Low-Bose Cyclosporine Therapy Combined With Standard Immunosuppression in Pediatric Renal Transplantation

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PEDIATRIC UROLOGY

are managed with high-dose steroids but heterologous antilymphocyte globulin and pan-T monoclonal antibodies can be used with success in steroid-resistant rejection episodes. Finally, as our understanding of the mechanism of rejection of renal allografts increases other monoclonal antibodies directed at the leukocyte subpopulations are likely to emerge. 30 references William J. Cromie, M.D. Albany, New York

Parent-to-Child Transplantation With Cyclosporine Immunosuppression B. D. KAHAN, S. CONLEY, R. PORTMAN, R. LEMAIRE, C. WIDEMAN, S. FLECHNER AND C. VAN BUREN, Division of Immunology and Organ Transplantation, The University of Texas Medical School, Houston, Texas

J. Ped., 111: 1012-1016 (Dec.) 1987 During the last 5 years the outcome of 20 renal transplants of parental grafts to recipient children was compared to that in a concurrent group of haploidentical grafts in adults. The incidence of allograft loss and treated rejection episodes was much greater in pediatric than in adult recipients and nephrotoxicity lessened with the use of cyclosporine. Although resistance of the child's immune system to the effects of cyclosporine cannot be excluded, it appeared that the increased allograft loss was related to the rapid clearance of the agent in children. These findings indicate that this effect caused trough serum levels to be below the putative threshold. They demonstrate the need for higher cyclosporine doses and frequency in pediatric compared to adult recipients. 3 tables, 9 references William J. Cromie, M.D. Albany, New York

Low-Dose Cyclosporine Therapy Combined With Standard Immunosuppression in Pediatric Renal Transplantation S. K. S. So, J. S. NAJARIAN, T. E. NEVINS, D. S. FRYD, M. KNAAK, B. CHAVERS, S. MAUER AND R. L. SIMMONS, Departments of Surgery and Pediatrics, University of Minnesota, Health Sciences Center, Minneapolis, Minnesota

J. Ped., 111: 1017-1021 (Dec.) 1987 The authors report on the combined immunosuppressive regimen of antilymphocyte globulin, azathioprine, prednisone and low-dose cyclosporine in 28 children 9 months to 17 years old who received primary renal allografts. After a mean followup of 17.3 months the patient and graft survival rate was 100 per cent (18 of 18) for mismatched-related kidneys and 90 per cent (9 of 10) for cadaver kidneys. The only graft failure was owing to death of technical complications. The mean serum creatinine level after transplantation was 0.85 mg./dl. The probability of a rejection episode within 1 year was 45 per cent and 60 per cent for mismatched-related and cadaver kidneys, respectively. Cyclosporine nephrotoxicity was recognized in only 3. 7 per cent of 27 children and it was reversed rapidly after cyclosporine was discontinued. This preliminary experience suggests that the use of quadruple immunosuppressive

therapy in children is associated with an improved graft function rate and a low incidence of complications. 3 figures, 13 references William J. Cromie, M.D. Albany, New York

Editorial comment. There is no question that cyclosporine has improved graft survival after renal transplantation dramatically. Kropp recently has reviewed experiences in transplantation using cyclosporine and azathioprine in alternate patients. Graft survival was 30 per cent better at 1 year in the cyclosporine group. Lowell R. King, M.D. Durham, North Carolina

PEDIATRIC UROLOGY Endoscopic Correction of Grades IV and V Primary Vesicoureteric Reflux: Six to 30 Month Follow-up in 42 Ureters P. PURI AND B. O'DONNELL, Children's Research Centre, Our Lady's Hospital for Sick Children, Dublin, Ireland

J. Ped. Surg., 22: 1087-1091 (Dec.) 1987 The authors report a 2-year experience with 31 children with grades IV and V primary vesicoureteral reflux treated by en doscopic subureteral injection ofpolytetrafluoroethylene (Polytef) paste. The patient population consisted of 23 girls and 8 boys between 3 months and 14 years old (mean age 5.4 years). Twenty patients had unilateral and 11 had bilateral reflux. Of the ureters 36 had grade IV and 6 had grade V reflux. Shortterm followup demonstrated resolution of reflux after 1 injection of polytetrafluoroethylene in 28 ureters (67 per cent), 2 injections in 6, 3 injections in 3 and 4 injections in 1. Two ureters showed improvement in the grade of reflux and 2 were unchanged. Long-term followup (6 to 30 months) in 38 ureters revealed resolution of reflux in 84 per cent. Followup excretory urography did not show evidence of obstruction in any patient treated by endoscopic injection. 3 figures, 2 tables, 6 references George W. Kaplan, M.D. San Diego, California

Editorial comment. The results achieved with transurethral polytetrafluoroethylene injection to correct reflux have been impressive. Hundreds of cases currently have been reported with an over-all success rate of perhaps 85 per cent and no significant complications, particularly no ureteral obstruction. The technique appears to be especially simple technically when some intravesical ureter is present under which the tip of the needle can be placed before injection. When the orifice is golf hole size and the intravesical ureter is missing it is less clear how polytetrafluoroethylene injection can help effectively. These 31 children had severe reflux and so they often would have had golf hole or nearly golf hole orifices. Despite this fact reflux was corrected in almost all instances with polytetrafluoroethylene injection even though more than 1 treatment was required in more than a quarter of the patients. I believe that polytetrafluoroethylene injection is proving to be safe and is so inexpensive relative to other modes of therapy that it is bound to enjoy more general use. Lowell R. King, M.D. Durham, North Carolina