Pediatric renal transplantation: A retrospective single-center study on epidemiology and morbidity due to EBV.

Pediatric R-Tx patients are at high risk of developing EBV primary infection. Although high DNA replication is a risk factor for PTLD, some patients develop PTLD with low viral load. In this retrospective single-center study including all pediatric patients having received R-Tx (2003-2012 period), we aimed to identify risk factors for uncontrolled reactions to EBV (defined as the presence of a viral load >10 000 copies/mL or PTLD). A Cox proportional hazard model was performed. A total of 117 patients underwent R-Tx at a mean age of 9.7 ± 5.3 years, 46 of them being seronegative for EBV at the time of R-Tx. During follow-up, 54 patients displayed positive EBV viral load, 22 of whom presenting with primary infection. An uncontrolled reaction to EBV was observed in 24 patients, whilst 4 patients developed PTLD. Univariate and multivariate analyses suggested the following risk factors for an uncontrolled reaction: age below 5 years, graft from a deceased donor, ≥5 HLA mismatches, EBV-seronegative status at the time of R-Tx, and a secondary post-Tx loss of anti-EBNA. Monitoring anti-EBNA after R-Tx may contribute to the early identification of patients at risk for uncontrolled reaction.

[Factors influencing the acceptability of pediatric galenic formulations]. / Facteurs influençant l'acceptabilité des formulations galéniques en pédiatrie ­ revue de la littérature.

BACKGROUND AND GOAL OF THIS STUDY: Few available galenic formulations of drugs have pediatric doses, so that many of them are used off label in children. The influence of such pharmaceutical formulation on therapeutic adherence was evaluated in a systematic review of the literature. MATERIALS AND METHODS: This search was performed in 4 data bases: Medline, the Cochrane Library, Web of Science and Science Direct. Included articles were in French or English and focused on therapeutic adherence and route of administration. RESULTS: Overall, 51 articles were included in the study: 46 from Medline (27 selected), 1 from The Cochrane Library (1 duplicate), 61 from Web of Science (13 selected) and 23 articles from Science Direct (11 selected). The two main pharmaceutical formulations studied were liquid dosage form 51% (n=28) and solid oral form 35% (n=19). DISCUSSION: Easy use of liquid forms (n=18) (easy dose adjustment and administration) was associated with good adherence. Optimization of organoleptic properties was found to improve adherence (n=20). The main limitations to the use of solid oral formulations are the risk of choking in a child under 6 and difficulty adapting doses for pediatric use. Commercialization of minitablets should help solve these problems (n=3) and therapeutic education sessions could make it possible to prescribe selected pills to children aged 4 or older (n=2). A risk of misuse because of incorrect administration seems to be the reason that aerosols are underused. CONCLUSION: Drug formulation influences therapeutic adherence in children, which is a cornerstone for successful pharmacotherapeutic management.

Are plasma proteins a valid alternative for assessing nephrotic syndrome in children from low-income countries?

BACKGROUND: A diagnosis of nephrotic syndrome (NS) in children with edema relies on urinary albumin excretion and usually plasma protein (Pprot) and albumin (Palb) concentrations. METHODS: In order to fit laboratory tests to optimal healthcare in low-resource countries, we established correlations between Pprot and Palb in children with NS (217 measurements in 60 patients) and in children with exudative enteropathy and chronic hepatopathy/liver insufficiency (186 measurements in 21 patients); all patients had repeated measurements at various stages of their disease. RESULTS: There was a good correlation between Pprot and Palb in children with idiopathic NS and genetic NS (ICC=0.8, p < 0.0001, 95% CI: 0.8-0.9 and ICC=0.8, p < 0.0001, 95% CI: 0.7-0.8, respectively), whereas the correlation was average (exudative enteropathy) or absent (chronic hepatopathy) in those without renal protein loss. CONCLUSION: Since Palb measurement is around two times more expensive than Pprot measurement, these results suggest giving priority to total Pprot measurement in the diagnosis and follow-up of children with the NS, mainly in low-resource countries.

A randomized trial to assess the impact of early steroid withdrawal on growth in pediatric renal transplantation: the TWIST study.

