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Outcome of renal transplantation in children with pericardiopleural effusion
Outcome of Renal Transplantation in Children With Pericardiopleural Effusion Y. Chen, T.-H. Yen, K.-L. Liu, Y.-J. Chiang, C.-T. Wu, H.-W. Chen, and S.-H. Chu ABSTRACT Introduction. Children with end-stage renal disease may present with pericardiopleural effusion secondary to volume overload and overhydration. The present study was designed to investigate the efficacy and safety of renal transplantation in these pediatric patients. Methods. From 1981 to 2001, six of 20 patients (30%) under 18 years old who received renal transplants showed pericardiopleural effusion after serial pretransplant imaging studies. These patients also displayed associated diseases, such as congestive heart failure (n ⫽ 3), ascites (n ⫽ 2), and splenomegaly (n ⫽ 2). The recipients included five boys and one girl of mean age of 12.7 years (range, 8 to 17 years), all of whom had undergone hemodialysis before transplantation. The waiting time for grafts ranged from 1.3 to 6 years (mean ⫽ 2.6 years). Episodes of acute pulmonary edema had been observed in three patients pretransplant. Results. One recipient died with a functioning graft due to heart failure with acute pulmonary edema at 4 months after transplantation. Acute rejection episodes were observed in three, and chronic rejection in two children. The median follow-up was 11 years (range ⫽ 6 to 16 years) in the other five recipients, all of whom presently survive with functioning grafts. The posttransplant mean serum creatinine levels at 1 year, 3 years, and 5 years were 1.54 ⫾ 0.44, 1.74 ⫾ 0.56, and 1.92 ⫾ 0.56 mg/dL, respectively. Conclusion. Renal transplantation in children displaying pericardiopleural effusion was associated with a high success rate. However, these patients must be followed closely with regular cardiopulmonary evaluation since their condition may deteriorate.
A
CCORDING TO THE US Renal Data System, the adjusted end-stage renal disease (ESRD) incidence per million population was 11 for patients aged 0 to 19 years with the highest incidence among children 15 to 19 years old.1 In the last decade, transplantation has become the optimal treatment for children with ESRD, because a successful graft allows normal growth, neurodevelopment, and an improved quality of life.2 Although children with ESRD often display pericardiopleural effusions secondary to volume overload and overhydration, data regarding the prognosis and risks of these young recipients have not been available. The present study was designed to investigate the efficacy and safety of renal transplantation in these pediatric patients. MATERIALS AND METHODS From 1981 to 2001, 20 patients under 18 years old received renal transplants. After infectious causes of pericardiopleural effusion
were excluded, six patients (30%) were found after serial pretransplant imaging studies to have noninfectious pleural effusions; one patient had combined of pericardiac effusion. Associated diseases such as congestive heart failure (n ⫽ 3), ascites (n ⫽ 2), and splenomegaly (n ⫽ 2) were also observed in the patients. The recipients included five boys and one girl of mean age 12.7 years (range ⫽ 8 to 17 years). All patients underwent hemodialysis before their first transplant. Five kidneys were obtained from cadaveric donors and one kidney from a living donor. The waiting time for grafts ranged from 1.3 to 6 years (mean ⫽ 2.6 years). The underlying diseases before transplantation included hypertension From the Departments of Urology (Y.C., K.-L.L., Y.-J.C., C.-T.W., H.-W.C., S.-H.C.) and Nephrology (T.-H.Y.), Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan. Address reprint requests to Yu Chen, MD, Department of Urology, Chang Gung Memorial Hospital, 5, Fu-Hsing St, Kweishan, Taoyuan, 333, Taiwan. E-mail: [email protected]
0041-1345/04/$–see front matter doi:10.1016/j.transproceed.2004.08.014
© 2004 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
2032
Transplantation Proceedings, 36, 2032–2033 (2004)
CHILDREN WITH PERICARDIOPLEURAL EFFUSION (n ⫽ 4), hepatitis B carrier (n ⫽ 3), hepatitis C carrier (n ⫽ 1), and asthma (n ⫽ 1). Episodes of acute pulmonary edema were observed among three patients pretransplant. Immunosuppression with cyclosporine (adjusted to target trough blood levels) and low-dose prednisone was used in all recipients. Addition of azathioprine was presented for one of them.
