Many pediatric centers utilize a variety of protocols including preemptive plasmapheresis to prevent the recurrence of FSGS post‐transplant. But the effectiveness of this expensive, time‐consuming process of plasmapheresis in the prevention of FSGS recurrence is still unclear. We retrospectively reviewed all pediatric cases of FSGS in our center that received a kidney transplant and compared the transplant and patient outcomes of those transplanted after 2006 who received pretransplant plasmapheresis to those prior to 2006 who did not. Of the 57 children with FSGS, 31 and 26 were transplanted before and after 2006, respectively. The cohorts differed significantly in keeping with the center immunosuppression protocol changes, and prior to 2006, the recipients were significantly younger. All children with FSGS transplanted after 2006 underwent three and one sessions of 1.0 plasma volume/exchange plasmapheresis with fresh frozen plasma replacement prior to the transplant in living and deceased donors, respectively, in addition to five sessions of every other day post‐transplant pheresis. The incidence (27% vs 26%, P = 1.0) and time to recurrence of FSGS in the kidney allograft (P = .22) were not significantly different in patients that did and did not undergo prophylactic plasmapheresis. We need to re‐evaluate the role of preemptive plasmapheresis in the prevention of FSGS recurrence in a prospective multicenter study.

In small children with end-stage renal disease, an adult-sized kidney transplant is the best option. However, in the face of a completely thrombosed inferior vena cava (IVC), such transplants can be challenging, given the difficulty of achieving adequate renal venous outflow and the risk of graft thrombosis. Using a new technique to anastomose the renal vein to the right hepatic vein/IVC junction, we successfully implanted an adult-sized graft in two small children (9.8 and 14 kg) who had end-stage renal disease and a completely thrombosed IVC. After mobilizing the right lobe of the liver and obtaining total vascular occlusion of the liver, we used a Fogarty catheter to dilate the retrohepatic IVC. In the right hepatic vein, we made a venotomy and extended it inferiorly onto the retrohepatic IVC. To that venotomy, we anastomosed the donor left renal vein, using continuous 7-0 Prolene sutures. Both patients attained excellent renal allograft function: One had a serum creatinine level of 0.30 mg/dL at 6 mo after transplant, and the other had a level of 0.29 mg/dL at 1 year. In these two small children with completely thrombosed IVC, our technique for transplanting an adult-sized kidney provided adequate venous outflow.

The association of blood transfusions with GS after pediatric KTx is unclear. We retrospectively analyzed blood transfusions post-KTx and subsequent outcomes. Between 1984 and 2013, 482 children (<18 years of age) underwent KTx at our center. Recipient demographics, outcomes and transfusion data were collected. Cox regression with post-KTx blood transfusion as a time-dependent covariate was performed to model the impact of blood transfusion on outcomes. Of the 208 (44%) that were transfused, 39% had transfusion < 1 month post-KTx; 48% > 12 months. Transfused and non-transfused recipients were not significantly different. In univariate and multivariate analyses, there was no difference between transfused and non-transfused recipient patient survival, antibody-mediated and ACR, and DSA free survival. Transfusions <1 month post-KTx did not impact DCGS (P=NS). Patients transfused >12 months post-KTx had significantly lower 12 month eGFR (compared to non-transfused) and worse subsequent DCGS. Post-KTx blood transfusions have increased in pediatric KTx over time but have no negative association with rejection or DSA production. DCGS is unaffected by transfusion within first month. Transfusions after the first year occur in patients with more advanced chronic kidney disease and are associated with significantly worse DCGS.

Objectives: Infants(age=<2 years) with end stage renal disease requiring dialysis experience high rates of morbidity and mortality. Yet, because of technical and management issues, there are still concerns about transplanting infants. We analyzed the Long term outcomes of renal transplants(tx) in infants. Methods: Between 1984-2012, n=132 infants underwent primary kidney tx(115 Living donor(LD); 17 deceased donor(DD). Outcomes were compared to those of children 2-18 yrs(n=381). Actuarial survival rates were estimated using Kaplan Meier methods. Cox regression analyses were performed to determine whether age had a significant impact on graft survival(with and without deaths censored) after adjusting for known risk factors for graft loss. Results: There was no statistical difference in actuarial outcomes(patient survival(PS),graft-survival(GS),& death censored GS) between infants and older children(HR=1.088(95%CI 0.8-1.5). In LDs, acute rejection free GS(71%[email protected] post-tx;p=0.05) and chronic rejection free GS(75%@5yrs post-txp; p=0.003) was higher in infants compared to 2-18 group. The LOS was longer-for-infants(18 vs.14days,p=<0.001). Those having tx in ≥>2002 (vs pre-2002) had improved PS and GS(p=<0.05). Since 2002, the 5-year patient survival of infants has been 100%. LD grafts had significantly improved outcomes. For those LDtx ≥ 2002, Graft half-life(starting @1yr post tx) for infants is 34years. Renal artery thrombosis was not different but incidence of urine leaks was higher in infants(p=0.02). CMV and BK virus infection were similar between age groups. By Cox regression analyses factors associated with decreased graft survival were DD donor graft(HR=1.47,p=0.025 compared to LD,

INTRODUCTION: We studied the impact of FK versus CsA immunosuppression on patient (PS), death censored graft survival (DCGS), acute rejection (AR), and infection in pediatric KTx recipients at a single center. METHODS: A retrospective cohort study of 106 KTx between 2002 and 2013 in patients age 5-18 years using a SA protocol (thymoglobulin, Mycophenolate mofetil and CsA [5/2002-11/2011, n= 77] or FK [12/2011-6/2013, n=29]). All patients received the same postTx antibacterial and antiviral prophylaxis. Actuarial PS, DCGS, and time to AR were calculated using Kaplan-Meier methods. RESULTS: There was no difference in 1-year PS, GS, or AR rates. The incidence of CMV viremia was 7 times higher in patients on FK compared to those on CsA. Risk factors for CMV on multivariate analysis were only FK use (hazard ratio [HR] 7.2, p=0.0001) and donor + recipient - status preTx (HR 5.7, p = 0.009). The incidence of BK viremia was about 4 times higher but this did not achieve statistical significance. There was no significant difference in the incidence of EBV viremia (p=0.601). The difference in incidence of PTLD at 1-year trended towards significance. There was no significant difference in CMV or EBV recipient and donor positivity pre transplant, incidence of urinary tract infection, pneumonia, or C. difficile diarrhea between the groups.Table: No Caption available.CONCLUSION: CMV infection risk is increased during the first year postTx in Fk versus CsA treated pediatric KTx patients on a SA protocol. BK infection and PTLD also tended to be increased. A protocol monitoring for infection during the first postTx year and consideration of change in immunosuppression is warranted for FK recipients on a SA protocol.

Graft survival among adult African American kidney transplant patients remains low compared to whites, but little information is available for children and adolescents. We examined trends in graft failure among US incident primary kidney transplant patients aged <19 years (n = 13 692), 1980-2004. Trends in 1-year and 2- to 5-year graft failure (for patients whose grafts survived the first year) were analyzed in 5-year intervals. One-year graft failure declined 70% for white and 77% for African American patients over the 25-year period, and 1-year graft failure rates improved at a slightly higher rate for African American compared to white patients (p = 0.02). In contrast, the graft failure rates for years 2-5 declined 53% for white and only 41% for African American patients over the 25 years (p = 0.29). In fully adjusted Cox proportional hazards analysis, the rate of graft failure among African Americans was approximately 2-fold higher than for white patients over the entire study period. Graft survival has improved slightly more for African American than white pediatric patients over the past 25 years. However, graft survival for African American pediatric patients remains poor compared with white patients.