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Renal Transplantation: The Pediatric Experience
Accepted 573
574
RENAL TRANSPLANTATION IN C'AP[) PATIFNTS. *1effrey Glaser, Stephen Weinstein, *Kart Nolph, Gilbert Ross, Jr. (Presentation to be made by nr. Ross) During the period 1981-85, 39 adults and 2 children on continuous ambulatory peritoneal dialysis (CAPO) u.nderwent renal transplantation (cadaveric 30, living related 11). Results were compared to 108 hemodialysis patients (Hn). Actuarial cadaveric graft survival at one and two years was 60% and 56% for C'.APD patients and 56% and 52% for HI) patients. For living related grafts at one and two years the figures were CAPD 91% and 71% and Hn 100% and 100% respectively. 27% of the CAP[) patients experienced episodes of preoperative peritonitis and the same number had transient postoperative ascites. Exit site infection .prompted catheter removal in 7 patients post-operatively between one and 12 weeks. 50% of the patients required post-operative dialysis; two-thirds of these were managed with CAPO alone. Perivascular fibrosis was noted rather commonly (15%) and wound infections were more frequent (10%) than in Hn patients, One incisional hernia developed, Although wound problems were slightly more frequent in CAPn patients, results were equivalent in the two groups.
RENAL TRANSPLANTATION: THE PEDIATRIC EXPERIENCE.
*Mark R.
Zaontz, *Richard Cohn, *Craig Langman, *Donaid I. Moel and Casimir R. Firlit, Chicago, Il. (Presentation to be made
by Dr. Zaontz) Renal transplantation is a highly acceptable form of
treatment for patients with end stage renal disease (ESRD). Advances in surgical technique, renal imaging, earlier treatment of rejection and better forms of immunosuppression have significantly improved graft survival. Herein we present our experience in renal transplanta-
tion over the past 14 years in 121 children, aged 14 months to 18 years. A total of 148 transplants were performed with 87% (48/55) survival from having related donors and 56% (52/93) survival from cadaver related donors. The introduction of cyclosporine in 1984 saw 100% graft survival from living (10/10) and cadaver related donors (7 /7). In the living related transplants, graft loss was due to acute rejection (3), by hyperacute rejection (1), donorspecific transfusion and rejection (1), pneumococcol sep-
sis (1), and pneumocystic pneumonia (1), Major morbidity in both groups (living and cadaver related) included steroid induced diabetes (6), avascular necrosis (6), varicella zoster (4), peptic ulcer (4) and psuedotumor cerebri (4). Deaths occurred in 13 patients, nine of whom had normal renal function at the time of their demise. Detailed review of this series indicates excellent prognosis for living related graft survival and improving statistics for those cadaver related. Issues particular to the pediatric age group such as donor source, surgical approach and postoperative management will also be discussed.
575
576
EFFECTS OF COMBINED SACRAL DECENTRALIZATION AND HYPOGASTRIC NEURECTOMY ON INTRINSIC INNERVATION OF THE FELINE BLADDER BASE. Ahmad Hanno* and Ahmad Elbadawi, Syracuse, New York. (Presentation to be made by Dr. Hanno) It has been shown previously that sacral ventral rhizotomy leads within 3 weeks to transsynaptic degeneration of m:>st cholinergic axons, with loss of their neuroeffector junctions, in the feline bladder base (Elbadawi et al, 1984) . Within 10 weeks, the cholinergic axons are rest<:>red by axon sprouts .and re-establish the jtmctions, with concomitant adrenergic hyperinnervation (Atta et al, 1984). The present study was conducted to determine the effect of bilateral hypogastric neurectomy on the above changes. Bilateral hypogastric neurectomy and sacral ventral rhizotomy were done at the same time in 4 adult male cats. Specimens from the bladder base were obtained for electron microscopy 3 and 10 weeks after operation (2 cats each period). In the 3-week sffinples, there was widespread degeneration of both cholinergic and adrenergic axon tenninals and varicosities, with loss of their neuroeffector jtmctions. Intact adrenergic axon profiles were observed only in axon bundles and within Schwann cells. In the 10-week Sil111Ples, both cholinergic and adrenergic axons and their neuroeffector jtmctions were partially restored, with sparse cholinergic axon sprouting, and no adrenergic hyperinnervation; but there was a m:>dest increase in the adrenergic axon content of large dense-core vesicles, suggesting the presence of an increased population of copeptidergic axons. Our observations indicate that an intact sympathetic pathway is necessary for the eventual adrenergic hyperinnervation, and cholinergic axon sprouting that 're-innervates' the decentralized feline lissosphincter (conceivably through neurotrophic influence on parasympathetic peripheral ganglion cells). It would be interesting to find out if the reverse situation is true, namely, that an intact parasympathetic pathway is necessary for adrenergic axon sprouting and cholinergic hyperinnervation following preganglionic interruption of sympathetic innervation of the bladder, [Supported by NIH Grant #AG-06202-01]
THE PROPHYLACTIC USE OF CLEAN INTERMITTENT CATHETERIZATION IN CHILDREN WITH MYELODYSPASIA; *Evangelos G. Geraniotis, M.D., & Stephen A. Koff, M.D,, Columbus, Ohio, (Presentation made by Dr. Geraniotis) The development of clean intermittent catheterization
(CIC) during the past 12 years as well as the increased use of diagnostic urodynamic studies has revolutionized the urologic treatment and management of children with
myelomeningocele (MMC).