RESULTS
One recipient died with a functioning graft due to heart failure with acute pulmonary edema 4 months after transplantation. The course of one recipient was complicated with a urinoma, which responded to revision of the ureteroneocystostomy. Acute rejection episodes occurred in three and chronic rejection in two patients. The median follow-up was 11 years (range ⫽ 6 to 16 years) in the other five recipients, all of whom presently survive with functioning grafts and recovery from the pericardiopleural effusion, congestive heart failure, or ascites. The posttransplant mean serum creatinine levels at 1 year, 3 years, and 5 years were 1.54 ⫾ 0.44, 1.74 ⫾ 0.56, and 1.92 ⫾ 0.56 mg/dL, respectively. DISCUSSION
Renal transplantation is the optimal treatment for children with ESRD. Broyer et al reported that children develop ESRD at an annual rate of 0.5 to 5.5 persons per million population.3 The implication of pericardiopleural effusion for pediatric recipients either before or after kidney transplantation has not been extensively studied. In our series, infectious pleural effusions were excluded, because Ettenger et al had reported that they cause significant morbidity in renal transplant candidates.4 Pleural effusions are common (20%) among patients receiving chronic hemodialysis.5 As a result, congestive heart failure, uremic pleurisy, atelectasis, and parapneumonic effusions are major forms of presentation.5 In our series, 6 (30%) patients showed a
2033
pleural effusion with one of them also displaying a pericardiac effusion. At the same time, three patients presented with congestive heart failure and two patients, ascites. These data suggest that young children may be more prone to pleural effusions than adults on chronic hemodialysis. Fluid overload is a common initiating cause for pulmonary congestion, pleural effusion, and ascites formation among patients on maintenance hemodialysis.6 Effective fluid removal by ultrafiltration may be hampered if hypotension occurs during dialysis.6 A danger of overdehydration during hemodialysis commonly exists when, inadequate fluid is removed from young children. As a result, fluid overload commonly remains unabated in these young patients. Although pleural effusions usually resolve with continued or adequate dialysis over several weeks, they may be recurrent.7 In our series, five of six recipients survived with functioning grafts and after transplantation recovered completely from the pericardiopleural effusion, congestive heart failure, or ascites. As a result, we agree with Wang et al6 that the ideal therapy for these young patients is a successful renal transplant. In conclusion, renal transplantation in children with pericardiopleural effusion is associated with a high success rate. However, these patients must be followed closely with regular cardiopulmonary evaluation since their condition may deteriorate. REFERENCES 1. United States Renal Data System (USRDS): Am J Kidney Dis 22:69, 1993 2. Miller LC, Bock GH, Lum CT, et al: J Pediatr 100:675, 1982 3. Broyer M, Rizzoni G, Brunner H, et al: Proc Eur Dial Transplant Assoc 22:55, 1985 4. Ettinger NA, Trulock EP: Am Rev Respir Dis 143:1386, 1991 5. Jarratt MJ, Sahn SA: Chest 108:470, 1995 6. Wang F, Pillay VKG, Ing TS, et al: Nephron 12:105, 1974 7. Berger HW, Rammohan G, Neff MS, et al: Ann Intern Med 82:362, 1975
A
CCORDING TO THE US Renal Data System, the adjusted end-stage renal disease (ESRD) incidence per million population was 11 for patients aged 0 to 19 years with the highest incidence among children 15 to 19 years old.1 In the last decade, transplantation has become the optimal treatment for children with ESRD, because a successful graft allows normal growth, neurodevelopment, and an improved quality of life.2 Although children with ESRD often display pericardiopleural effusions secondary to volume overload and overhydration, data regarding the prognosis and risks of these young recipients have not been available. The present study was designed to investigate the efficacy and safety of renal transplantation in these pediatric patients. MATERIALS AND METHODS From 1981 to 2001, 20 patients under 18 years old received renal transplants. After infectious causes of pericardiopleural effusion
were excluded, six patients (30%) were found after serial pretransplant imaging studies to have noninfectious pleural effusions; one patient had combined of pericardiac effusion. Associated diseases such as congestive heart failure (n ⫽ 3), ascites (n ⫽ 2), and splenomegaly (n ⫽ 2) were also observed in the patients. The recipients included five boys and one girl of mean age 12.7 years (range ⫽ 8 to 17 years). All patients underwent hemodialysis before their first transplant. Five kidneys were obtained from cadaveric donors and one kidney from a living donor. The waiting time for grafts ranged from 1.3 to 6 years (mean ⫽ 2.6 years). The underlying diseases before transplantation included hypertension From the Departments of Urology (Y.C., K.-L.L., Y.-J.C., C.-T.W., H.-W.C., S.-H.C.) and Nephrology (T.-H.Y.), Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan. Address reprint requests to Yu Chen, MD, Department of Urology, Chang Gung Memorial Hospital, 5, Fu-Hsing St, Kweishan, Taoyuan, 333, Taiwan. E-mail: [email protected]
0041-1345/04/$–see front matter doi:10.1016/j.transproceed.2004.08.014
© 2004 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
2032
Transplantation Proceedings, 36, 2032–2033 (2004)
CHILDREN WITH PERICARDIOPLEURAL EFFUSION (n ⫽ 4), hepatitis B carrier (n ⫽ 3), hepatitis C carrier (n ⫽ 1), and asthma (n ⫽ 1). Episodes of acute pulmonary edema were observed among three patients pretransplant. Immunosuppression with cyclosporine (adjusted to target trough blood levels) and low-dose prednisone was used in all recipients. Addition of azathioprine was presented for one of them.
