Sleep disturbances in children and adolescents after kidney transplantation.

BACKGROUND: Disturbances of sleep are prevalent among children with chronic kidney disease. However, the aetiology of sleep disorders in children particularly after kidney transplantation is not clear. We sought to ascertain the prevalence and type of sleep disturbances in paediatric kidney transplant recipients and to identify predictors of sleep disturbances in this population. METHODS: Caregivers of kidney transplant recipients completed online questionnaires about their child's sleep. The questionnaires utilised were the Sleep Disturbance Scale for Children (SDSC), the Epworth Sleepiness Scale for Children and Adolescents (ESS-CHAD), questions about sleep hygiene, and questions about restless leg syndrome. Demographic and clinical details were collected from medical records. RESULTS: Thirty-five children were included in the study, with a median (IQR) age of 14.1 years (9.5-16.1) and median years (IQR) since transplant of 3.7 (0.7-8.7) years, and 72.0% were identified to have at least one category of sleep disturbance according to scores on the SDSC. The most common sleep disturbances reported were disorders of initiating and maintaining sleep (DIMS) (40.0%) and disorders of excessive somnolence (DOES) (31.4%). Statistically significant predictors of sleep disturbances include low estimated glomerular filtration rate and increased age. Among children who screened positive for DIMS and DOES, the majority indicated use of electronic devices in 1 h before bed. CONCLUSIONS: A high prevalence of sleep disturbances has been identified in children after kidney transplants, and some risk factors may be modifiable. Further studies are required to understand whether there are other readily modifiable predictors of sleep disturbances.

Effect of perioperative management on early graft function in living donor paediatric kidney transplantation.

BACKGROUND: Paediatric kidney transplantation has an increased risk of surgical and vascular complications, with intensive care monitoring required postoperatively. This study aimed to determine if perioperative management affects early graft function in living donor paediatric kidney transplantation. METHODS: Clinical data was extracted from the electronic medical record for living donor kidney transplants at two paediatric centres covering the state of New South Wales (NSW), Australia from 2009 to 2021. Estimated glomerular filtration rate (eGFR) of 7 days and 1-month post-transplant were calculated as measures of early graft function. RESULTS: Thirty-nine eligible patients (female n (%) 13 (33%)) with a median (IQR) age of 6 (3-9) years and pre-transplant eGFR of 7 (6-10) mL/min/1.73 m2 were analysed. Mean (SD) central venous pressure (CVP) after revascularisation was 11 (4) mmHg. Intraoperatively, mean volume of fluid administered was 84 (39) mL/kg, and 34 (87%) patients received vasoactive agents. Average systolic blood pressure (BP) in the first 24-h post-transplant was 117 (12) mmHg. Postoperatively, median volume of fluid administered in the first 24 h was 224 (159-313) mL/kg, and 17 (44%) patients received vasoactive agents. Median eGFR 7 days and 1-month post-transplant were 115 (79-148) and 103 (83-115) mL/min/1.73 m2, respectively. Linear regression analyses demonstrated that after adjusting for age, the average CVP after revascularisation and average systolic BP in the first 24-h post-transplant were not associated with eGFR in the first month post-transplant. CONCLUSIONS: Targeted intraoperative and postoperative fluid and haemodynamic characteristics were achieved but did not correlate with early graft function.

Does the Nutritional Intake and Diet Quality of Children With Chronic Kidney Disease Differ From Healthy Controls? A Comprehensive Evaluation.

