Immunosuppressive Management of Pediatric Kidney Transplant Recipients

2020 ◽  
Vol 26 (28) ◽  
pp. 3451-3459
Author(s):  
Tomáš Seeman
Keyword(s):  
Immunosuppressive Therapy ◽  
Kidney Transplant ◽  
Induction Therapy ◽  
Graft Loss ◽  
Calcineurin Inhibitors ◽  
Mtor Inhibitors ◽  
Therapeutic Drug ◽  
High Dose ◽  
Transplant Recipients ◽  
Kidney Transplant Recipients

: Kidney transplantation is a preferable treatment of children with end-stage kidney disease. All kidney transplant recipients, including pediatric need immunosuppressive medications to prevent rejection episodes and graft loss. : Induction therapy is used temporarily only immediately following transplantation while maintenance immunosuppressive drugs are started and given long-term. There is currently no consensus regarding the use of induction therapy in children; its use should be decided based on the immunological risk of the child. : The recent progress shows that the recommended strategy is to use as maintenance immunosuppressive therapy a combination of a calcineurin inhibitor (preferably tacrolimus) with an antiproliferative drug (preferably mycophenolate mofetil) with steroids that can be withdrawn early or late in low-risk children. The mTOR-inhibitors (sirolimus, everolimus) are used rarely in pediatrics because of common side effects and no evidence of a benefit over calcineurin inhibitors. The use of calcineurin inhibitors, mycophenolate, and mTOR-inhibitors should be followed by therapeutic drug monitoring. : Immunosuppressive therapy of acute rejection consists of high-dose steroids and/or anti-lymphocyte antibodies (T-cell mediated rejection) or plasma exchange, intravenous immunoglobulines and/or rituximab (antibodymediated rejection). : The future strategies for research are mainly precise characterisation of children needing induction therapy, more specific indications for mTOR-inhibitors and for the far future, the possibility to reach the immuno tolerance.

scholarly journals MO713ENCAPSULATING PERITONEAL SCLEROSIS IN KIDNEY TRANSPLANT RECIPIENTS

2021 ◽  
Vol 36 (Supplement_1) ◽  
Author(s):  
Imen Ouertani ◽  
Azzabi Awatef ◽  
Sahtout Wissal ◽  
Ben Aicha Narjes ◽  
Mrabet Sanda ◽  
...  
Keyword(s):  
Peritoneal Dialysis ◽  
Intestinal Obstruction ◽  
Kidney Transplant ◽  
Corticosteroid Therapy ◽  
Clinical Symptoms ◽  
Case Reports ◽  
Calcineurin Inhibitors ◽  
Mtor Inhibitors ◽  
Transplant Recipients ◽  
Kidney Transplant Recipients

Abstract Background and Aims Encapsulating peritoneal sclerosis (EPS) is a life-threatening complication of long-term peritoneal dialysis (PD). Causative factors are the chronic exposure to bioincompatible PD and peritonitis episodes. Pro-inflammatory state and oxidative stress associated with chronic uremia may further accelerate these pathomechanisms. Clinical symptoms are, essentially, signs of intestinal obstruction. Treatments commonly used are corticosteroids, tamoxifen, immunosuppressants like azathioprine, mycophenolate mofetil (MMF), or mTOR inhibitors which has fibrinolytic properties and may help with reducing inflammation. In the last ten years, the incidence of SEP in kidney transplant recipients has increased, but few cases have been reported. Given the rare nature of this pathology, we decided to publish the cases of two EPS happening after kidney transplantation (KT). Case report We report the cases of two male patients aged 46 and 25 with a history of chronic renal failure, who benefited of continuous ambulatory peritoneal dialysis (CAPD) for three years. The first patient was switched to haemodialysis (HD) for sub-dialysis, with one episode of peritonitis and one episode of catheter infection. The second patient had three episodes of peritonitis complicated by asymptomatic EPS, hence its transfer to HD. Our two patients presented, at 30 and 40 days post KT, an episode of acute intestinal obstruction with abdominal scans fitting with a mechanical bowel obstruction on an encapsulating peritonitis without signs of complication. Both patients were on corticosteroid therapy (15 and 17.5 mg/day) combined with MMF and Calcineurin inhibitors (CNIs) (Tacrolimus). Medical measures were not effecient. Surgical treatment was then considered. During the operation, a classical picture of EPS was found characterized by a thin cocoon-like sclerotic membrane encasing the small bowel. A complete resection of the encapsulating sclerotic membrane and total adhesiolysis were performed, with an immediate improvement on the clinical level. No recurrence was noted for both patients at 5 and 24 months respectively. Conclusion The specificities of our patients compared to the reported cases were the short duration of the PD and the relatively young age. In fact, some studies demonstrated an increased incidence of EPS in younger patients. In addition, this complication has declared itself despite corticosteroid therapy. Some case reports have demonstrated an increase in the incidence of SEP in kidney transplant patients, suggesting the possible implication of CNIs which have a profibrotic effect and may promote peritoneal matrix accumulation.

scholarly journals SARS-CoV-2 infection in kidney transplant recipients: clinical impact and outcomes - a single center experience

2021 ◽  
Author(s):  
Afonso Santos ◽  
Luís Leite de Sousa ◽  
Rita Calça ◽  
Anna Lima ◽  
Célia Nascimento ◽  
...  
Keyword(s):  
Kidney Transplant ◽  
Calcineurin Inhibitors ◽  
Mtor Inhibitors ◽  
Hospitalized Patients ◽  
Transplant Recipients ◽  
Single Center ◽  
Kidney Transplant Recipients ◽  
Single Center Experience ◽  
Poor Outcomes ◽  
A Prospective Study

