[Acute tubular necrosis in kidney transplantation]. / La nécrose tubulaire aiguë en transplantation rénale.

BACKGROUND: The acute tubular necrosis (ATN) is common after kidney transplantation. Acute tubular necrosis (ATN) is multifactorial and represents one of the main causes of the delayed graft function. Its impact on graft and patients survival is documented. AIMS: To study the prevalence of the ATN in kidney transplanted patients, the acute rejection rate and their impact on the graft and the patient survival. METHODS: We retrospectively studied the frequency of ATN, its causes and its impact on patient and graft survival in 255 kidney transplanted patients between 1986-2006. RESULTS: Thirty-nine patients had ATN (15.29%). They are 25 men and 14 women with mean age of 30.1 ± 12.6 years (8-61) followed for an average of 98 ± 61.76 months. The majority was treated by hemodialysis (79.48%) and half of them were transplanted from kidney of deceased donor. All patients received anti lymphocyte serum and the majority anticalcineurins (69.23%). The outcome was favorable in 26 patients (66.66%) with recovery of diuresis and normalization of renal function after 6 weeks on average. An acute rejection was diagnosed in 21 patients (53.48%). The mean creatinine at 1, 5 and 10 years was 135.3, 159.9 and 121.4 µmol / l. Eight patients had creatinine ² 130 µmol / l at 10 years. Ten patients died from infectious and cardiovascular causes. By comparing the 2 groups ATN + and ATN - we found a statistically significant correlation between ATN and cold ischemia (10 ± 10.9 vs 1.2 ± 4.7 hours, p <0.0001) and the interval between the start of dialysis and transplantation (42.18 ± 38.44 vs. 31.1 ± 25.2 months, p= 0.02). No statistical correlation was found between the ATN and gender, age of recipient and donor, warm ischemia, acute rejection, chronic rejection and graft and patient survival at 1, 5 and 10 years. CONCLUSION: The ATN is more common among transplanted patients from deceased donors. It had good evolution in the majority of cases and it's correlated to cold ischemia and duration of dialysis. Finally, it has no impact on patients and graft survival.

Tuberculous meningitis in Bacille Calmette-Guerin-vaccinated children: clinical spectrum and outcome.

The Bacille Calmette-Guérin vaccination (BCG) contributed widely to reduce tuberculosis incidence in developing countries. The aim of this report was to assess the clinical "spectrum" and outcome of tuberculous meningitis in 16 Bacille Calmette-Guérin-vaccinated Tunisian children. They were 9 boys and 7 girls aged 2 to 168 months (median 72 months ± 65.88). Patients presented mainly with nonspecific symptoms. Neurologic severity was classified as grade I (n = 6) and grade II or III (n = 10). At short-term course, the majority of patients developed serious complications: hydrocephalus (n = 12), seizures (n = 8), tuberculoma (n = 6), and acute respiratory failure (n = 2). Three patients died. Among survivors, 4 patients showed a complete recovery while 9 developed permanent sequelae which were mild (n = 6) to severe (n = 3). Despite the Bacille Calmette-Guérin vaccination, tuberculous meningitis remains a life-threatening condition; vaccinated children have shown common presentation of tuberculous meningitis in terms of severity and poor outcome.

Reversible nephrotic syndrome secondary to pulmonary hydatid disease.

Most patients with pulmonary hydatidosis are children. The disease may be asymptomatic or revealed by unusual events such as a glomerulopathy. An 8-year-old boy from a rural part of Tunisia presented with generalised oedema and macroscopic haematuria. There was no familial history of renal disease. He had a normal blood pressure (100/60 mmHg), and a pleural effusion was detected. Urinalysis showed nephrotic range proteinuria (375 mg/kg/d) and microscopic haematuria. His serum total protein concentration was 40 g/l and his serum albumin was 10 g/l. Renal biopsy showed capillary wall thickening and duplication, and mesangial cell proliferation in the glomeruli, characteristic of mesangiocapillary glomerulonephritis. Renal and abdominal ultrasound images showed increased echogenicity of the kidneys and mild ascites. Radiology revealed three large pulmonary hydatid cysts. The largest cyst occupied the entire right upper lobe and compressed the superior vena cava. Hydatid disease was confirmed by a strongly positive serum enzyme-linked immunosorbent assay (ELISA) for echinococcus. The patient was treated with high protein intake, dipyramidol and captopril; both right lung cysts were resected, followed by the left pulmonary cyst 4 weeks later. Hydatid cyst was confirmed histopathologically. He recovered well, the serum ELISA for echinococcus became negative, and follow-up urine examination and thoracic computerised tomography were normal 6 months after surgery, confirming good renal recovery and absence of pulmonary hydatid disease.

Surgical complications in pediatric and adolescent renal transplantation.

To report the surgical complications among our pediatric and adolescent renal transplants and to compare these results with other reported series in the literature. A total of 50 pediatric and adolescent renal transplants were included in this study. There were 30 boys and 20 girls with a mean age of 13 years (range 6 - 18 years). 70% of patients received their kidneys from living donors. Two patients underwent renal re-transplantation. Among the 52 transplantations, 17 surgical complications were encountered in 15(30%) patients. The incidence of urological and vascular complications was respectively 13.2% and 18.9%. These complications included vesico-ureteral reflux (9.4%), urinary leakage (3.8%), lymphocele (5.8%), peri-renal hematoma (1.9%), renal artery stenosis (3.7%), and thrombosis of the allograft (7.5%). The patients with vesico-ureteral reflux were treated by antibiotic prophylaxis. In four recipients, thrombosis of the allo-graft with subsequent graft loss occurred. The graft survival rate was 90% in 1 year, 77% in 5 years and 40% in 10 years follow-up. The patient survival rate was 94.4% in 1 year and 84% after 8 years follow-up. We conclude that surgical complications can be minimized if basic principles of careful transplant techniques are used. Prompt identification and treatment of any complication are critical for graft and patient survival.