Risk factors associated with the progression of acute kidney injury to chronic kidney disease in pediatric allogeneic hematopoietic cell transplantation (AlloHCT) recipients are not well described. ...We retrospectively investigated the risk factors for the progression to CKD in 275 AlloHCT recipients. AKI and CKD grading was defined according to the Kidney Disease Improving Global Outcomes classification. PRI90 was defined as persistent renal insufficiency (estimated GFR < 90 ml/min/1.73 m
) 90 days after the first episode of AKI. The median age was 9.1 years. Incidence of stages 1, 2, and 3 AKI were 43%, 41%, and 15%, respectively. 86.1% met our study criteria for PRI90. Of the 236 PRI90 patients, 213 and 152 patients were evaluable for CKD at 1 and 3 years, respectively. The incidence of CKD at 1 and 3 years was 63.1% and 62.9%, respectively. On multivariable analysis, estimated GFR at initial episode of AKI (<80 ml/min/1.73 m
) and estimated GFR (<70 ml/min/1.73 m
) at PRI90 was a risk factor associated with CKD development and both risk factors were associated with significantly lower overall survival. To conclude, eGFR at the time of AKI and PRI90 may be considered for screening pediatric AlloHCT recipients at risk for the progression to CKD.
Background
Focal segmental glomerulosclerosis (FSGS) predisposes patients for risk of recurrent disease in allografts.
Methods
We report a case of a recipient of an unrelated living donor renal ...transplant and discuss considerations for utilization of ofatumumab and eplerenone in treatment for recurrent FSGS.
Results
The recipient was initially managed with scheduled plasmapheresis, intravenous immunoglobulin (IVIG), and rituximab post‐transplant during index hospitalization. With notable recurrence of FSGS noted on kidney transplant biopsy, she was initially treated with additional plasmapheresis sessions leading to downtrend in proteinuria. The patient was then transitioned to LDL‐A pheresis, which resulted again in uptrend in proteinuria. This prompted return to scheduled plasmapheresis sessions weekly, leading again to a downtrend in proteinuria. Albumin levels remained within normal range throughout her course. Following initiation of eplerenone and ofatumumab, the patient demonstrated normalization of urine protein:creatinine ratio and remission of FSGS recurrence without need for additional apheresis.
Conclusions
With notable risk of recurrence of FSGS in kidney transplants leading to allograft failure, the use of ofatumumab and eplerenone in conjunction should be considered for management to induce remission.
Background
Adult kidney transplant recipients (KTRs) fully vaccinated against COVID‐19 have substantial morbidity and mortality related to SARS‐CoV‐2 infection compared with the general population. ...However, little is known regarding the safety and efficacy of the COVID‐19 vaccination series in pediatric KTRs.
Methods
A multicenter, retrospective observational study was performed across nine pediatric transplantation centers. Eligible KTRs fully vaccinated against COVID‐19 were enrolled and data were collected pertaining to SARS‐CoV‐2 infection incidence and severity, graft outcomes and post‐vaccination safety profile, as well as overall patient survival.
Results
A total of 247 patients were included in this investigation with a median age at transplantation of 11 years (IQR 5–15). SARS‐CoV‐2 infection was observed in 30/110 (27.27%) of fully vaccinated patients, tested post‐transplant, within the defined follow‐up period. Of these patients, 6/30 (18.18%) required hospitalization and 3/30 (12.12%) required reduction in immunosuppression, with no reported deaths. De novo donor‐specific antibodies (DSAs) were found in 8/86 (9.30%) of DSA‐tested patients with two experiencing rejection and subsequent graft loss. The overall incidence of rejection and graft loss among the total cohort was 11/247 (4.45%) and 6/247 (3.64%), respectively. A 100% patient survival was observed.
Conclusions
Observationally, infectious outcomes of SARS‐CoV‐2 in fully vaccinated pediatric KTRs are excellent, with a low incidence of infection requiring hospitalization and no associated deaths. Though de novo DSAs were observed, there was minimal graft rejection and graft loss reported in the total cohort.
This observational, retrospective investigation demonstrates temporal associations pointing to a reassuring vaccine safety profile and mild SARS‐Cov‐2 infectious phenotype in pediatric renal transplant recipients fully vaccinated against COVID‐19.
In 2005, the Banff committee expanded the “borderline changes” category to include lesions with minimal (<10%) inflammation: “i0” borderline infiltrates. Clinical significance and optimal treatment ...of i0 borderline infiltrates are not known. Data suggest that i0 borderline infiltrates may have a more favorable prognosis than borderline infiltrates with higher grades of interstitial inflammation. In this single‐center, retrospective, observational study, we assessed 90 renal transplant recipients with i0 borderline infiltrates on biopsies indicated for graft dysfunction. We studied the impact of treatment with corticosteroids on allograft function, allograft survival, and patient survival. We found no differences between treated and untreated groups with respect to eGFR at 4 weeks and 6 months after biopsy. Follow‐up biopsies, available in 67% of patients, were negative for rejection in almost half of all cases, regardless of treatment status. The frequencies of persistent borderline infiltrates (38%) and higher‐grade T cell–mediated rejection (1A or greater, 14%) on follow‐up biopsies were similar between the two groups. There were no differences in rejection‐free allograft survival, death‐censored graft failure, or patient mortality among treated vs non‐treated i0 borderline patients. Our findings suggest that the natural history of i0 borderline infiltrates, in relatively low immunologic risk patients, is not affected by corticosteroid treatment.