Minimizing steroid exposure in pediatric renal transplant recipients can improve linear growth and reduce metabolic disorders. This randomized multicenter study investigated the impact of early steroid withdrawal on mean change in height standard deviation score (SDS) and the safety and efficacy of two immunosuppressive regimens during the first 6 months after transplantation. Children received tacrolimus, MMF, two doses of daclizumab and steroids until day 4 (TAC/MMF/DAC, n=98) or tacrolimus, MMF and standard-dose steroids (TAC/MMF/STR, n=98). Mean change in height SDS was 0.16 +/- 0.32 with TAC/MMF/DAC and 0.03 +/- 0.32 with TAC/MMF/STR. The mean treatment group difference was 0.13 (p < 0.005 [95% CI 0.04-0.22]), 0.21 in prepubertal (p = 0.009 [95% CI 0.05-0.36]) and 0.05 in pubertal children (p = ns). Frequency of biopsy-proven acute rejection was 10.2%, TAC/MMF/DAC, and 7.1%, TAC/MMF/STR. Patient and graft survival and renal function were similar. Significantly greater reductions in total cholesterol and triglycerides but significantly higher incidences of infection and anemia were found with TAC/MMF/DAC (p < 0.05 all comparisons). Early steroid withdrawal significantly aided growth at 6 months more so in prepubertal than pubertal children. This was accompanied by significantly better lipid and glucose metabolism profiles without increases in graft rejection or loss.

Survey of first-year medical students to assess their knowledge and attitudes toward organ transplantation and donation.

BACKGROUND: The important shortage of organ donors is still a fundamental public health problem in France. Improving the knowledge and attitudes of health care professionals could help to promote organ donation. The aim of this survey was to evaluate the level of knowledge of medical students and their gaps about organ donation prior to any medical course. MATERIALS AND METHODS: A survey was conducted among 571 first-year medical students at a medical faculty in Lyon. Their knowledge, attitudes, personal views, and perceptions toward organ donation and transplantation were investigated prior to any medical course. A 31-item anonymous questionnaire including queries about personal views of organ donation, factual knowledge, and awareness of French law was distributed to the students. RESULTS: To "willingness to donate a kidney to a relative," 97.7% of respondents consented, 0.9% objected, and 1.4% did not answer. Their attitudes toward cadaveric organ donation were different: 81.1% agreed, 13.5% refused, and 5.4% did not answer. Regarding their knowledge about which organs could be transplanted, 95% of the respondents were aware of the possibility to transplant a face and 14% thought that xenotransplantation was performed nowadays. CONCLUSIONS: First-year medical students have a good knowledge level regarding the organ donation and transplantation system prior to their medical course. Some gaps remain which could be improved. The results of this study supported a greater emphasis on providing information regarding transplantation in medical schools to improve the knowledge of future health care professionals. A follow-up survey of the participants at the end of their medical course will be interesting to assess the progress of their attitudes.

[Active drug monitoring of adverse drug reactions in pediatric emergency department]. / Recueil systématique et actif des évènements indésirables médicamenteux chez les enfants admis aux urgences pédiatriques.

OBJECTIVES: The aim of this study was to systematically evaluate adverse drug reactions (ADRs) in children consulting at the pediatric emergency unit during a 6-month period. METHOD: The regional pharmacovigilance center (CRPV) and the department of clinical pharmacology prospectively and systematically recorded all potential ADRs among patients younger than 18 years of age in the pediatric emergency unit reported at the daily staff meetings. All cases were then screened and validated by the CRPV. For validated cases, preventability, seriousness, and off-label use were evaluated. RESULTS: During the study period, from 1 March to 1 September 2005, 90 children presented potential adverse drug events. ADRs were confirmed in 43 patients, 19 females and 24 males. Thirty-four patients (79%) were under the age of 5. According to the European definition, 14 patients (33%) had serious ADRs. One anaphylactic shock after amoxicillin injection; antimalarial prophylaxis misuse leading to convulsive status epilepticus, convulsion, and coma after hepatitis B and MMR vaccines were deemed life-threatening. Three ADRs were considered avoidable. Antibiotics and vaccines were the most common possible cause of ADRs (76%). Skin reactions (n=27), fever (n=8), and gastric disorders (n=5) were the most common clinical manifestations. CONCLUSIONS: Because ADRs were reported by clinicians on a voluntary basis, serious ADRs were probably reported more systematically. Compared to a similar period without active monitoring, active drug monitoring of ADRs doubled the number of confirmed cases 43 vs 17, p<0.001. Close collaboration between the pharmacovigilance center, pharmacologists, and clinicians is necessary and seems feasible for improving the monitoring of ADRs in children.

[Pediatric nephrology in developing countries]. / Néphrologie pédiatrique dans les pays en développement.