OBJECTIVE: Children with chronic kidney disease (CKD) experience many obstacles to achieving optimal dietary intake. Dietary intake patterns remain unexplored or poorly described. This study compares nutritional intake and diet quality of Australian children with CKD to controls. METHODS: A food frequency questionnaire captured intake data and was compared to controls. Nutritional intake was determined using individualized nutrient reference values, and diet quality described using the Australian Guide to Healthy Eating and the Australian Child and Adolescent Recommended Food Score. RESULTS: Children with CKD (n = 36) and controls (n = 82) were studied. Children with CKD had lower weight and height z scores, but higher body mass index (P < .0001 for all parameters). Children with CKD had adequate energy intake, and excessive protein and sodium intake (336% and 569%). They were significantly less likely to meet requirements for vitamin A (P < .001), thiamine (P = .006), folate (P = .01), vitamin C (P = .008), calcium (P < .0001), iron (P = .01), magnesium (P = .0009), and potassium (P = .002). No child met recommended vegetable intake; however, less than half of children with CKD met fruit (44%), grains (31%), and dairy serves (31%). They were also less likely to meet recommended fruit and dairy serves (P = .04 and P = .01, respectively). Non-core foods provided 36% of energy, and although comparable to controls, was contributed more by takeaway foods (P = .01). CONCLUSION: Children with CKD have reduced nutritional intake of key nutrients and consume more takeaways than controls. Attention to increasing core foods, limiting sodium intake, and managing restrictions while promoting nutrient density appears necessary.

Medical student interactions with children in their daily lives.

Learning to communicate effectively with children in clinical interactions can be challenging. This study aimed to determine the extent to which medical students are exposed to children in their daily lives, in order to understand the experience students bring when entering paediatric rotations. METHODS: A cross-sectional survey of medical students entering paediatric rotations from two medical schools was conducted. Students were asked to rate the frequency of their interactions with infants, preschool-aged and school-aged children and their confidence in doing so. RESULTS: 339 out of 476 students participated in this study. Interactions with infants and preschool-aged children were rare, with most students reporting interactions once or two times per year or less (83% and 67%, respectively). Students interacted with school-aged children more frequently (43% most weeks or days). Students who interacted more frequently with children were more confident when entering their paediatric placements. CONCLUSIONS: Medical students have limited exposure to infants and preschool-aged children in their daily lives and this affects their confidence. Supervisors should incorporate activities aimed at building confidence interacting with young children early in clinical attachments.

Oral health status and factors associated with oral health of primary school children in Gulu district, northern Uganda.

BACKGROUND: Globally, oral diseases remain a major public health problem. However, there is limited information about the oral health status and factors associated with oral disease among children in Uganda. The aim of this study was to examine the oral health status and factors associated with oral health of primary school children in urban and rural areas of the Gulu district of northern Uganda. METHODS: A comparative cross-sectional study was conducted among 356 school children aged 11-13 years attending six schools located in urban and rural areas. The children received a clinical oral examination and participated in a questionnaire survey that collected information on sociodemographic and oral health knowledge, attitude, and practices. All data were entered and analysed using IBM SPSS Statistics for Windows, Version 26.0. Armonk, NY: IBM Corp statistical software. Logistic regression analyses examined factors associated with dental caries and gingival bleeding. RESULTS: Of the 356 children (11-13 years) included, the mean age was 12.2 years, 140 (39.3%) were male and 176 (49.4%) were from urban areas. The proportion of school children with dental caries was 33.6% (n = 119), with the mean decayed, missing due to caries, and filled teeth (DMFT) index of 0.81 (25th percentile = 0; 75th percentile = 1.00). There was no significant difference in caries prevalence between rural and urban children (31.6% versus 35.6%, p = 0.33). Of the children involved in the study, 141(39.8%) had gum bleeding. The mean oral knowledge score was 2.85 ± 1.53 (range, 0-7), while the mean attitude, hygiene practice, frequency of sweets consumption, and oral health related impact scores were 4.25 ± 1.23 (range, 1-6), 5.40 ± 1.81 (range, 0-9), 25.66 ± 4.29 (range 9-54) and 2.1 ± 1.65 (range, 0-6), respectively. Using logistic regression analyses, as oral health knowledge score increased the odds of not having dental caries increased (aOR = 1.19, 95% CI 1.02-1.39). CONCLUSION: The prevalence of dental caries and gum bleeding of primary school children in Gulu district is high. Children lacked knowledge on causes of oral disease, and behaviour towards oral disease prevention. In addition, oral health knowledge scores were significantly associated with dental caries. Oral health education programs in schools should emphasise providing skills-based education.

