Pediatric Transplantation

When pediatric kidney transplant recipients were compared based on the achievement (or not) of a CD3+ T-cell count < 25 cells/mm³ following rabbit anti-thymocyte globulin induction, there were no differences in infectious or graft outcomes by 12-months post-transplant.

This study investigated the incidence of allograft rejection and de novo donor-specific antibody formation following COVID-19 vaccination or infection among pediatric kidney transplant recipients.

After review of suspected EBV-driven Post-Transplant Lymphoproliferative Disorders (PTLD), according to the WHO 2022 criteria, the incidence was 11.7% in our cohort. Non-destructive PTLD was the most common subtype. Spatial/temporal heterogeneity required multiple biopsies. mTOR inhibitors were well tolerated. A diagnostic algorithm was developed to enhance the management of PTLD.

The balance between activated Treg/T effector cells demonstrates potential as a minimally invasive immune monitoring metric that can be used to help identify chronic allograft inflammation in pediatric kidney transplant recipients. Identifying patients with chronic allograft inflammation can help inform earlier intervention and precision medicine.

Elevated LDH levels, advanced tumor stages, and increased number of involved sites are associated with poor prognosis in post-liver transplantation–Burkitt lymphoma (PLT-BL). Immunosuppression withdrawal is a safe strategy, and that also helps pediatric LT recipients diagnosed with PLT-BL to become free from or to reduce the cumulative toxicity of the immunosuppressant drugs.

This retrospective quality assurance study aimed to investigate the incidence and management of pediatric PTLD among all 457 pediatric solid organ transplant recipients In Norway since 1995. We found a PTLD incidence rate of 4.8% (kidney 4.4%, liver 5.7%, and heart 4.2%) and a fatality rate of 23%.

Reduced mycophenolate mofetil with a sufficient trough tacrolimus level in a population of mainly corticosteroid-free pediatric kidney transplant recipients did not lead to unacceptable alloimmunity.

Post-transplant norovirus diarrhea persists for a median of 16 days (IQR 6–41.5 days) with 30% of patients developing chronic diarrhea. Morbidity is high, including AKI in 53% of patients, reduction in immunosuppression 20%, and acute rejection in 8% within 6 months of diagnosis.

Early BKV DNAemia is common post-pediatric kidney transplant, especially in younger ages, with ~30% incidence within 18 months post-transplant. Favorable outcomes are achieved with (1) frequent monitoring of viremia and (2) timely reduction of immunosuppressive medications, which must be balanced against risk of rejection and development of HLA antibodies.

This observational, retrospective investigation demonstrates temporal associations pointing to a reassuring vaccine safety profile and mild SARS-Cov-2 infectious phenotype in pediatric renal transplant recipients fully vaccinated against COVID-19.

Pediatric kidney transplant recipients given two doses of alemtuzumab induction immunosuppression, with steroid-free maintenance immunosuppression, had a ten-year living-donor graft survival of 86.5% and a deceased donor graft survival of 57.7%. The incidence of viral infections was similar to that reported in other cohorts, and growth improved after transplant.

In this large cohort of pediatric kidney transplant recipients with antibody mediated rejection, nearly one-third of patients experienced graft failure or significant graft dysfunction within 12 months of diagnosis. Poor graft function at time of diagnosis was associated with higher odds of graft failure.

In the largest pediatric kidney transplant recipient case series with EBV DNAemia given rituximab to prevent PTLD, rituximab achieved a short-term reduction in DNA load; however, recurrent DNAemia is common.

Leflunomide is a promising adjunctive treatment for BK virus eradication and prevention of BK nephropathy, along with IS reduction, particularly anti-proliferative immunosuppression reduction, without significant risk for the development of biopsy-proven rejection in pediatric kidney transplant recipients. Given the significant risk for the development of biopsy-proven rejection with complete AP discontinuation and CNI reduction in our study cohort, we suggest anti-proliferative reduction, not discontinuation, and judicious reduction in CNI trough goals with close monitoring as a strategy for treatment of BK viremia with concomitant use of leflunomide therapy.