ABSTRACT Introduction: Kidney transplant recipients are a subgroup of patients at higher risk of critical forms of Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) infection and poor outcomes due to immunosuppression treatment. Herein, we present data from a single center cohort of kidney transplant recipients with SARS-CoV-2 infection. Methods: In a prospective study, baseline characteristics, clinical features, antiviral and immunosuppression management were compared between outpatients and hospitalized patients, during a one-year period. Results: Seventy-seven kidney transplant recipients were analyzed, including outpatients and hospitalized patients, with a median age of 57.7 (IQR 49.7-64.9) years. Twenty-eight (36.4%) were managed as outpatients, while 49 (63.6%) patients required hospital admission. Among hospitalized patients, 18.4% were admitted in ICU, 49% had AKI, and 20.4% died. Immunosuppression adjustments were performed in 95.9% of hospitalized patients, with dose of anti-metabolites adjusted in 83.7%, mTOR inhibitors in 14.3%, calcineurin inhibitors in 12.2%, and corticosteroid therapy in 81.6%. Conclusion: Among hospitalized patients, immunosuppression management included reduction or withdrawal of anti-metabolite and increase of corticosteroid dose. AKI occurred in almost half of patients and mortality in hospitalized patients reached 20%, reflecting greater disease severity than the general population.

scholarly journals BK Polyomavirus Micro-RNAs: Time Course and Clinical Relevance in Kidney Transplant Recipients

Viruses ◽  
2021 ◽  
Vol 13 (2) ◽  
pp. 351
Author(s):  
Baptiste Demey ◽  
Véronique Descamps ◽  
Claire Presne ◽  
Francois Helle ◽  
Catherine Francois ◽  
...  
Keyword(s):  
Viral Replication ◽  
Kidney Transplant ◽  
Clinical Relevance ◽  
Graft Loss ◽  
First Year ◽  
Transplant Recipients ◽  
Kidney Transplant Recipients ◽  
Post Transplantation ◽  
Bk Polyomavirus ◽  
Micro Rnas

Background: Kidney transplant recipients (KTRs) are exposed to a high risk of BK polyomavirus (BKPyV) replication, which in turn may lead to graft loss. Although the microRNAs (miRNAs) bkv-miR-B1-3p and bkv-miR-B1-5p are produced during the viral cycle, their putative value as markers of viral replication has yet to be established. In KTRs, the clinical relevance of the changes over time in BKPyV miRNA levels has not been determined. Methods: In a retrospective study, we analyzed 186 urine samples and 120 plasma samples collected from 67 KTRs during the first year post-transplantation. Using a reproducible, standardized, quantitative RT-PCR assay, we measured the levels of bkv-miR-B1-3p and bkv-miR-B1-5p (relative to the BKPyV DNA load). Results: Detection of the two miRNAs had low diagnostic value for identifying patients with DNAemia or for predicting DNAuria during follow-up. Seven of the 14 KTRs with a sustained BKPyV infection within the first year post-transplantation showed a progressive reduction in the DNA load and then a rapid disappearance of the miRNAs. DNA and miRNA loads were stable in the other seven KTRs. Conclusions: After the DNA-based diagnosis of BKPyV infection in KTRs, bkv-miR-B1-3p and bkv-miR-B1-5p levels in the urine might be valuable markers for viral replication monitoring and thus might help physicians to avoid an excessive reduction in the immunosuppressive regimen.

Time-Varying Proteinuria and the Risk of Cardiovascular Disease and Graft Failure in Kidney Transplant Recipients

2021 ◽  
Vol 31 (4) ◽  
pp. 288-297
Author(s):  
Tanya Kuper ◽  
Olusegun Famure ◽  
Jamie Greenfield ◽  
Yanhong Li ◽  
Syed Ibrahim ◽  
...  
Keyword(s):  
Kidney Transplant ◽  
Graft Failure ◽  
Graft Loss ◽  
Major Adverse Cardiac Events ◽  
Transplant Recipients ◽  
Kidney Transplant Recipients ◽  
Cardiac Events ◽  
Urine Protein ◽  
Hazard Ratios ◽  
Adverse Cardiac Events

Introduction: Proteinuria is recognized as an independent risk factor for cardiovascular disease in kidney transplant recipients, but previous studies have not considered the impact of changes in urine protein over time. Research Question and Design: We used time-dependent, multivariable Cox proportional hazards models in this observational cohort study of adult kidney transplant recipients to evaluate whether proteinuria measured by dipstick on random spot urine samples starting from 1-month post-transplant was associated with the risk of major adverse cardiac events and graft loss. Results: A total of 144 major adverse cardiac events, defined as acute myocardial infarction, cerebrovascular accident, revascularization, or all-cause mortality, were observed in 1106 patients over 5728.7 person-years. Any level of proteinuria greater or equal to trace resulted in a two-fold increase in the risk of major adverse cardiac events (hazard ratio 2.00 [95% confidence interval 1.41, 2.84]). This relationship was not found to be dose-dependent (hazard ratios of 2.98, 1.76, 1.63, and 1.54 for trace, 1+, 2+, and 3+ urine protein, respectively). There was an increased risk of graft failure with greater urine protein concentration (hazard ratios 2.22, 2.85, 6.41, and 19.71 for trace, 1+, 2+, and 3+, respectively). Conclusion: Urine protein is associated with major adverse cardiac events and graft loss in kidney transplant recipients. The role of interventions to reduce proteinuria on decreasing the risk of adverse cardiovascular and graft outcomes in kidney transplant recipients requires further study.

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