M ORNING R EPORT February 17, 2010

R ENAL T RANSPLANTS Most frequent transplant 45% of all pediatric transplants 7% of renal transplants ≤ 17y 3 year survival exceeds survival on dialysis Age 0-14 Life expectancy increased by 30 years Age Life expectancy increased by 25 years

R ENAL T RANSPLANTS Males 59% African American 28% Hispanic 33% Adolescents 38.4%

Lupus Medullary cystic disease

I MMUNOSUPPRESSION Prograf

I MMUNOSUPPRESSION Cellcept

I MMUNOSUPPRESSION

I NFECTIOUS COMPLICATIONS Most common cause of hospitalization during the first 24 months Most common in first 6 months Post-operative Bacterial UTI Pulmonary Infections Bactrim prophylaxis

I NFECTIOUS C OMPLICATIONS Viral BK virus Infects 90% of the population 5% incidence nephritis Important cause of allograft dysfunction Active disease in kidney transplant patients are more common in patients who are initially BKV antibody- negative Routine screening may be effective Cidofovir

I NFECTIOUS C OMPLICATIONS Viral CMV Chronic rejection and late graft loss 2 routes Primary infection with negative recipient and positive donor Positive recipient with reactivation or reinfection with a different strain Symptoms Asymptomatic Fever, leukopenia, thrombocytopenia, pneumonitis, hepatitis, graft dysfunction Incidence is higher in seronegative recipients Ganciclovir and valganciclovir

I NFECTIOUS C OMPLICATIONS Viral Varicella Severe disease Encephalitis, pneumonitis, hepatic dysfunction, death If non-immune and exposed PEP within 72 hours If infected IV acyclovir Withdrawl of immunosuppressants Prevention Immunization prior to transplant ? Immunization post transplant

I NFECTIOUS C OMPLICATIONS Viral EBV Most common in seronegative recipients Reactivation is more likely to be asymptomatic PTLD (Posttransplant lymphoproliferative disease) Treatment Reduce immunosuppression Rituximab Herpes Severity depends on immunosuppression Treatment Acyclovir Valacyclovir

O UTCOMES Rejection rate <16% Increased risk Deceased donation Race (African-American) HLA-DR mismatches Lack of induction therapy >5 lifetime transfusions Reversal of rejection 53% Living donors 47% Deceased donors

O UTCOMES Rejection 41.3% chronic rejection 7.4% acute rejection 8.1% graft thrombosis 7.9% disease recurrence 6.3% nonadherence Prevalent among adolescence

O UTCOMES Graft Survival 1 year LD – 92.2% DD – 83.6% 5 years LD – 79.7% DD – 65.1% Patient Survival >95% at 5 years Primary causes of death Infection Cardiopulmonary disease Cancer

L ONG -T ERM I SSUES Growth Fail to reach normal genetic adult height Baseline renal function Corticosteroids Treatment Growth hormone Hyperlipidemia Hypertension Obesity New-onset diabetes

L ONG -T ERM I SSUES Malignancy Lymphoproliferative Immunosuppressants Hirsutism Gum hyperplasia Nonadherence Adverse effects Need for peer acceptance