Baseline characteristics of participants in the NAVKIDS2 trial: a patient navigator program in children with chronic kidney disease.

BACKGROUND: Children with chronic kidney disease (CKD) require multidisciplinary care to meet their complex healthcare needs. Patient navigators are trained non-medical personnel who assist patients and caregivers to overcome barriers to accessing health services through care coordination. This trial aims to determine the effectiveness of a patient navigator program in children with CKD. METHODS: The NAVKIDS2 trial is a multi-center, waitlisted, randomized controlled trial of patient navigators in children with CKD conducted at five sites across Australia. Children (0-16 years) with CKD from low socioeconomic status rural or remote areas were randomized to an intervention group or a waitlisted control group (to receive intervention after 6 months). The study primary and secondary endpoints include the self-rated health (SRH) (primary), and utility-based quality of life, progression of kidney dysfunction of the child, SRH, and satisfaction with healthcare of the caregiver at 6 months post-randomization. RESULTS: The trial completed recruitment in October 2021 with expected completion of follow-up by October 2022. There were 162 patients enrolled with 80 and 82 patients randomized to the immediate intervention and waitlisted groups, respectively. Fifty-eight (36%) participants were from regional/remote areas, with a median (IQR) age of 9.5 (5.0, 13.0) years, 46% were of European Australian ethnicity, and 65% were male. A total of 109 children (67%) had CKD stages 1-5, 42 (26%) were transplant recipients, and 11 (7%) were receiving dialysis. CONCLUSION: The NAVKIDS2 trial is designed to evaluate the effectiveness of patient navigation in children with CKD from families experiencing socioeconomic disadvantage. A higher resolution version of the Graphical abstract is available as Supplementary information.

Effectiveness of primary school-based interventions in improving oral health of children in low- and middle-income countries: a systematic review and meta-analysis.

BACKGROUND: Risk factors for oral disease can potentially be ameliorated by school-based interventions. This review evaluates the effectiveness of primary school-based interventions in improving oral health among children in low-and middle-income countries (LMICs). METHODS: Our systematic review was conducted in accordance with the Joanna Briggs Institute methodology for systematic reviews of effectiveness. Medline, Embase, Global Health, CINAHL, Emcare, Scopus, Web of Science, WHO website, Google Advanced and Google Scholar were searched for experimental and observational studies published between 1995 and 2021 in English. Quality assessment and data extraction of the articles were performed by two independent reviewers. The primary outcome was decayed, missing, and filled teeth/surfaces [dmft(s)/DMFT(S)] scores. Seven meta-analyses were conducted. RESULTS: The search yielded 1178 publications and after removing duplicates, 753 remained. A further 648 publications were excluded after screening titles and abstracts. 105 publications were reviewed in full and 34 were included. Narrative synthesis showed school-based interventions had a positive effect on oral health outcomes. Meta-analysis showed a significant positive effect on dental caries measured by DMFT scores (standardised mean difference (SMD) = - 0.33; 95% CI - 0.56 to - 0.10; P = 0.005), net increment in DMFS scores (SMD = - 1.09; 95% CI - 1.91 to - 0.27; P = 0.009), dmft and DMFT/S score > 1 (Risk Ratio = 0.70; 95% CI 0.53 to 0.94; P = 0.02) and plaque scores (SMD = - 0.32; 95% CI - 0.46 to - 0.18; P < 0.00001). Non-significant positive effect was observed for dental caries measured by net increment in DMFT scores (SMD = - 0.34; 95% CI - 0.69 to 0.02; P = 0.06) and DMFS scores (SMD = - 0.26; 95% CI - 0.70 to 0.18; P = 0.24), and gingival health (SMD = 0.12; 95% CI - 0.32 to 0.55; P = 0.60). Certainty of evidence was assessed as very low for all oral health outcomes. CONCLUSION: School-based interventions can be effective in reducing the burden of oral disease among primary school children in LMICs, with skills-based education, teacher training, provision of access to oral health services and parental engagement emerging as particularly promising. Further research is required to provide evidence of effectiveness of primary school-based interventions to improve oral health. Systematic review registration The title of this review was registered with PROSPERO (registration number: CRD42020202599).

