The demand for kidney retransplants in the pediatric population is increasing as children are receiving their first transplants at a younger age. This retrospective study included 51 children who underwent a second transplantation during childhood. We compared demographic and transplant characteristics, together with the clinical approach at the first and second transplants. Outcomes of second transplants were reported, and factors influencing repeat graft survival were investigated. Most of the children were male (69

BACKGROUND:The survival of pediatric chronic kidney disease (CKD) patients has improved in recent decades due to advances in dialysis and transplantation. However, cardiovascular disease (CVD) emerges as the main cause of mortality in patients with CKD. OBJECTIVES:To estimate cardiovascular risk in children with CKD at least 1 year after kidney transplantation. In addition, the possible association of cardiovascular risk with classic biochemical markers and potential new markers of this outcome was investigated. METHODS:An observational ambidirectional (retrospective capture of risk factors and prospective study of outcomes) research including 75 patients who underwent renal transplant between 2003 and 2013 with postoperative follow-up of at least 1 year was conducted. The outcome variables adopted were the LV mass Z-score and the presence of coronary calcification on computed tomography using calcium Agatston score. RESULT:Only one patient had an elevated calcium score, and three children (4%) had an LV mass Z-score ≥ 2.0. After multivariable analysis, only gender, serum triglyceride, and serum renalase concentration remained significantly associated with LV mass. CONCLUSION:The low incidence of cardiovascular changes in the population studied confirms the benefit of transplantation for the cardiovascular health of children. Nevertheless, long-term follow-up of these patients is recommended, given the limited duration of kidney function provided by transplantation and the high likelihood of further dialysis and kidney transplants being required in these children.

Background: The supply of essential micronutrients plays a critical role in children with intestinal failure (IF), because they are at risk of deficiency owing to reduced intestinal absorption, insufficient intake, losses from diarrhea, drains, fistulas and use of medications. Long term parenteral nutrition in children is associated with a risk of trace element deficiency, specially zinc, which is essential for immune function, antioxidant defenses and protein synthesis. Methods: For the preparation of this case report, the appropriate information was obtained through consultation of data from the patient’s electronic medical records. The study was approved by the ethics committee of the hospital and the consent form was applied to the patient’s parents. Due to the clinical picture of the patient, it was not possible to apply an assent term Results: This report presents a case of a 5- year- old boy, who has been receiving parenteral nutrition, since birth, due to necrotizing enterocolitis (NEC). He was a premature baby of 25 weeks, weighed 1115 g at birth, with tracheal atresia, needing a traqueostomy. During the first weeks of life, he developed NEC with a massive intestinal resection and needed a jejunostomy. At 7 months of age, an intestinal reconstruction with duodenoileoanastomosis was performed. At 8 months of age, he was discharged home for the first time. He is completely dependent on parenteral nutrition, with poor tolerance for enteral nutrition. After 5 years in parenteral nutrition, he developed a skin rash, first in perioral area, and quickly evolved into perineal region and around the gastrostomy and tracheostomy. He also presented with alopecia, brittle nails, and irritability. He was receiving the adequate amount of energy and protein requirement in his tailored made parenteral nutrition,with polivitamin and trace elements. His zinc sulfate prescription was 40mcg/kg/day and the blood level of zinc was in the normal range of 0,5mcg/ml (reference range 0,5 – 1,1 micrograms/ml). We performed blood tests, to look for infection, specially fungus, micronutrient tests, including copper, iron, aluminium, cromium, manganese, vitamins and excluded all of them, including fatty acid deficiency and essential aminoacid deficiency. We also performed a tricology test that revealed zinc deficiency. After nine days of zinc sulfate suplementation with 200mcg/kg/day, he solved completely the skin eruption. Conclusion: In general, it´s assumed that if we provide the ESPGHAN recomendation of trace element products, children will mantain their blood level of micronutrients adequate. However, children with intestinal failure depending on long term parenteral nutrition, might need a tailored provision of trace elements, accordingly to routinely measurements of blood levels and also taking into account their clinical condition with emphasis on those at risk of deficiency.

Background: Iodine is essential for thyroid hormone biosynthesis. We investigated the prevalence of iodine deficiency (ID) and hypothyroidism in children with intestinal failure (IF) followed up longitudinally, considering selenium status, which is also essential for thyroid gland function. Methods: Children admitted to an intestinal rehabilitation program and receiving home PN were regularly followed-up for urine iodine concentration (UIC), selenium, and thyroid function tests from April 2019 to June 2022. The outcome variable ID was defined as a UIC value < 100 μg/L. Generalized estimating equations were used to assess the effects of potential variables associated with UIC. The study was approved by the hospital’s ethics committee. Results: Twenty-four patients aged 62.7 (39.1; 79.7) months receiving PN for 46.5 (21.5) months were included. The average energy supply was 81.2 kcal/kg/day, 77.6% of which was provided by PN. An average of 5.2 UIC measurements per patient were performed. The prevalence of ID decreased from the first assessment (83.3 %) to the last (45.8%). Three patients developed hypothyroidism secondary to iodine and selenium combined severe deficiency. In the adjusted analysis, iodine intake from oral or enteral nutritional formulas was associated with UIC (β= 0.71 [0.35, 1.07]; p < 0.001). Normal UIC values were observed in patients who reached ≥ 80% of the recommended iodine intake from nutritional formula.Figure 1.: Adjusted linear prediction of iodine intake adequacy from oral or enteral nutritional formulas on urinary iodine concentration (µg/L). The dotted line represents the lower limit of UIC (urinary iodine concentration).Conclusion: ID is highly prevalent in children with IF who receive long-term PN, and its frequency decreases with iodine intake by nutritional formula. Patients who developed hypothyroidism had severe combined iodine and selenium deficiency. Iodine and selenium status, thyroid function, and iodine intake should be monitored in children with IF.

