Abstract
Epstein–Barr and BK Virus PCR Monitoring in Kidney Transplantation as a Guideline for Immunosuppressive Therapy
Immunosuppressive (IS) therapy in transplantation is mainly empiric. Over-IS leads to side effects, especially virus proliferation. A routine virus polymerase chain reaction (PCR) test for Epstein-Barr virus (EBV) and polyomavirus BK type (BKV) was introduced into our protocol in 1998.
Objectives: To report our EBV and BKV PCR monitoring experience in kidney transplantation in the Pediatrics Hospital in Toulouse, France.
Methods: In 70 successive kidney transplantations, 12 children experienced prolonged positive blood PCR tests: 7 for EBV (4 reactivation, 3 primary infection) and 5 for BKV (3 proven BKV nephropathy) undergoing classical triple IS therapy (steroid/AZA, or MMF/CsA, or FK). In these patients, we prospectively decided to reduce the drug dosage—first, the antimetabolite, and then the anti-calcineurin, until a negative PCR test was obtained.
Results: Lowering of the IS drugs allowed all patients to reach negative clinical virus symptoms and PCR test without rejection (follow-up: 1 – 5 years) or lymphoma. The drug dosage was continuously adapted to the level of the PCR test, and today, 4 patients remain free of anti-calcineurin; 1 takes only low-dose steroid; and 8 continue triple therapy with a halfdose of AZA or MMF and low-level anti-calcineurin (trough level in sera: CsA 60 – 70 ng/mL, FK 3 – 5 mg/L).
Conclusions: Routine virus detection is mandatory in transplantation. A positive EBV or BKV blood PCR test is a sign of over-IS. The IS regimen can be reduced, with no risk of rejection, to cure the viral disease and avoid EBV B lymphoma previously experienced in these patients.
Continuous Ambulatory Peritoneal Dialysis in Children: A SingleCenter Experience from a Developing Country
Aim: Continuous peritoneal dialysis is the most commonly used modality of dialysis in children. This study prospectively followed children initiated on continuous ambulatory peritoneal dialysis (CAPD).
Results: The duration of the study was 9 years. There were 19 endstage renal disease (ESRD) patients on CAPD. Mean age was 12.73 ± 4.01 years (range: 2 months – 18 years). There were 11 boys. The mean break-in period was 12 ± 3 days. Six (31.57%) children performed exchanges themselves; in the rest (68.42%), parents performed the exchanges. Only 10 (52.63%) children had a separate room for exchanges. Of the 13 parents, 11 were illiterate (84.61%). In 17 patients, 4 had a total of 5 episodes of peritonitis. The peritonitis rate was 0.027 episodes per patient–month. Escherichia coli was the most common causative organism. Omental wrap and hemoperitoneum was reported in 2 patients each (10.52%). Heights in 15 children (78.94%) fell below the 5th percentile of ICMR references for heights of Indian children. On outcome analysis, 2/19 patients (10.52%) received a renal graft; 7/19 (36.84%) continued on CAPD awaiting kidney transplantation; and 4/19 patients (21.05%) died. Three children (15.78%) experienced technique failure, and three (15.78%) were lost to follow-up after a mean duration of 4 ± 2 months. The median cumulative survival on CAPD was 44 months.
Conclusions: We conclude that CAPD is a viable option for dialysis in ESRD children in a developing country. It is a successful bridge between ESRD and renal transplantation.
Is Continuous Ambulatory Peritoneal Dialysis an Effective Modality for Dialysis in Children in Developing Countries?
Ambulatory peritoneal dialysis (APD) is the modality of choice for dialysis in children with end-stage renal disease (ESRD). However, it is an expensive form of therapy beyond the reach of most children in developing countries. Continuous ambulatory PD (CAPD) had been an established form of therapy in adult patients with ESRD in India for more than a decade. Published experience with CAPD in children from developing countries is scarce.
We retrospectively studied all children with ESRD on chronic PD at our center over the last 10 years. The case records were reviewed for age, sex, basic disease, break-in period, biochemical investigations, peritonitis rate, and outcome. The number of episodes of peritonitis (P) and the organisms isolated were recorded and analyzed. Rate of P was calculated as episodes per patient–year. Serum albumin (SA) at initiation of therapy was noted, and its effect on P episodes was analyzed. Outcome was analyzed in terms of mortality, renal transplantation, shift to hemodialysis, and loss of follow-up.