Primary school teachers' contributions to oral health promotion in urban and rural areas of the Gulu District, Northern Uganda: a qualitative study.

BACKGROUND: Dental caries remains the most prevalent non-communicable disease globally affecting 60-90% of children. The World Health Organisation's (WHO) health-promoting school program offers a framework for dental intervention in low- and middle-income countries (LMICs). This study explored teacher contributions to children's oral health in relation to the WHO health-promoting school framework in rural Uganda. METHODS: Semi structured interviews were conducted with a purposive sample of 18 teachers. All interviews were transcribed verbatim and analysed thematically. RESULTS: Many teachers reported preparing children to practise proper oral hygiene care through skills training and demonstrations around proper teeth brushing. Teachers' roles included raising health awareness by providing information on oral health topics using different educational methods. Many teachers mentioned performing oral health examinations on children at the school, first aid, referral for dental treatments and engaging parents, students and health workers in oral health promotion. CONCLUSIONS: Teachers play an essential role in oral health promotion in countries like Uganda. Teachers are implementing key principles of the WHO's health-promoting school framework on the ground and need to be considered as a key public health resource. If improvements in oral health are to be attained in Sub-Saharan Africa and other LMICs, government interventions need to harness teachers' contributions in delivering oral health promotion.

Congenital subpendymal giant cell astrocytoma in children with tuberous sclerosis complex: growth patterns and neurological outcome.

BACKGROUND: Literature regarding congenital subependymal giant cell astrocytomas (SEGA) is limited, and suggests they are at risk of rapid growth and complications. We sought to characterise the growth patterns of congenital SEGA. The second part of the study was an exploratory analysis of congenital SEGA as a possible biomarker for poor neurological outcome. METHODS: This single-centre case series describes ten patients with TSC who had SEGA diagnosed before 12 months. SEGA diameter and volumetric growth were analysed using serial MRIs. Neurological outcomes were compared to a genotype-matched group. RESULTS: All children with congenital SEGA had a TSC2 mutation. Patients were followed for 1-8.7 years, during which median SEGA growth rate was 1.1 mm/yr in diameter or 150 mm3/yr volumetrically. SEGA with volume > 500 mm3 had a significantly higher growth rate compared with smaller SEGA (462 mm3/yr vs. 42 mm3/yr, p = 0.0095). Children with congenital SEGA had a high prevalence of severe epilepsy, developmental disability and autism spectrum disorder. CONCLUSION: Congenital SEGA can follow a relatively benign course with a lower growth rate compared with published literature. Frequent neuroimaging surveillance is recommended for congenital SEGA with volumes exceeding 500 mm3. IMPACT: Congenital SEGA occur in 9.2% of paediatric patients with tuberous sclerosis complex. There are few published cases of congenital SEGA to date. This case series of ten patients adds our experience seen in a tertiary referral hospital over 10 years. Congenital SEGA can follow a relatively benign course with a lower growth rate compared with published literature. Congenital SEGA with volume exceeding 500 mm3 had a significantly higher growth rate compared with smaller SEGA and should have more frequent neuroimaging surveillance.

Renal tumors in tuberous sclerosis complex.