However, the timing of the
initiation of CIC in these children is an issue that remains unresolved and controversial. We present our data from a controlled, prospective,
randomized study in which children with MMC were classified into 2 groups based on initial urodynamic studies:
1) Coordinated external sphincter, 2) Uncoordinated external sphincter. Those in the 2nd group were then randomized into 2 treatment groups: 1) Treatment with
self voiding and observation. 2) Treatment with prophylactic CIC. Follow-up has consisted of frequent urine analysis and culture as well as regular renal ultrasound, IVP, and nuclear cystograms. Preliminary results to date show that greater than 50% of children with uncoordinated sphincters treated with
self voiding deteriorated, even while adhering to a frequent follow-up program, and required the instituticin of CIC. However, this did not always reverse the destructive
changes which had taken piace. In contrast, only 10% of children initially treated with CIC showed evidence of deterioration. We therefore conclud~ that regular urodynamic studies
of myelomeningocele children from birth can identify parameters which will predict the fate of these children's
urinary tracts, and that the prophylactic use of CIC in these neonates can prevent the deterioration which still occurs on even an ideal screening program.
247A
574
RENAL TRANSPLANTATION IN C'AP[) PATIFNTS. *1effrey Glaser, Stephen Weinstein, *Kart Nolph, Gilbert Ross, Jr. (Presentation to be made by nr. Ross) During the period 1981-85, 39 adults and 2 children on continuous ambulatory peritoneal dialysis (CAPO) u.nderwent renal transplantation (cadaveric 30, living related 11). Results were compared to 108 hemodialysis patients (Hn). Actuarial cadaveric graft survival at one and two years was 60% and 56% for C'.APD patients and 56% and 52% for HI) patients. For living related grafts at one and two years the figures were CAPD 91% and 71% and Hn 100% and 100% respectively. 27% of the CAP[) patients experienced episodes of preoperative peritonitis and the same number had transient postoperative ascites. Exit site infection .prompted catheter removal in 7 patients post-operatively between one and 12 weeks. 50% of the patients required post-operative dialysis; two-thirds of these were managed with CAPO alone. Perivascular fibrosis was noted rather commonly (15%) and wound infections were more frequent (10%) than in Hn patients, One incisional hernia developed, Although wound problems were slightly more frequent in CAPn patients, results were equivalent in the two groups.
RENAL TRANSPLANTATION: THE PEDIATRIC EXPERIENCE.
*Mark R.
Zaontz, *Richard Cohn, *Craig Langman, *Donaid I. Moel and Casimir R. Firlit, Chicago, Il. (Presentation to be made
by Dr. Zaontz) Renal transplantation is a highly acceptable form of
treatment for patients with end stage renal disease (ESRD). Advances in surgical technique, renal imaging, earlier treatment of rejection and better forms of immunosuppression have significantly improved graft survival. Herein we present our experience in renal transplanta-
tion over the past 14 years in 121 children, aged 14 months to 18 years. A total of 148 transplants were performed with 87% (48/55) survival from having related donors and 56% (52/93) survival from cadaver related donors. The introduction of cyclosporine in 1984 saw 100% graft survival from living (10/10) and cadaver related donors (7 /7). In the living related transplants, graft loss was due to acute rejection (3), by hyperacute rejection (1), donorspecific transfusion and rejection (1), pneumococcol sep-
sis (1), and pneumocystic pneumonia (1), Major morbidity in both groups (living and cadaver related) included steroid induced diabetes (6), avascular necrosis (6), varicella zoster (4), peptic ulcer (4) and psuedotumor cerebri (4). Deaths occurred in 13 patients, nine of whom had normal renal function at the time of their demise. Detailed review of this series indicates excellent prognosis for living related graft survival and improving statistics for those cadaver related. Issues particular to the pediatric age group such as donor source, surgical approach and postoperative management will also be discussed.