Pediatric nephrology is not a priority medicine in developing countries, but it should improve along with the development of both preventive and curative simple measures since the mortality rate is still important. This can be applied to the management of urinary tract infection, acute nephritis and some other cases of acute renal failure. The identification and management of chronic kidney diseases is mainly based on blood pressure measurement, proteinuria screening and plasma creatinine assessment. However renal replacement therapy (i.e., dialysis and transplantation) is highly expensive and its access is therefore limited to selected growing countries. The improvement in the care of renal children therefore requires better medical knowledge, nurse training and population information.

Paediatric systemic lupus erythematosus: prognostic impact of antiphospholipid antibodies.

OBJECTIVES: The aim of our study was to investigate the prognostic impact of aPL in paediatric onset systemic lupus erythematosus (p-SLE). METHODS: This retrospective study included 56 patients with p-SLE. Chi2-test, Fisher's exact test, incidence rate ratio and Kaplan-Meier survival curves were used to compare aPL-positive and aPL-negative patients considering the value of SDI (Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index for SLE) at the end of follow-up, the occurrence of thromboses, organ system involvements and need for immunosuppressive treatment in addition to corticosteroids. RESULTS: Anti-cardiolipin antibodies and lupus anticoagulants were detected in 27 (49%) and 19 (35%) patients, respectively. These aPL were frequently transient or intermittent (10 and 15 cases, respectively), and only rarely persistent over time (five cases). The risk of thrombosis was significantly higher (odds ratio = 6.42) and occurred earlier in the presence of aPL, especially if aPL were persistent (P < 0.05). The association between aPL and neurological, renal, haematological manifestations or need for immunosuppressive treatment was not statistically significant. After a mean follow-up of 7.2 yrs, 30 patients (54.5%) had an SDI score > or = 1. The risk of damage (SDI > or = 1) in aPL-positive patients was three times higher than in aPL-negative patients (P < 0.05). Four of the six fatal cases occurred in the aPL-positive group. CONCLUSIONS: The presence of aPL in p-SLE could represent not only a risk factor for thrombosis but also a poor prognostic factor overall.

[Urinary tract infection and antibiotics: oral or intravenous route?]. / Antibiothérapie de l'infection urinaire: orale ou parentérale ?

Management of acute pyelonephritis has long been discussed. The French drug agency (Agence Française de Sécurité Sanitaire des Produits de Santé [AFSSAPS]) has published guidelines for clinical practice in 2007: two to four days of initial parenteral antibiotic therapy followed by oral antibiotics, for a total duration of 10 to 14 days. However, recent data are conflictable and oral antibiotic therapy may be sufficient in some cases. Clinical trials on oral therapy of acute pyelonephritis in selected groups of children are currently ongoing. We suggest following AFSSAPS recommendations in clinical practice until the results of such trials become available. In the future, we can speculate that antibiotic therapy may be reduced in some low risk patients, keeping in mind that around 15% of children with acute pyelonephritis will develop renal scars which may lead to hypertension and microalbuminuria in adulthood.

[What about the long-term renal outcome of premature babies?]. / Le rein des anciens prématurés est-il menacé ?

Long-term renal prognosis of expreterm children remains uncertain. The fetal programming theory partially explains adult-onset hypertension, metabolic syndrome and cardiovascular risk in populations of small for gestational age infants. Further studies about long-term renal outcome are warranted because there is a reduction of nephron number in animal models of intrauterine growth restriction (IUGR). An early prevention focused on cardiovascular risks, nutritional mistakes and obesity must be scheduled in populations of expreterm children and IUGR. Since long-term renal outcome is not well known, it may be interesting to perform a regular follow-up of renal parameters (for example: blood pressure, serum creatinine and urinary albumin/creatinine ratio) and to refer children when abnormalities are highlighted.

[Long-term steroid therapy in children: is adjunct therapy relevant in nephrotic syndrome?]. / Corticothérapie prolongée chez l'enfant : quelle place pour un traitement adjuvant dans le syndrome néphrotique ?

The impact of glucocorticoids on bone is specifically relevant in children exposed to a long course of treatment. Corticosteroids lead to a decrease in bone formation, mainly by osteoblastic inhibition in trabecular bone. They also play an indirect role in bone metabolism through systemic actions, such as bone maturation delay, hypogonadism, pubertal delay, and IGF1 inhibition. A systematic review of the literature was conducted. We found 12 clinical trials of interventions including calcium, vitamin D, growth hormone, calcitonin, and bisphosphonates for preventing bone disease in children receiving steroid therapy. There were few randomized controlled trials (n=7), with a limited number of patients, so that a meta-analysis could not be performed. Calcium and vitamin D supplementation may, however, have a beneficial effect on bone in children with nephrotic syndrome receiving long-term steroid therapy. We, therefore, recommend routine vitamin D supplementation, use of steroid-sparing protocols, and global prevention of risk to bone (adequate calcium intake, sun exposure, and physical activity).