Tuberous sclerosis complex (TSC) is a multisystem hereditary disorder characterized by the growth of benign tumors (hamartomas) in multiple organs, including the kidneys. Renal angiomyolipomas (AML) are a major diagnostic feature of TSC and are present in the majority of patients by adulthood. However, AML are usually asymptomatic during childhood when neurological and developmental manifestations are the main source of morbidity. Kidney manifestations of TSC have historically been the main cause of morbidity and mortality of adults with TSC. The recognition that the complications of TSC are caused by dysregulation of the mammalian target of rapamycin (mTOR) pathway has led to an enormous progress in the management of patients with TSC in the last two decades, the establishment of diagnostic guidelines, and trials which have shown the therapeutic benefit of mTOR inhibitors. Kidney surveillance of children with TSC now provides the opportunity for timely interventions to reduce the impact of TSC in adulthood. In this review, we discuss the current management of kidney tumors associated with TSC, including the diagnosis, surveillance, and treatment options for these lesions. We also present outcome data from international registries demonstrating the effectiveness of the current management strategies. With clear management guidelines and efficient treatment of kidney tumors, we envisage that the long-term outcomes of patients with TSC will further improve in the future.

Levamisole and ANCA positivity in childhood nephrotic syndrome.

BACKGROUND: This study aimed to determine the prevalence of ANCA positivity in children managed with levamisole as a steroid-sparing agent for nephrotic syndrome (NS). METHODS: Medical records of children with steroid-sensitive NS managed with levamisole therapy at Sydney Children's Hospital between 1/1/2000 and 31/12/2018 were retrospectively reviewed. Main outcome measure was side effects of levamisole therapy including ANCA positivity. RESULTS: Seventy-one children, median age 3 years and 1 month (IQR 29-68 months) at first presentation, were subsequently managed with levamisole. 60.6% were male and 65% Caucasian. 47.9% had frequently relapsing (FR)NS and 52.1% steroid-dependent (SD)NS. Overall, there was a median reduction in relapses from 3 (IQR 1-5) to 0.4 relapses (IQR 0-1) per year after levamisole was commenced. Levamisole was successful in preventing relapse in 19 (29%) patients and was used for median 24 (22 to 25) months. Levamisole was discontinued due to relapse in 25 patients (38%) after median 12 (5-28) months. Side effects occurred in 28 patients (42.4%); the most common side effect was ANCA positivity in 12 patients. In eleven of these patients, levamisole was discontinued; in one patient, low-level titres were documented and spontaneously resolved without cessation of levamisole. Two patients developed ANCA-associated vasculitis. CONCLUSION: ANCA positivity is a common side effect of levamisole and was seen in 18.2% of our patients. Monitoring is required to determine side effects including ANCA positivity and treatment modified accordingly.

Incidence and predictors of vascular events following end-stage kidney disease in childhood.

AIM: Cardiovascular death is a leading cause of mortality in paediatric end-stage kidney disease (ESKD). There is however little known about the clinically relevant vascular disease in this population. We aimed to describe the incidence of new onset vascular disease and vascular death in Australian children receiving renal replacement therapy (RRT). We also aimed to identify demographic or childhood risk factors for these endpoints, and whether vascular disease predicts mortality. METHODS: Data on Australian patients who commenced RRT at <18 years of age from 1991 to 2017 were extracted from the Australian and New Zealand Dialysis and Transplant Registry (ANZDATA). Multivariable competing risks regression was used to identify factors associated with vascular events. RESULTS: A cohort of 1268 patients were followed up for a median of 10.31 years. Vascular disease was reported in 5.4%, and vascular death in 4.1%. The cumulative incidence of any vascular event, that is, disease or death, at 10 and 20 years was 5.5% and 12.8%, respectively. Childhood vascular events were associated with non-Caucasian, non-Indigenous ethnicity, and for the 804 patients followed up after 18 years of age, vascular events were associated with lack of childhood transplantation, longer childhood dialysis duration and Indigenous ethnicity. Vascular disease was only reported for 25.49% of patients who had a vascular death, and although a significant risk factor for mortality, it had limited ability to predict mortality. CONCLUSION: Cumulative incidence of vascular events is significant after commencing RRT during childhood and is associated with ethnicity, longer childhood dialysis duration and lack of childhood transplantation.

