Edith Renoult

Abstract:  A new prevention strategy for CMV infection was evaluated in our pediatric kidney transplant unit. This approach comprises a pre‐emptive therapy, based upon the monitoring of CMV pp67 mRNA in whole blood by the qualitative NASBA, combined with prophylactic CMV‐IG in high risk (R−/D+) children. Thirty‐one kidney transplant children were followed for six months with serial measurements of CMV pp67 mRNA in the blood. The R−/D+ patients were given prophylactic CMV‐IG for the first 16 wk after transplantation. I.v. ganciclovir was administered upon CMV detection by NASBA and was discontinued after two consecutive negative results. CMV infection, detected by NASBA, developed in 11 (35%) recipients: one (33%) of the R+/D− patients and 10 (72%) of the R−/D+ patients. CMV disease developed in 9.6% of the patients (3/31), exclusively in the R−/D+ group. These three patients presented concurrently with CMV viremia and disease. It is noteworthy that two of the three patients could not receive a complete course of CMV‐IG, and one of the latter two subjects had been treated for acute rejection 15 days before CMV infection. Ganciclovir was given for the 11 cases of primary infection, and for three cases of relapsed CMV infection. pp67 NASBA‐based pre‐emptive ganciclovir therapy, combined with prophylactic CMV‐IG in high‐risk patients leads to a lower rate of CMV disease, as long as a complete course of CMV‐IG has been administered and ganciclovir is given during the period of treatment for acute rejection in high‐risk populations.

Background. Robot-assisted laparoscopic donor (RALD) nephrectomy, a new procedure for the removal of a kidney from a living donor, was performed on 13 subjects at our centre.

Background: The yield of routine chest radiography (CXR) as part of the initial management of febrile neutropenic pediatric oncology patients is questionable.Procedure: We retrospectively analyzed the clinical records of neutropenic (absolute neutrophil count ≤0.5 × 10⁹/L) children with cancer, admitted with oral temperature ≥38°C to our institution, between January 2001 and October 2002. Following admission, patients received tobramycin plus (piperacillin or ticarcillin–clavulanic acid). Admission routine CXRs were reviewed. Clinical and radiological features were compared with the discharge diagnosis. Age, underlying disease, and the presence of pulmonary symptoms or signs were studied as possible predictors of CXR findings related to pneumonia.Results: In total, 88 patients experienced 170 episodes of fever. A routine admission CXR was obtained for 157 of the episodes. Radiologists found 20 (12.7%) abnormal CXR (6 with a segmental or lobar consolidation considered as a pneumonia). In addition, two patients with abnormal admission CXR developed lobar consolidation on a repeat film, later in their hospital course. There were no differences in age and type of underlying disease between children with or without pneumonia. Respiratory symptoms were initially present in 58 cases. Seven (12%) had pneumonia. Among the 99 asymptomatic cases only one (1%) patient had a pneumonia (P = 0.0041). This child had a positive blood culture for P. aeruginosa at the time of admission. None of the children had initial therapy modified on the basis of radiologic findings.Conclusion: In this study, pneumonia is an unusual cause of fever (5%), especially in the absence of respiratory signs or symptoms (1%). Admission CXR should be reserved for the neutropenic pediatric oncology patient presenting with fever and abnormal respiratory findings.

Chronic alcoholism and malnutrition are uncommon causes of complicated acute pyelonephritis (APN). Since 1997, we have seen 5 patients with chronic alcoholism (3 women and 2 men, mean age 53.4 +/- 13 years) without cirrhosis, diabetes or renal failure who developed severe APN in a state of malnutrition (albumin 22 +/- 3 g/l, total cholesterol 0.86 +/- 0.2 g/l). Diagnosis was made 14.6 +/- 9 days after onset of atypical symptoms which the patients neglected. There was a major bacterial inoculum: Escherichia coli 10(6.2 +/- 2) (3 multisusceptible and 2 amoxicillin-resistant strains); positive blood cultures in 3 cases. The imaging study showed bilateral diffuse lesions with focal swelling and kidney enlargement, without obstacle, abscess, or papillary necrosis. All patients had severe acute renal failure (maximum serum creatinine: 582 +/- 210 mumol/l; 3 patients underwent dialysis). Mean duration of antibiotic therapy was 40 +/- 7 days (i.v.: 22 +/- 3 d). Renal scarring occurred since creatinine clearance was 33 +/- 22 ml/min 2 months after the initial episode. One patient progressed to end-stage renal failure. In malnourished alcoholic patients, APN may be unusually severe due to late diagnosis leading to the risk of irreversible renal damage and severe chronic renal failure.