RESULTS
One recipient died with a functioning graft due to heart failure with acute pulmonary edema 4 months after transplantation. The course of one recipient was complicated with a urinoma, which responded to revision of the ureteroneocystostomy. Acute rejection episodes occurred in three and chronic rejection in two patients. The median follow-up was 11 years (range ⫽ 6 to 16 years) in the other five recipients, all of whom presently survive with functioning grafts and recovery from the pericardiopleural effusion, congestive heart failure, or ascites. The posttransplant mean serum creatinine levels at 1 year, 3 years, and 5 years were 1.54 ⫾ 0.44, 1.74 ⫾ 0.56, and 1.92 ⫾ 0.56 mg/dL, respectively. DISCUSSION
Renal transplantation is the optimal treatment for children with ESRD. Broyer et al reported that children develop ESRD at an annual rate of 0.5 to 5.5 persons per million population.3 The implication of pericardiopleural effusion for pediatric recipients either before or after kidney transplantation has not been extensively studied. In our series, infectious pleural effusions were excluded, because Ettenger et al had reported that they cause significant morbidity in renal transplant candidates.4 Pleural effusions are common (20%) among patients receiving chronic hemodialysis.5 As a result, congestive heart failure, uremic pleurisy, atelectasis, and parapneumonic effusions are major forms of presentation.5 In our series, 6 (30%) patients showed a
2033
pleural effusion with one of them also displaying a pericardiac effusion. At the same time, three patients presented with congestive heart failure and two patients, ascites. These data suggest that young children may be more prone to pleural effusions than adults on chronic hemodialysis. Fluid overload is a common initiating cause for pulmonary congestion, pleural effusion, and ascites formation among patients on maintenance hemodialysis.6 Effective fluid removal by ultrafiltration may be hampered if hypotension occurs during dialysis.6 A danger of overdehydration during hemodialysis commonly exists when, inadequate fluid is removed from young children. As a result, fluid overload commonly remains unabated in these young patients. Although pleural effusions usually resolve with continued or adequate dialysis over several weeks, they may be recurrent.7 In our series, five of six recipients survived with functioning grafts and after transplantation recovered completely from the pericardiopleural effusion, congestive heart failure, or ascites. As a result, we agree with Wang et al6 that the ideal therapy for these young patients is a successful renal transplant. In conclusion, renal transplantation in children with pericardiopleural effusion is associated with a high success rate. However, these patients must be followed closely with regular cardiopulmonary evaluation since their condition may deteriorate. REFERENCES 1. United States Renal Data System (USRDS): Am J Kidney Dis 22:69, 1993 2. Miller LC, Bock GH, Lum CT, et al: J Pediatr 100:675, 1982 3. Broyer M, Rizzoni G, Brunner H, et al: Proc Eur Dial Transplant Assoc 22:55, 1985 4. Ettinger NA, Trulock EP: Am Rev Respir Dis 143:1386, 1991 5. Jarratt MJ, Sahn SA: Chest 108:470, 1995 6. Wang F, Pillay VKG, Ing TS, et al: Nephron 12:105, 1974 7. Berger HW, Rammohan G, Neff MS, et al: Ann Intern Med 82:362, 1975