Posterior reversible encephalopathy syndrome after kidney transplantation in pediatric recipients: Two cases.

PRES is a neuro-clinical and radiological syndrome that can result as a consequence of several different conditions including hypertension, fluid overload, and immunosuppressive treatment. Herein, we report two children who received kidney and combined liver-kidney transplantation as treatment for renal hypodysplasia associated with bilateral vesico-ureteral reflux and methylmalonic acidemia, respectively. Early after surgery (seven and 10 days), both patients presented with hypertension and seizures. The patients' immunosuppressive regimen included steroid and calcineurin inhibitors (tacrolimus and cyclosporine, respectively) and basiliximab and one with anti-IL2 receptor. In both cases, the imaging strongly supported the diagnosis of PRES. In details, the CT scan showed hypodensities in the posterior areas of the brain, and brain MRI demonstrated parieto-occipital alterations indicative of vasogenic edema. Treatment with calcineurin inhibitors was temporally discontinued and restarted at lower dosage; arterial hypertension was treated with Ca-channel blockers. Both children fully recovered without any neurological sequels. In conclusion, in children undergoing solid organ transplantation, who develop neurological symptoms PRES, should be carefully considered in the differential diagnosis and once the diagnosis is ruled in, we recommend strict arterial blood pressure control and adjustment or withholding of calcineurin inhibitor therapy should be considered based upon blood levels.

What has changed in more than 40 years of activity and 3000 kidney transplants at Policlinico University Hospital, Milan.

The activity of kidney transplantation at Policlinico University Hospital, now the Ca' Granda Foundation, was established by Professor Edmondo Malan, who performed the first deceased donor transplantation in Milan, Italy, in 1969. Since then, 2989 kidney transplant procedures (2760 first, 219 second, 10 third transplants) have been performed through the end of November 2011, 2617 of them coming from deceased donors and 372 from living donors. Patient and graft survival have increased since the introduction of cyclosporine and tacrolimus in the last 28 years: 323 living donor-recipients under calcineurin inhibitors (CNI) show patient survival of 95.4% at five years and 88% at 10 years, not significantly different when compared with those of 1968 deceased donor-recipients (93.5% and 86.2%, respectively, at the same time points). Crude graft survival for living donor-recipients under CNI is 84.2% at 5 years and 70.2% at 10 years, not significantly different from those of deceased donor-recipients (80.3% and 64.3% for at the same time points). Actuarial graft survival censored by death is 87.2% at 5 years and 76.5% at 10 years for living donor-recipients vs. 84.4% and 72.2% for deceased donor-recipients, respectively. Previously unacceptable living or deceased kidneys are now successfully transplanted after being repaired with microsurgical techniques at bench. The rate of donors over 60 years of age has increased from 3.8% in the period of 1983-1995 to 20.8% in the last 15 years. It is interesting to note that 306 older kidneys (living donor, deceased donor, first, second, third transplants, with mean donor age of 64.6 +/- 4.0 yrs. and range 60-77 yrs.), always transplanted singularly, have similar behavior if compared with organs coming from donors aging 11-49 years. Survival rates are 93.1%, 90.1%, 88.4%, and 73.2% at 1, 3, 5, and 10 years post-transplant for the older donor grafts vs. 91.2%, 88.1%, 85.4%, and 74.4% for the younger donor grafts at the same time points. Perhaps the practice of dual transplant should be revisited and reserved to very old and ECD-donors. An open subcostal mini-incision (MINI) has been utilized in 177 living donors since 1996. This technique offers the same advantages of hand assisted videolaparoscopic technique, no disadvantages, and no major complications. Although more older and unrelated living donors are included in the MINI-group, very good results are obtained in these recipients, with graft survival censored by death of 97.2%, 95.3%, 93.8%, and 86.3% at 1, 3, 5, and 10 years post-transplant.