The impact of caring for children with posterior urethral valves.

AIM: To investigate and describe factors contributing to the impact of caring for a child with posterior urethral valves and to determine the extent to which families view their care as family-centred, and whether this can affect the impact of care. METHODS: A cross-sectional, survey-based study involving primary caregivers of children with posterior urethral valves. Caregivers completed the Impact on Family Scale (IOFS) and the Measure of Processes of Care (MPOC). Regression analyses were used to assess the relationship between child-related variables, demographic variables, MPOC and IOFS scores. RESULTS: Thirty-one primary caregivers completed both questionnaires. Caregivers of children with moderate/severe chronic kidney disease (CKD) scored higher on the IOFS compared to those caring for children with mild CKD. Caregivers rated care received highly but reported lower scores in subscales related to information provision. Receiving less respectful and supportive care was significantly associated with lower IOFS scores. CONCLUSION: The impact of caring for a child with posterior urethral valves is variable and is strongly determined by the severity of the associated CKD. Further research is required to show whether improving family centredness of care can reduce the impact of caring for children with posterior urethral valves.

Multidrug-resistant organisms in urinary tract infections in children.

The global spread of multidrug-resistant organisms has led to an increase in urinary tract infections (UTIs) in children that are difficult to treat. This review explores the current literature regarding multidrug-resistant UTIs in childhood and proposes an approach to management. Multidrug-resistant organisms include a wide range of potential urinary tract pathogens and, while most literature on drug resistance in UTIs during childhood has focused on extended-spectrum beta-lactamase producing organisms, in this review, we have included a discussion of multidrug resistance including and beyond beta-lactamase production. We provide definitions for multidrug-resistant organisms in line with current consensus guidelines and summarise clinically relevant mechanisms of resistance. Additionally, in this review, we outline the global epidemiology of multidrug-resistant UTIs in children, summarising published prevalence rates, which range from 5 to 90% in different settings. Finally, we also critically review the evidence on risk factors for colonisation and infection of the urinary tract with multidrug-resistant organisms, including prior antibiotic use, hospitalisation and underlying urological malformations. We also highlight multidrug-resistant UTI occurring in children without any identifiable risk factors, reflecting an increasing prevalence of colonisation with these organisms in the general community. Taken as a whole, this emphasises a need for careful and evidence-based use of antibiotics when treating UTIs in children and, to aide clinicians, we have outlined here potential management strategies for when infection with a multidrug-resistant organism is suspected or confirmed.

Long-term outcome of kidney transplantation in patients with congenital anomalies of the kidney and urinary tract.

BACKGROUND: Congenital anomalies of the kidney and urinary tract (CAKUT) are a leading cause of end-stage kidney failure in the young. However, there is limited information on long-term outcomes after kidney transplantation in this group. We explored the outcomes of kidney transplant in patients with the 3 most common severe forms of CAKUT: posterior urethral valves (PUV), reflux nephropathy and renal hypoplasia/dysplasia. METHODS: Data were extracted from the Australian & New Zealand Dialysis & Transplant Registry on first kidney transplants performed between 1985 and 2015 in recipients with a primary diagnosis of PUV, renal hypoplasia/dysplasia or reflux nephropathy (under the age of 30 years). Using multivariate Cox regression, we compared death-censored graft survival between the three groups. RESULTS: One hundred twenty-seven patients with PUV, 245 with hypoplasia/dysplasia and 727 with reflux nephropathy were included. A 10-year graft survival in PUV, hypoplasia/dysplasia and reflux nephropathy was 70%, 76% and 70%, respectively and a 20-year graft survival was 30%, 53% and 49%. After adjusting for age at transplant, graft source and HLA matching, there was evidence for poorer graft survival in PUV (HR, 1.65; 95% CI, 1.15 to 2.38). CONCLUSIONS: Graft survival of the first transplant in CAKUT is favourable at 10 years; however, recipients with PUV have increased risk of graft loss beyond a 10-year post-transplant, which may be related to bladder dysfunction.