[Multicystic dysplastic kidney disease: update and information for parents at the time of prenatal diagnosis]. / Dysplasie rénale multikystique: mise au point et information pour les parents lors du diagnostic anténatal.

Multicystic kidney disease (MCKD) is the most common form of Congenital Abnormality of Kidney and Urinary Tract (CAKUT). This anomaly of renal development is characterized by unilateral enlarged cystic formations and fibrous dysplastic parenchyma. The long-term prognosis is usually good; however because of reduced nephron mass, an early prevention of cardiovascular risk and nephrotoxicity is recommended. A lifelong follow-up of blood pressure, serum creatinine and microalbuminuria seems logical as well as in other patients with a single kidney. MCKD is usually diagnosed during pregnancy so that parents often question about long-term prognosis and follow-up. Therefore, we propose an information sheet for parents.

[Renal tubular dysgenesis and mutation in the renin gene]. / Dysgénésie tubulaire proximale et mutation du gène de la rénine.

Renal tubular dysgenesis is a severe and rare disorder of the renal development characterized by fetal anuria, oligohydramnios and early death from pulmonary hypoplasia and refractory arterial hypotension. We report on a female patient who presented with anuria in the neonatal period, requiring peritoneal dialysis until 5 months of age with unexpected diuresis recovery at 2 months of age. Clinical, histological and pathophysiological issues are discussed for this disease related to a mutation in the renin gene.

[Renal abnormalities in Down syndrome: A review]. / Atteintes rénales de la trisomies 21.

Down syndrome (DS) is often associated with cardiac malformations, so that kidney damage is little known. The objective of this study was to present the diversity of renal abnormalities and their potential progression to chronic renal failure. Among congenital abnormalities of the kidney and urinary tract (CAKUT) abnormalities appear to be frequent: pyelectasis, megaureters, posterior urethra valves, as well as renal malformations such as renal hypoplasia, horseshoe kidney, or renal ectopia. Contributing factors to acute kidney failure have been described in patients with DS: bilateral lesions and minor renal injury, such as glomerular microcysts, tubular dilation, and immature glomeruli. Histological lesions can be found, albeit nonspecific; they occur earlier than in the general population. Two metabolic specificities have also been described: decreased clearance of uric acid and a hypercalciuria by passive hyperabsorption. End-stage renal disease can occur, thus raising the problem of the best choice of management. In conclusion, renal abnormalities in patients in DS should be known so as to preserve a good renal functional prognosis: systematic screening with renal ultrasound can be proposed.

[What is new in pediatric nephrology?]. / Quoi de neuf en néphrologie pédiatrique?

Recent advances in the knowledge of physiology, genetics, imaging, and therapeutics have lead to novel practical approaches in paediatric nephrology. Many inherited syndromes have been revisited in order to identify precise renal diseases at the molecular level. In addition, a large number of epidemiological studies and clinical trials have allowed guidelines and recommendations to be provided for chronic and end-stage renal failure, urinary tract infection, glomerular diseases, etc.

Neonatal transient hypophosphatemic hypercalciuric rickets in dizygous twins: A role for maternal alendronate therapy before pregnancy or antireflux medications?

BACKGROUND: Bisphosphonates (BP) are sometimes used in children and young women, but their use requires expertise and caution due to the relative lack of long-term efficacy and safety data. CLINICAL CASES: We report on two dizygotic male twins with a past of mild prematurity who presented at the age of 2 months with moderate clinical craniotabes, hypophosphatemia, normal circulating calcium, severe hypercalciuria, and low parathyroid hormone levels. Following supplementation with oral phosphorus and native vitamin D, the clinical and biological abnormalities disappeared within 2 months. Since the twins were dizygotic and were identical in terms of clinical presentation and progression, the only likely explanation for these transient mineral abnormalities was prenatal or neonatal exposure to a toxic agent. Taking into account their medical past, two drugs were possibly involved: either oral alendronate that their mother had received before pregnancy for misdiagnosed osteoporosis or antireflux medications, or both. DISCUSSION: We believe that these two cases could correspond to the first description of a potential mother-to-fetus transmission of alendronate, inducing early and transient hypophosphatemic rickets, the clinical picture being worsened by the antireflux drugs impairing intestinal phosphate absorption. For pediatric rheumatologists, this raises the question of more clearly defining the indications for BP in female children and teenagers; for rheumatologists, this also demonstrates the importance of correctly diagnosing osteoporosis and not using BP off-label, especially in women of child-bearing age.