Background
Cytomegalovirus (CMV) is a significant cause of morbidity among immunocompromised patients who have undergone kidney transplantation and is known to rarely induce collapsing focal ...segmental glomerulosclerosis (FSGS) among adults.
Methods
We present the first reported case of CMV‐induced collapsing FSGS in a pediatric patient after kidney transplant.
Results
Our patient underwent a deceased donor kidney transplant due to end‐stage renal disease secondary to lupus nephritis. Approximately 4 months after transplantation, he developed signs of worsening kidney function in the setting of CMV viremia and was found to have collapsing features of FSGS on kidney transplant biopsy. He was managed with a prompt escalation of antiviral therapy along with a reduction of immunosuppression and recovered without significant complication. At follow‐up, he continued to have undetectable CMV titers, creatinine within normal limits, and no significant proteinuria.
Conclusion
This report demonstrates CMV as a cause of collapsing FSGS and should be considered among pediatric transplant recipients who present with acute kidney injury, as should early assessment of APOL1 genetic status in both donor and recipient.
Multisystem inflammatory syndrome in children (MIS-C) is a recently identified entity in association with COVID-19. AKI has been widely reported in patients with primary COVID-19 infection. However, ...there is a paucity of literature regarding renal injury in MIS-C. We aim to characterize AKI in MIS-C in this cohort identified at a major children's hospital in New York City during the COVID-19 pandemic.
We conducted a retrospective cohort study of children 0-20 years old admitted to Morgan Stanley Children's Hospital (MSCH) between April 18th and September 23rd, 2020. Patients were included if they met criteria for MIS-C on the basis of CDC guidelines. All patients were evaluated for the presence of AKI, and AKI was staged according to KDIGO criteria.
Of the 57 children who met inclusion criteria, 46% (26 of 57) were found to have AKI. The majority of patients (58%; 15 of 26) were classified as KDIGO stage 1. AKI was present upon admission in 70% of those identified. All patients had resolution of AKI at discharge, with 61% achieving recovery by day 2. One patient required dialysis. When compared with those without renal injury, the AKI cohort was older (
<0.001) and had higher median peak values of CRP (
<0.001), IL-6 (
=0.02), ferritin (
<0.001), and procalcitonin (
=0.02). More patients with AKI had left ventricular systolic dysfunction (
<0.001) and lymphopenia (
=0.01) when compared with those without AKI. No differences in body mass index or sex were found.
Although children with MIS-C may develop AKI, our study suggests that most experience mild disease, swift resolution, and promising outcome. Older age, increased inflammation, and left ventricular systolic dysfunction may be risk factors. Our study highlights the substantial differences in epidemiology and outcomes between AKI associated with pediatric MIS-C versus primary COVID-19 infection.
Introduction
Recurrent focal and segmental glomerulosclerosis (FSGS) in kidney transplant recipients is associated with lower graft survival and increased morbidity. There are limited data to guide ...the decision to re‐transplant patients with transplant failure due to FSGS recurrence. We aimed to evaluate outcomes in patients re‐transplanted after having initial graft failure due to recurrent FSGS and to study physician attitudes and practice patterns.
Methods
Retrospective data from 10 centers were collected on 20 patients transplanted between January 1997 and September 2018. A survey was sent to nephrologist members of the Pediatric Nephrology Research Consortium.
Results
Mean patient age (years) was 9.8 ± 4.8 at first transplant and 15.9 ± 4.9 at re‐transplantation. Pre‐transplant plasmapheresis was used in 1 (5.3%) primary transplant vs. 7 (38.9%) re‐transplants (p = .03). Nephrotic syndrome recurred in 14 patients (70%) after re‐transplantation and was severe in 21.1% vs. 64.7% after first transplant (p = .04). Graft survival was significantly higher in the second transplant (p .009) with 70% having functioning grafts at a median of 25.2 months. Thirty‐one physicians from 21 centers completed the survey, 94% indicated they would re‐transplant such patients, 44.4% preferred a minimum waiting period before re‐transplantation, 36.4% preferred living donors, and 22.2% indicated having protocols for re‐transplantation at their centers.
Conclusions
Consideration for re‐transplantation is high among pediatric nephrologists. Pre‐transplant plasmapheresis was more frequent in re‐transplanted patients. Nephrotic syndrome recurrence was less severe, with better graft survival. More data and a larger population are necessary to further evaluate outcome determinants and best practices in this special population.
Background
Medullary sponge kidney (MSK) disease predisposes patients to recurrent nephrolithiasis, which affects one in every 5000 people in the United States.
Methods
We report a rare case of a ...pediatric recipient of a living donor MSK transplant and discuss considerations when discussing risks and benefits of accepting MSK allografts for this population.
Results
The recipient was admitted due to concerns for nephrolithiasis, hydronephrosis, and urinary tract infection at 1‐month post‐transplant. The hydronephrosis was resolved by surgical removal of an encrusted ureteral stent; this was followed by supplementation with oral medications to prevent future episodes of nephrolithiasis. The recipient did not have any further episodes after this as seen at a 1‐year follow‐up. The donor has remained well through this period.
Conclusions
With increasing organ shortages, the use of variety of donors may need to be considered to enlarge the organ pool.
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