575
576
EFFECTS OF COMBINED SACRAL DECENTRALIZATION AND HYPOGASTRIC NEURECTOMY ON INTRINSIC INNERVATION OF THE FELINE BLADDER BASE. Ahmad Hanno* and Ahmad Elbadawi, Syracuse, New York. (Presentation to be made by Dr. Hanno) It has been shown previously that sacral ventral rhizotomy leads within 3 weeks to transsynaptic degeneration of m:>st cholinergic axons, with loss of their neuroeffector junctions, in the feline bladder base (Elbadawi et al, 1984) . Within 10 weeks, the cholinergic axons are rest<:>red by axon sprouts .and re-establish the jtmctions, with concomitant adrenergic hyperinnervation (Atta et al, 1984). The present study was conducted to determine the effect of bilateral hypogastric neurectomy on the above changes. Bilateral hypogastric neurectomy and sacral ventral rhizotomy were done at the same time in 4 adult male cats. Specimens from the bladder base were obtained for electron microscopy 3 and 10 weeks after operation (2 cats each period). In the 3-week sffinples, there was widespread degeneration of both cholinergic and adrenergic axon tenninals and varicosities, with loss of their neuroeffector jtmctions. Intact adrenergic axon profiles were observed only in axon bundles and within Schwann cells. In the 10-week Sil111Ples, both cholinergic and adrenergic axons and their neuroeffector jtmctions were partially restored, with sparse cholinergic axon sprouting, and no adrenergic hyperinnervation; but there was a m:>dest increase in the adrenergic axon content of large dense-core vesicles, suggesting the presence of an increased population of copeptidergic axons. Our observations indicate that an intact sympathetic pathway is necessary for the eventual adrenergic hyperinnervation, and cholinergic axon sprouting that 're-innervates' the decentralized feline lissosphincter (conceivably through neurotrophic influence on parasympathetic peripheral ganglion cells). It would be interesting to find out if the reverse situation is true, namely, that an intact parasympathetic pathway is necessary for adrenergic axon sprouting and cholinergic hyperinnervation following preganglionic interruption of sympathetic innervation of the bladder, [Supported by NIH Grant #AG-06202-01]
THE PROPHYLACTIC USE OF CLEAN INTERMITTENT CATHETERIZATION IN CHILDREN WITH MYELODYSPASIA; *Evangelos G. Geraniotis, M.D., & Stephen A. Koff, M.D,, Columbus, Ohio, (Presentation made by Dr. Geraniotis) The development of clean intermittent catheterization
(CIC) during the past 12 years as well as the increased use of diagnostic urodynamic studies has revolutionized the urologic treatment and management of children with
myelomeningocele (MMC).
However, the timing of the
initiation of CIC in these children is an issue that remains unresolved and controversial. We present our data from a controlled, prospective,
randomized study in which children with MMC were classified into 2 groups based on initial urodynamic studies:
1) Coordinated external sphincter, 2) Uncoordinated external sphincter. Those in the 2nd group were then randomized into 2 treatment groups: 1) Treatment with
self voiding and observation. 2) Treatment with prophylactic CIC. Follow-up has consisted of frequent urine analysis and culture as well as regular renal ultrasound, IVP, and nuclear cystograms. Preliminary results to date show that greater than 50% of children with uncoordinated sphincters treated with
self voiding deteriorated, even while adhering to a frequent follow-up program, and required the instituticin of CIC. However, this did not always reverse the destructive
changes which had taken piace. In contrast, only 10% of children initially treated with CIC showed evidence of deterioration. We therefore conclud~ that regular urodynamic studies
of myelomeningocele children from birth can identify parameters which will predict the fate of these children's
urinary tracts, and that the prophylactic use of CIC in these neonates can prevent the deterioration which still occurs on even an ideal screening program.
247A