Oral drug dosage forms administered to hospitalized children: Analysis of 117,665 oral administrations in a French paediatric hospital over a 1-year period.

Selecting the most appropriate dosage form, that ensures safe administration and adherence of medications, is a major issue for children. Marketed drugs, however, have rarely been tested for their use in children. There is a need for more data on drug formulations administered to children to identify unmet needs, and drive future paediatric research. We observed, over a 12-month follow-up, 117,665 oral drug administrations to 1998 hospitalized children. Nine-tenths belonged to five Anatomical Therapeutic Chemical classes: Alimentary tract & metabolism, Nervous system, Cardiovascular system, Anti-infectives for systemic use and Blood & blood forming organs, one third of drug doses administered to school-age children and adolescents were liquids, and extemporaneous capsules were commonly used in younger children. Our study shows that despite the advantages of solid dosage forms and recent evidence from randomized controlled trials showing their acceptability in infants, they are seldom used in paediatric practice.

Interleukin-2 and lymphokine-activated killer cells in 15 children with advanced metastatic neuroblastoma.

A phase II trial using interleukin-2 (IL2) and lymphokine-activated killer (LAK) cells was carried out in an attempt to treat children with end-stage neuroblastoma. Fifteen patients (median age, 7 years) were enrolled in the study. Twelve were in relapse after massive chemotherapy and autologous bone marrow transplantation (ABMT), and three had a primary refractory disease after conventional chemotherapy. IL2 was administered as an 18 x 10(6) IU/m2/d continuous infusion. One course consisted of a double 5-day treatment period separated by a 6-day break. Cytapheresis to harvest LAK progenitor cells was performed during the rest period. After a 4-day in vitro culture, LAK cells were reinjected during the second cycle of therapy. A phenotypic and functional analysis of immunologic parameters was conducted along with the therapeutic protocol. Toxicity was significant with two toxic deaths (cardiotoxicity and respiratory distress). The reinfusion of large amounts of LAK cells was clearly involved in one case, but this particularly severe toxicity has to be related to the patient's status (ie, heavy pretreatment). No significant clinical response was seen. The immunologic monitoring showed phenotypic and functional modifications in these patients before initiation of treatment and an unexpected absence of evolution of these parameters during IL2 therapy. Although the origin of these immune dysfunctions is not clear, they could be involved in the failure of IL2 therapy. Future studies of IL2 therapy in neuroblastoma should be undertaken earlier in the course of the disease.

[Relation between ocular manifestations and organ involvement in ten patients with Fabry disease]. / Relation entre les manifestations ophtalmologiques et les atteintes générales chez dix patients atteints de la maladie de Fabry.

PURPOSE: To describe ocular manifestations in Fabry disease and compare them to other organ involvement in this disease. PATIENTS AND METHODS: Ten patients were included in a clinical trial, all of whom had specialized investigations in ophthalmology, cardiology, nephrology and dermatology. RESULTS: All the patients presented with ocular damage, some of which were rather characteristic of this disease, such as cornea verticillata and spoke-like cataract. However, such anomalies were not responsible for any visual acuity changes in most patients. Some patients had renal or cardiovascular damage at early stages of the disease. We therefore tried to establish a correlation between the severity of such involvement and ocular damage. CONCLUSION: Many ocular manifestations are frequently observed that should suggest a diagnosis of Fabry disease. However, there is no clear relationship between the presentation of the systemic cardiac and renal manifestations of the disease and the presence of ocular abnormalities.

[MURCS association: a challenging diagnosis]. / Association MURCS: difficultés diagnostiques à propos d'un cas.

MURCS association includes Mullerrian duct aplasia-hypoplasia (MU), renal malformations (R) and cervicothoracic somite dysplasia (CS). This rare disease (1/50 000 females) is sporadic and of unknown aetiology. The reported case is the first one with additional esophageal atresia and ovarian mature teratoma. Esophageal atresia first led to the diagnosis of VACTERL association, which is more frequent and well known, showing that the identification of such malformative association may be challenging. The presence of mullerrian abnormality has allowed the diagnosis of MURCS association, as there is no mullerrian hypoplasia in VACTERL association. Therefore the association of isolated or combined renal and cervical malformation with VACTERL features should lead to the search for mullerrian abnormalities.