Prevalence and predictors of blood transfusion after pediatric kidney transplantation.

BACKGROUND: Blood transfusion after kidney transplant carries a risk of sensitization to the graft as well as blood borne infections. The aim of this study was to describe the prevalence of blood transfusions in pediatric recipients of kidney transplants and to determine the factors associated with transfusions during the perioperative period. Additionally, to describe the changes in hemoglobin levels during the first 12 months following transplant. METHOD: A retrospective, single center analysis using data collected prospectively between 2010 and 2017. Red blood cell transfusion within the first week after transplant and anemia at 3 months were used as outcomes. Multivariate analysis was performed on significant variates with results described according to odds ratio (OR) and interquartile range (IQR). RESULTS: Transfusions were given after 21 of 42 (50%) transplants in recipients aged between 1 and 17 years (median 14 years). Age, height, weight, and pre-transplant hemoglobin predicted transfusion in univariate analyses. Regression analysis identified pre-transplant hemoglobin as an independent factor (OR 0.85, IQR 0.73-0.98; p = 0.02). Anemia was present at 3 months after 15 (36%) transplants. Anemia at 3 months was associated with older and larger recipients, lower pre-transplant hemoglobin, and lower estimated glomerular filtration rate (eGFR) on univariate analysis. Logistic regression analysis identified eGFR at 3 months as the only independent predictor of anemia at 3 months (OR 0.93, IQR 0.87-0.99; p = 0.04). CONCLUSIONS: Transfusions are prevalent in the perioperative period after pediatric kidney transplantation. Lower pre-transplant hemoglobin increases the risk of transfusion. Graft function predicts hemoglobin levels at 3 months.

Age-specific risk of renal graft loss from late acute rejection or non-compliance in the adolescent and young adult period.

AIMS: The aims of this study were to identify if an age-specific high-risk window for graft loss is present in Australia and New Zealand and identify the aetiology for such graft loss using the Australia and New Zealand Dialysis and Transplant Registry. METHODS: Retrospective cohort analysis of all renal transplants were performed in Australia and New Zealand during 1985-2010 in which the graft survived >3 months and the patient spent at least some time aged 10-30 years inclusive while the graft was functioning. Adjusted hazard ratio (aHR) for graft loss according to age, sex, race, cause of end-stage kidney disease, transition, era of transplantation, donor type and human leucocyte antigen mismatch were calculated using an extended Cox proportional hazards model for graft loss from any cause and graft loss from late acute rejection (LAR) or non-compliance. RESULTS: A total of 3289 grafts in 3048 recipients were included. A total of 757 grafts failed including 110 (15 %) from LAR or non-compliance. Age was strongly associated with graft loss from LAR or non-compliance (p < 0.001). Compared with age 10-12 years, the risk of graft loss from LAR or non-compliance was significantly increased from 16-24 years, peaking at 19-21 years (aHR 11.3, 95% confidence interval (CI) 1.5-84.3, p < 0.001). Indigenous race was associated with LAR or non-compliance (aHR 3.5, 95% CI 2.1-5.6) whereas paediatric-to-adult transition with a functioning transplant was not (aHR 1.2, 95% CI 0.4-3.5, p = 0.68). CONCLUSION: The high risk of graft loss during adolescence and young adulthood is primarily due to LAR or non-compliance. The elevated risk continues well into the 20s and is independent of paediatric-to-adult transition.

Parents' perceptions of counselling following prenatal diagnosis of congenital anomalies of the kidney and urinary tract: a qualitative study.

