Sarcopenia prevalence in pediatric intestinal transplant recipients: Implications on post-transplant outcomes.

BACKGROUND: Sarcopenia has been associated with poor surgical outcomes but has not been studied in pediatric intestinal transplantation. We aimed to determine sarcopenia prevalence in intestinal transplant recipients and the association of sarcopenia with outcomes. METHODS: We performed a cross-sectional retrospective chart review of intestinal transplant recipients from 2000-present. We estimated total psoas muscle area (tPMA) at L3-L4 and L4-L5 from computed tomography scans prior to or in the immediate peri-operative period. Sarcopenia was defined by tPMA below the 5th percentile for age and sex. We built a Cox-proportional hazards model to determine the association between sarcopenia and patient and graft survival. RESULTS: Of the 56 intestinal transplant recipients included, 36 (64%) were sarcopenic. Graft survival was 79% at one year and 59% at five years. Overall patient survival was 86% at one year and 76% at five years. Peri-transplant sarcopenia was associated with improved graft survival (Hazard ratio 0.42, 95% confidence interval: 0.20-0.88) but not overall survival (Hazard ratio 0.47, 95% confidence interval: 0.19-1.20). CONCLUSIONS: In this first report of sarcopenia in pediatric intestinal transplant, we found a high sarcopenia prevalence without an association with worse outcomes. The potential improved graft survival in sarcopenic patients along with underlying mechanisms warrant further exploration.

Ingestion of kinetic sand leading to intussusception and bowel obstruction in a child: a case report.

Background: Kinetic sand is a type of play sand that is marketed to children above the age of three years old. It is comprised of sand coated with silicone oil, holding its shape when squeezed or pressed. It is described as a non-toxic, hypoallergenic, safe sand for arts and crafts, and is highly appealing due to its realistic appearance and odor. We present the first reported case of bowel obstruction due to small and large bowel intussusceptions caused by ingestion of kinetic sand leading to hospitalization for medical treatment in a young girl. Case Description: We present a two-year-old female patient with a past medical history of autism, trichotillomania, and pica who presented to our hospital as a transfer for two days of abdominal pain and non-bloody bilious emesis. Radiographic workup included abdominal ultrasound, abdominal X-ray, and computed tomography that revealed both small bowel intussusceptions and colo-colonic intussusception. Fluoroscopic gastrografin enema was performed and yielded free reflux of contrast into the distal ileum. The admitted patient continued to pass the sand with an eventual resolution of abdominal pain. Conclusions: Intussusception is considered a medical emergency and should be treated as soon as possible before potentially fatal complications occur. This report serves to highlight the potential dangers of kinetic sand ingestion and provide guidance for the management of intussusception and bowel obstruction after kinetic sand ingestion in the pediatric population.

Midgut volvulus in a pediatric patient with chronic constipation, congenital intestinal malrotation and internal transmesocolic hernia.

Congenital intestinal malrotation occurs in 1 of 500 newborns and can predispose patients to intestinal volvulus and internal herniation, putting patients at risk for intestinal ischaemia. A male patient in early childhood with a history of severe constipation presented with acute abdominal pain, progressing rapidly to compensated shock. CT scan was suspicious for small bowel ischaemia and superior mesenteric artery compression. He underwent emergency exploratory laparotomy. Intraoperative findings were significant for partial intestinal malrotation with mobile ascending colon and high-riding caecum, and internal herniation with midgut volvulus of the ascending colon through a mesenteric defect in the proximal transverse colon. Derotation of the volvulus, reduction of the internal hernia, resection of necrotic segments of the bowel and a modified Ladd's procedure were performed. Postoperatively, the patient is total parenteral nutrition (TPN) dependent due to short bowel syndrome. A high index of suspicion with prompt imaging is paramount for paediatric patients with symptoms indicating intestinal obstruction.

The loss of renal dendritic cells and activation of host adaptive immunity are long-term effects of ischemia/reperfusion injury following syngeneic kidney transplantation.

Ischemia/reperfusion injury associated with kidney transplantation induces profound acute injury, influences early graft function, and affects long-term graft outcomes. To determine whether renal dendritic cells play any role during initial innate ischemia/reperfusion injury and the subsequent development of adaptive immune responses, we studied the behavior and function of renal graft and host infiltrating dendritic cells during early and late phases of renal ischemia/reperfusion injury. Wild type to green fluorescent protein (GFP) transgenic rat kidney transplantation was performed with and without 24-h cold storage. Ischemia/reperfusion injury in cold-stored grafts resulted in histopathological changes of interstitial fibrosis and tubular atrophy by 10 weeks, accompanied by upregulation of mRNAs of mediators of interstitial fibrosis and inflammation. In normal rat kidneys, we identified two populations of renal dendritic cells, predominant CD103(-)CD11b/c(+) and minor CD103(+)CD11b/c(+) cells. After transplantation without cold storage, grafts maintained CD103(-) but not CD103(+) GFP-negative renal dendritic cells for 10 weeks. In contrast, both cell subsets disappeared from cold-stored grafts, which associated with a significant GFP-expressing host CD11b/c(+) cell infiltration that included CD103(+) dendritic cells with a TNF-α-producing phenotype. These changes in graft/host dendritic cell populations were associated with progressive infiltration of host CD4(+) T cells with effector/effector-memory phenotypes and IFN-γ secretion. Thus, renal graft ischemia/reperfusion injury caused graft dendritic cell loss and was associated with progressive host dendritic cell and T-cell recruitment. Renal-resident dendritic cells might function as a protective regulatory network.

Carbon monoxide inhibits apoptosis during cold storage and protects kidney grafts donated after cardiac death.

Ischemia/reperfusion (I/R) injury remains as a serious deleterious factor in kidney transplantation (KTx). We hypothesized that carbon monoxide (CO), an endogenous potent cytoprotective molecule, inhibits hypothermia-induced apoptosis of kidney grafts. Using the rat KTx model mimicking the conditions of donation after cardiac death (DCD) as well as nontransplantable human kidney grafts, this study examined effects of CO in preservation solution in improving the quality of marginal kidney grafts. After cardiac cessation, rat kidneys underwent 40 min warm ischemia (WI) and 24 h cold storage (CS) in control UW or UW containing CO (CO-UW). At the end of CS, kidney grafts in control UW markedly increased mitochondrial porin release into the cytosol and resulted in increased cleaved caspase-3 and PARP expression. In contrast, grafts in CO-UW had significantly reduced mitochondrial breakdown and caspase pathway activation. After KTx, recipient survival significantly improved with CO-UW with less TUNEL(+) cells and reduced mRNA upregulation for proinflammatory mediators (IL-6, TNF-α, iNOS). Furthermore, when nontransplantable human kidney grafts were stored in CO-UW for 24 h, graft PARP expression, TUNEL(+) cells, and proinflammatory mediators were less than those in control UW. CO in UW inhibited hypothermia-induced apoptosis and significantly improved kidney graft function and outcomes of KTx.