Introduction: Long-term parenteral nutrition (PN) has been associated with renal complications, including hypercalciuria, nephrocalcinosis/nephrolithiasis, proteinuria and reduced glomerular filtration rate (GFR). Pediatric data are scarce and mostly short-term or restricted to transversal studies. Our study aimed to evaluate renal complications in children with intestinal failure (IF) receiving long-term PN. Methods: We performed an observational longitudinal study of patients with IF followed up in a pediatric intestinal rehabilitation center. Outcome variables were estimated glomerular filtration (eGFR) rate, hypercalciuria, nephrocalcinosis/nephrolithiasis, proteinuria, phosphaturia and oxaluria during the follow-up period. The exposure variables were age, duration of parenteral nutrition and type of short bowel syndrome (SBS). The study was approved by the hospital’s ethics committee. Methods: Twenty-four children (54% males), aged 74 months (16; 205) with a median time receiving parenteral nutrition of 47.5 months (IQ 26.5). Data related to renal function were evaluated in two moments, with a median interval of 8 months (IQ 4.5 months). Hypercalciuria was observed in 60.8% and 58.3%, increased phosphaturia in 25% and 18.7%, increased oxaluria in 36.8% and 25% and increased microalbuminuria/proteinuria was observed in 19% and 13.6% of patients, respectively, at moments 1 and 2. Despite de high incidence of hypercalciuria, nephrolithiasis was observed in one patient. In addition to the patient with nephrolithiasis, small and hyperechogenic kidneys were observed in another patient in the image evaluation. The median eGFR rate was 164.5 ml/min/1.73m2 (IQ 52.7) and 195 ml/min/1.73m2 (IQ 38.7) at moments 1 and 2, respectively. There was only one patient with reduced eGFR (77.7 and 78 ml/min/1.73m2) at both times. A significant association was observed between SBS (type 3) and eGFR, with β-coefficient = - 41.07 (95% confidence interval [CI], -66.5; -15.6, p=0,002). Conclusion: The high frequency of hypercalciuria, microalbuminuria and proteinuria, in addition to the state of glomerular hyperfiltration represent risk factors for long-term renal dysfunction. Despite the high incidence of hypercalciuria, nephrocalcinosis/nephrolithiasis was observed in olnly one patient. Long-term monitoring of various aspects of renal function is essential to characterize the effects of prolonged PN on kidney functions in pediatric patients.

The use of small pediatric kidneys as single grafts for transplantation is controversial, due to the potential risk for graft thrombosis and insufficient nephron mass. Aiming to test the benefits of transplanting these kidneys, 375 children who underwent kidney transplantation in a single center were evaluated: 49 (13.1%) received a single graft from a small pediatric donor (≤ 15 kg, SPD group), 244 (65.1%) from a bigger pediatric donor (> 15 kg, BPD group), and 82 (21.9%) from adult living donors (group ALD). Groups had similar baseline main characteristics. After 5 years of follow-up, children from the SPD group were comparable to children from BPD and ALD in patient survival (94%, 96%, and 98%, respectively, p = 0.423); graft survival (89%, 88%, and 93%, respectively, p = 0.426); the frequency of acute rejection (p = 0.998); the incidence of post-transplant lymphoproliferative disease (p = 0.671); the odds ratio for severely increased proteinuria (p = 0.357); the rates of vascular thrombosis (p = 0.846); and the necessity for post-transplant surgical intervention prior to discharge (p = 0.905). The longitudinal evolution of eGFR was not uniform among groups. The three groups presented a decrease in eGFR, but the slope of the curve was steeper in ALD children. At 5 years, the eGFR of the ALD group was 10 ml/min/1.73m2 inferior to the others. At that time, the eGFR from the SPD group was statistically similar to the BPD group (p = 0.952). In a specialized transplant center, the use of a single small pediatric donor kidney for transplantation is as successful as bigger pediatric or adult living donors, after 5 years of follow-up. A higher resolution version of the Graphical abstract is available as Supplementary information.

Background. Small children are less frequently transplanted when compared with older. The objective of the present study was to compare the preparation time for transplantation in children of different weights and to identify factors associated with a delay in the workup of small children. Methods. We report on a retrospective cohort comprising all children referred for renal transplantation (RTx) workup between 2009 and 2017. The main outcome was transplantation workup time, defined as the time elapsed between the first consultation and when the child became ready for the surgery. Results. A total of 389 children (63.5% males) were selected, with a median weight of 18 kg (interquartile range, 11–32). Patients were categorized into 2 groups: group A (study group): ≤15 kg (n = 165) and group B (control group): >15 kg (n = 224). The probability of being ready for RTx was comparable between groups A and B. The cumulative incidence rate difference between groups is −0.05 (95% confidence interval, −0.03 to 0.02). The median time for RTx workup was 5.4 (2.4–9.4) in group A and 4.3 (2.2–9.0) months in group B (P = 0.451). Moreover, the presence of urinary tract malformation was associated with the need for longer transplantation workup time (P < 0.001). Conclusions. In children >7 kg, the workup time for transplantation is not related to body weight. In a specialized center, children weighing 7–15 kg became ready within the same timeframe as children weighing >15 kg, despite the smaller children had greater difficulty being nourished, dialyzed, and a greater need for surgical correction of the urinary tract pretransplant.