OBJECTIVES: To explore parents' experiences of counselling after prenatal diagnosis of congenital anomalies of the kidney and urinary tract. SUBJECTS AND METHODS: Parents of a child born between September 2012 and March 2015 with posterior urethral valves (PUV) or multicystic dysplastic kidney (MCDK) completed a semi-structured telephone interview, demographic survey, and the 21-item self-report Depression, Anxiety and Stress Scales questionnaire. Qualitative data were analysed thematically using NVivo10 software. RESULTS: In all, 17 parents (PUV, eight; MCDK, nine) participated (response rate 40%), and most were offered counselling during pregnancy (14/17). Parents described feelings of shock, fear and uncertainty after diagnosis, and desired early information on all aspects of their child's condition. Most participants were satisfied with the information received; however, unmet information needs relating to treatment and prognosis were identified, particularly amongst fathers and parents in the PUV group. Some parents felt relieved after counselling (12/17); however, emotional distress often persisted long after diagnosis. Parents described a need for written and web-based information resources, specialised psychological services, and parent support groups. CONCLUSION: While parents valued counselling, many continued to report unmet informational and psychological needs. Early counselling addressing topics important to parents and provision of additional resources and support services may improve parents' adjustment to their baby's diagnosis.

The efficacy of valganciclovir for prevention of infections with cytomegalovirus and Epstein-Barr virus after kidney transplant in children.

This study evaluated the efficacy of prophylactic ValGCV in preventing CMV and EBV infections in a single-center pediatric kidney transplant population (2008-2014). Therapy duration was determined according to donor/recipient serostatus. EBV monitoring was performed using monthly plasma PCR for 18 months post-transplant and for CMV, monthly for 6 months after prophylaxis cessation. Data were collected on 35 children, median age 10.6 years. There were 15 (42.9%) and 11 (31.4%) recipients seronegative for CMV or EBV, respectively, who received a kidney from a seropositive donor. Prophylaxis was ceased by 6 months in 24 (69%), between seven and 13 months in 10 (29%) children. Fourteen (40%) and eight (23%) children experienced CMV and EBV DNAemia, respectively. Ten of the 14 (71%) episodes of CMV DNAemia occurred in the first 6 months following cessation of prophylaxis. Shorter prophylaxis was associated with increased CMV DNAemia (P = 0.044). There was an inverse correlation between adjusted ValGCV dose and EBV incidence/timing. Neutropenia was more common if ValGCV dosage was ≥10% of the dose predicted (by BSA and creatinine clearance). ValGCV prevents CMV and may modify EBV infection risk. Frequent dosing adjustment for BSA and creatinine clearance is required to optimize safety and efficacy.

Multicentre study of treatment outcomes in Australian adolescents and young adults commencing dialysis.

AIM: The aim of the study is to improve the understanding of outcomes and complications of dialysis in adolescents and young adults (AYA) to inform decisions about dialysis modality in this patient population. METHODS: Registry data on Australian AYA aged 13 to 20 years who commenced dialysis between 1/1/2000 and 31/12/2013 were retrieved from the Australia and New Zealand Dialysis and Transplantation Registry and analyzed to determine associations between demographic characteristics, dialysis modality and outcomes. RESULTS: During the study period 300 AYA commenced dialysis at a median age of 17.2 years (IQR 15.6 to 18.6 years). Haemodialysis (HD) was the initial dialysis modality in 201 patients (67%). No significant differences between AYA receiving HD and peritoneal dialysis (PD) were noted in patient gender, age, race, primary renal disease, treating centre type, remoteness of residential area, lateness of referral or period of study. Mean haemoglobin levels were lower in the HD group (P = 0.005) and significantly fewer HD patients attended school full time compared to patients managed on PD (P = 0.002 first year; P = 0.05 second year). CONCLUSION: Dialysis modality choice does not appear to be influenced by patient characteristics nor dialysis outcomes. Future research is required to examine the reasons that HD is preferred over PD and to determine the optimal method of dialysis for this age group.