Background. On 9/28/05, a national kidney (KI) allocation change known as Share 35 was implemented in the U.S., so that children listed before age 18y receive local priority for KI from donors <35y. After Share 35, the overall no. of transplants (tx) in pediatrics (ped) continues to increase, but there are more HLA mismatched (MM) tx in ped. This analysis was performed for the Organ Procurement and Transplantation Network (OPTN) Pediatric Transplantation Committee to compare 5y post-tx outcomes of ped tx pre-and post-Share 35. Data and Methods. OPTN data was analyzed for post-tx outcomes of ped recipients (age at listing <18y) of non-zero HLA MM deceased donor (DD) KI tx performed 3y pre- and 3y post-Share 35 policy. Serum creatinine and rate of treatment for acute rejection at 5y post-tx were calculated. Graft and patient survival within 5y post-tx were calculated using the Kaplan-Meier (KM) method. Retransplant (retx) rate within 5y was estimated among first tx using a competing risk method. Results. There were 1,207 ped recipients of non-zero HLA MM, DD KI tx pre-Share 35, and 1,731 tx post-Share 35. Percent of tx performed in the following categories was higher post-Share 35 than pre-Share 35: Hispanic ethnicity, pre-emptive tx, and 2-DR MM. Median serum creatinine (Cr) at 5y was comparable for tx performed pre- and post-Share 35 (1.1 vs. 1.09 mg/dL). 5y rate of treatment for acute rejection was similar pre- and post-Share 35 (52% vs. 51%). Unadjusted KM graft and patient survival were significantly higher post- vs. pre-Share 35, despite increased DR MM post-Share 35. For example, 5y graft survival was 70% post- and 67% pre-Share 35, and 5y patient survival was 97% post- and 94% pre-Share 35. Post-tx outcomes by DR MM level were not negatively affected after Share 35. Re-tx rate within 5y was comparable pre- and post-Share 35 (4.6% and 5.4%, respectively). Conclusions. Despite a higher percent of ped tx with 2-DR MM after Share 35, rates of treatment for acute rejection and median serum Cr at 5y post-tx did not increase, and retx rates were comparable. Unadjusted graft and patient survival within 5y post-tx were not adversely affected for ped recipients of non-zero HLA MM tx. Improvement in graft and patient survival post-Share 35 may be a reflection of improved immunosuppression after 2005. Longer follow-up (up to 10y) is needed to assess potential late effects of higher DR MM on post-tx outcomes.

Purpose Renal mycetomas are rare manifestations of candidia infection in children, which if untreated may lead to urinary tract obstruction (UTO), renal failure and high mortality. We report successful use of an AngioJet device to pulverize an obstructing renal pelvis candida mycetoma resistent to conventional nephrostomy tube (NT) drainage in a small child with UTO and renal failure. Materials and Methods Case history : A 2.5 year old, 10.5 kg, former 26 wk premature girl was admitted with recurrent candida urinary tract infection and fungal balls within the right pelvicalyceal system leading to UTO, oliguria and renal failure (serum Cr 2.7 mg/dL). NT placement and administration of IV Amphotericin B (AmB) failed to improve urine output or renal failure. Ultrasound and antegrade pyelogram showed persistent dilatation of an obstructed right collecting system plugged with fungal balls. Technique : The in situ 8.5F NT catheter was exchanged for a vascular sheath through which a 6-French AngioJet Spiroflex catheter (AngioJet ® Ultra thrombectomy system, Medrad International ® ) with a 15-mm active tip was advanced into the renal pelvis and calyces under ultrasound and fluroscopic monitoring. Fungal balls were drawn into the catheter,fragmented by saline pressure jets from the active tip and aspirated simultaneously. The saline in the AngioJet system was replaced with AmB solution and pharmacomechanical pulverization of the fungal balls was performed followed by upsizing of the NT to 10F. Results After mycetoma pulverization, NT urine output improved from 0 to 490mL in the first 12 hr, and serum Cr decreased to 1.65 within 24 hr. The patient had no complications from the AngioJet therapy. She completed a 21 day course of systemic and transcatheter AmB and NT was removed. At 2 week follow-up, serum Cr was 0.6 mg/dL, and ultrasound and antegrade studies showed reduced hydronephrosis with no recurrence of fungal balls. At 12 month follow- up, patient had no recurrence of candida infection, no imaging recurrence of mycetoma and serum Cr 0.5 mg/dL. Conclusion Pharmacomechanical pulverization using an AngioJet thrombectomy system is an effective treatment option for refractory renal collecting system mycetoma.