous genotypes).

[Neurologic manifestations of arterial hypertension in children]. / Manifestations neurologiques de l'hypertension artérielle chez l'enfant.

Neurological complications of arterial hypertension are analyzed in 31 children (mean age = 9 years). All patients presented a renal or renovascular disease (acute nephritis + hypoplastic dysplasia , transplantation = 58%) for which malignant hypertension was the first symptom in 16%. The mean +/- SD initial blood pressure was 189 +/- 33/113 +/- 25 mm Hg and was preceded by previous symptoms in 1 patient out of 6. Neurological abnormalities consisted in seizures (48%), acute intracranial hypertension (39%), cranial palsy (23%), coma (19%), hemiplegia/paresia (16%), retinal changes (6%) or aphasia (6%). The EEG was abnormal in 50% of the patients, sometimes showing permanent paroxysmal activity. Neuroradiologic investigations revealed hemorrhagic and/or ischemic lesions in 1/5 patients. On follow-up, hypertension disappeared in 41% of the children; a decrease in renal function was noted in 56% of the patients at the last examination; neurological sequellae were present in 40% (EEG anomalies +/- epilepsy, motor deficit, retinal changes, psychomotor delay, cranial palsy) and 1 patient died. The morbidity of malignant hypertension stresses the importance of early diagnosis and treatment (calcium channel blockers) when its prevention is not possible.