Candidosis of the ureter and the bladder is an infrequent complication after renal transplantation. A case occurring early after kidney transplantation is reported in a patient presenting with candiduria. Ultrasound examination detected several fungal bezoars, presenting as a proliferating, avascular lesions, located within the ureter and the bladder. It allowed to demonstrate the rapid extension of lesions, in spite of a medical treatment, leading to a successful endoscopic removal of fungus balls.

The objective of the study was to assess the evolution of renin, angiotensin II, atrial natriuretic factor (ANF) and blood pressure (BP) in the first trimester following renal transplantation in man Thirty-two recipients were investigated for 3 months post-transplantation. Twenty had a history of hypertension with moderate cardiac hypertrophy. Thirty-one retained their native kidneys. Five kidney donors had a history of mild hypertension. The recipients were perioperatively volume-expanded with 0.9% saline and diuresis was maintained for 48 h with furosemide and dopamine. The sodium intake was 25 mEq/24 hours. Prophylactic immunosuppressive therapy was antilymphocyteglobulins (25 cases), or anti-LFA1 (7 cases) and maintenance therapy was cyclosporine-prednisone (8 cases), or cyclosporine-prednisone-azathioprine (24 cases). Mean BP, serum creatinine, urinary sodium excretion (UNA) and hormonal (renin, angiotensin II and ANF) parameters were collected every other day for the first week after transplantation and then twice monthly. Twenty (62.5%) patients developed hypertension and hypertension was more frequent in patients with a delayed graft function, than in patients with immediate good graft function (10/20 vs. 4/12, p < 0.05%). Both hypertensive (group HBP) and normotensive (group NBP) patients had similar very low renin and angiotensin II plasma levels, after an initial early peak. Analysis of covariance with multiple regression analysis showed that in the HBP patients, BP was negatively correlated with UNA (p = 0.02) and positively with plasma ANF (p < 0.01). The normal BP patients also showed a correlation between BP and UNA, although it was limit of statistical significance (p = 0.05); there was no correlation between ANF and BP. We conclude that the RAS is rapidly depressed after renal transplantation and does not interfere with BP regulation. The hypertension in the early stage of post-transplantation varies inversely with the urinary sodium excretion. The defective sodium excretion, which dominates the effect of the low sodium diet, results in volume overload, increased ANF and volume-dependent hypertension.

IgA nephropathy (IgAN) is considered as a disease of young men under 30 years of age. Findings on clinical and histological presentation and outcome in older patients have rarely been published. In a prospective cohort of IgAN patients, recruited over 3 years, 33 patients over age 50 were compared to 96 patients under age 50, according to clinical and histological findings. Actuarial renal survival rate was studied after a mean post-biopsy follow-up of 41 months. Both groups of patients were comparable at baseline for frequency of proteinuria, microscopic haematuria and gross haematuria, but older patients had a significantly higher incidence of hypertension (65 vs 24%, P<0.01). Time between onset and diagnosis of IgAN was similar in both groups. Proteinuria/day, systolic blood pressure, and serum IgA levels were significantly higher, and Ccr was significantly lower in older patients at the time renal biopsy was performed, but serum creatinine and albumin were not. No difference was observed between the two groups for the presence of glomerular or tubulointerstitial lesions. Only endarteritis was significantly more common in older patients (75 vs 34%, P<0.01). End-stage renal failure (ESRF) was confirmed in five patients over 50 and 17 under 50. Renal actuarial survival curves did not show any significant difference between the two groups, even though the six patients who died were classified as ESRF. When the histological diagnosis of IgAN was established, factors that carry a poor prognosis, i.e. proteinuria, high blood pressure, and decreased Ccr were more commonly present in patients over 50 than under 50. However, after the completion of a relatively short follow-up period, renal survival was identical in the two study groups. Prolonged follow-up is necessary to confirm this trend.