The study group comprised 30 consecutive children [18 boys, 12 girls; mean age: 13 ± 8 years (range: 5 – 21 years)] with ESRD. The basic diseases in these patients were chronic interstitial nephritis (n = 14), chronic glomerulonephritis (n = 7), obstructive uropathy (n = 2), and unknown (n = 4). The mean break-in period (between Tenckhoff catheter insertion and start of PD) was 12 ± 3 days. Of the 30 children, 15 had a total of 21 episodes of P. The total duration of CAPD was 36.5 patient–years. The P rate was 0.58 episodes per patient–year. Escherichia coli was the most common organism causing P. In patients with SA below 3 g/dL, 16 episodes of P were observed as compared with 5 episodes in patients with SA above 3 g/dL (p = 0.035). The mean P-free period was longer in children with SA above 3 g/dL than in children with SA below 3 g/dL (26 mos vs. 17 mos, log rank p = 0.58). On outcome analysis, 7/30 patients (23.3%) received a renal graft, while 11/30 (36.6%) continued on CAPD awaiting transplantation. Of the rest, 8 patients (26.6%) died, 2 (6.7%) experienced technique failure and shifted to maintenance hemodialysis; 2 patients (6.7%) were lost follow up after 2 mos. The mean cumulative survival of the patient on chronic PD was 42 mos.
We conclude that chronic PD is a viable option for dialysis in ESRD children in developing countries, and a successful bridge between ESRD and renal transplantation.
Gulati S.,1 Prasad N.,2 Gupta A.,2 Sharma R.K.,2
Predictors of Hypoalbuminemia in Children on Continuous Peritoneal Dialysis
Introduction: Low serum albumin (SA) is reported to be an adverse prognostic factor in adults with end-stage renal disease on continuous peritoneal dialysis (CPD). Data on the prevalence, predictive factors, and prognostic value of hypoalbuminemia are lacking.
Methods: A retrospective analysis was done of 180 patients on CPD at The Hospital for Sick Children over the last 20 years. Patients excluded from the study were those on CPD < 4 months and those with nephrotic syndrome. Demographics and clinical and biochemical parameters were studied. Children continued on CPD until they received a transplant or were transferred to an adult unit at age 18 years, or were transferred to hemodialysis as a result of technique failure. The outcome variable was hypoalbuminemia on last follow-up. A univariate and multivariate analysis was done to identify factors predictive of hypoalbuminemia in these children on CPD.
Results: The study included 135 children. Mean age at CPD initiation in the study group was 10.5 ± 5.6 years. After a mean duration of CPD of 573.5 ± 437.5 days (range: 120 – 2960 days), 54/135 children (40%) were observed to have hypoalbuminemia. There were 5 deaths (3.7%). Of the rest, 7 children (5.2%) continued on continuous cycling PD, 13 (9.6%) were transferred to an adult unit for continuation of CPD, 94 (69.6%) were transplanted, and 16 (11.8%) were transferred to hemodialysis because of failure of CPD. Compared with children in group II (n = 81, SA > 35 g/L), children in group I (n = 54, SA < 35 g/L) were significantly younger at PD initiation (p = 0.05) and were more likely to have hypoalbuminemia at 1 month (p = 0.001) and 6 months after PD initiation.
Conclusions: Low SA before PD initiation, low SA at 1 month after PD, and multiple episodes of peritonitis are predictive of hypoalbuminemia in children on CPD. Appropriate corrective measures, if instituted early, might help in to lower the incidence of technique failure.
Automated Peritoneal Dialysis in Children with Chronic Renal Failure in China
Objectives: Automated peritoneal dialysis (APD) has been increasingly used as a long-term renal replacement therapy (RRT) in children with chronic renal failure (CRF).
Methods: We studied 12 CRF patients (6 boys, 6 girls; age range: 2 – 16 years; duration of APD: 2 months – 4 years) who underwent APD treatment from March 2001 to June 2009 in Shanghai, China. In 8 cases, a Tenckhoff catheter was placed by open placement, and in 4 cases, by laparoscopic technique. All patients received nightly intermittent PD or continuous cycling PD. Their parents were trained before the procedure to operate the APD machine themselves at home. Clinical data including Kt/V and creatinine clearance were tested regularly at the hospital to evaluate dialysis adequacy.
Results: Mean Kt/V was 2.2 ± 1.2. Residual renal function decreased by an average 0.13 ± 0.10 mL/min each month. The incidence of peritonitis was 1 episode in 20 patient–months. No exit-site infections occurred. One patient was complicated with a hernia. No acidosis or MODS was observed. At 38 days – 3 years after the start of APD treatment, 8 patients successfully underwent renal transplantation. Five patients returned to school while having APD at night at home; others received education at home. The laparoscopic technique may lessen mechanical outflow obstruction and leakage from the catheter exit site.
Conclusions: APD is a safe, effective, and successful long-term renal replacement therapy in CRF children in Shanghai, China. It greatly improves the quality of life of children with CRF. Laparoscopic technique is a new development for catheter placement.