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Background: The risk of progressing to end-stage renal disease in children with lupus glomerulonephritis is 18% to 50%. Published reports of transplantation secondary to end-stage renal failure in adult patients with systemic lupus erythematosus (SLE) demonstrate equivalent patient and graft survival. The purpose of this analysis is to compare patient and graft outcomes of pediatric SLE renal transplant recipients with an age-, race-, and gender-matched control group., Methods: A retrospective analysis of the North American Pediatric Renal Transplant Cooperative Study (NAPRTCS) database identified 100 renal transplants performed in 94 young SLE patients. A control group of 470 children having received 501 renal transplants was identified., Results: The SLE cohort was primarily female (82%), non-Caucasian (61%), adolescents and differed from the control group in being less likely to be preemptively transplanted, in receiving longer pretransplant dialysis, and in being likely to have received more than five pretransplant transfusions. After transplantation, there were no differences seen in patient survival at 3 years (89% vs. 95%, SLE vs. control) or in overall graft failure rates (31% vs. 29%, SLE vs. control). There was a trend toward poorer graft survival in non-white SLE patients receiving living donor grafts compared with white SLE patients. An increased graft failure rate was seen among those SLE cadaveric transplant recipients receiving peritoneal dialysis before transplant compared with controls and compared with SLE patients receiving hemodialysis. No differences were seen in rates of acute tubular necrosis or overall acute rejection incidence, although there was a significant increase in the percentage of living donor SLE patients who experienced greater than four rejection episodes. There were nonsignificant trends toward increased graft loss due to patient death with a functioning graft as well as increased mortality secondary to infection in the SLE patients., Conclusions: The results of renal transplantation in young SLE patients are comparable to those seen in an age-, race- and gender-matched control group. The similar patient and graft survival is seen despite the SLE patients having an underlying disease with multiorgan involvement and despite receiving immunosuppression for potentially prolonged periods before transplantation. No outcome differences were seen except for an unexplained increase in the incidence of recurrent rejections (> or =4) in the living donor SLE patients as well as increased graft failure rate in those patients receiving cadaveric renal transplants after a period of peritoneal dialysis. The nonsignificant trends toward increased graft failures in non-white SLE patients receiving living donor grafts, increased graft loss secondary to death with a functioning graft, as well as the increased mortality due to infection deserve recognition and further study.

Background: There are no large studies of the effect of pretransplant dialysis status on the outcome of renal transplantation (Tx) in children. This study evaluated the North American Pediatric Renal Transplant Cooperative Study (NAPRTCS) registry data for the outcome of Tx in pediatric patients who either (1) received their transplants preemptively or (2) were maintained on dialysis before receiving their transplants., Methods: We compared graft survival and patient survival rates, incidence of acute tubular necrosis (ATN), acute rejection episodes, and causes of graft failure in peritoneal dialysis (PD) patients with those maintained on hemodialysis (HD) and those undergoing preemptive Tx (PTx)., Results: Primary Tx was performed in 2495 children (59% male; 61% Caucasian; 1090 PD, 780 HD, 625 PTx) between 1/1/1992 and 12/31/1996. The overall graft survival rates of the PD and HD groups were similar, but were less than that of the PTx group (3-year: 82% PD and HD, 89% PTx, overall P = 0.0003). Improved graft survival in the PTx group was present only in recipients of grafts from living donors. There was no difference in the overall patient survival rate at 3 years, or in time to first acute-rejection episodes in the three groups. The incidence of ATN in the first 7 days post-Tx was higher in PD and HD patients than in PTx patients (11% PD and 12% HD vs. 2% PTx, P<0.001; HD vs. PD, P = NS). The major single cause of graft failure in each group was: PD, vascular thrombosis (200%); HD, chronic rejection (27%); PTx, acute and chronic rejection (21% each)., Conclusion: NAPRTCS data show that graft survival is improved in patients receiving PTx, compared with those receiving PD and HD. Graft loss resulting from vascular thrombosis is more common in children who receive PD than in those receiving HD.

The major impact of autolymphocytotoxic antibodies (ALCA) on renal transplantation has been in the interpretation of the pretransplant crossmatch as a cause of false-positive results. Less attention has been paid to the direct affects of ALCA on renal allografts. We have examined the sera of 38 recipients of 41 cadaver renal allografts for the presence of ALCA. There were 9 patients with ALCA who received 10 allografts. In these allografts with ALCA, actuarial graft survival was significantly improved (P less than 0.05) over that of 31 transplants without ALCA. In recipients with ALCA, graft survival was 90% at six months and 60% at one and two years; in recipients without ALCA, graft survival was 48% at six months, 35% at one year and 24% at two years. ALCA may be exerting graft-enhancing properties by means of an autoregulatory effect upon the recipient's immunologic system.

Two-hundred eighty sera from 78 dialysis patients were examined for autolymphocytotoxic antibodies (ALCAs). Thirty-five (12%) sera in 18 (23%) patients had ALCAs. Eight patients had ALCAs in multiple sera. Two patients had ALCAs against both T and B lymphocytes, 2 against T lymphocytes, and 14 against B lymphocytes. In those sera with ALCAs against both B and T lymphocytes, broad thermal reactivity was present. In sera with ALCAs against only B lymphocytes, the majority were reactive at 5 C. Sixteen (89%) patients with ALCAs had some form of glomerulonephritis; five had rapidly progressive glomerulonephritis (RPGN) and three had systemic lupus erythematosis (SLE). Nine of 10 sera with a positive crossmatch against B lymphocytes from a renal transplant donor did not have ALCAs against autologous B lymphocytes; three sera with ALCAs against B lymphocytes and two with ALCAs against T lymphocytes had negative crossmatches against transplant donor lymphocytes. Positive crossmatches against donor B and T lymphocytes attributable solely to ALCAs were therefore uncommon in our patients. Nevertheless, patients at risk to develop ALCA, including those with SLE and RPGN, should be identified and their sera tested for ALCAs. Once identified, studies can be carried out to distinguish a positive crossmatch attributable to ALCAs from that attributable to HLA alloantibody.

Posterior subcapsular cataracts (PSC) were noted in 41 of 69 (60%) recipients of renal allografts. The PSC were noted during the first posttransplant year (Group 1) in 21 (30%) recipients and after the first posttransplant (Group 2) year in 20 (30%) recipients. The dosage of prednisone during the first posttransplant year corrected for patient weight showed a significant correlation with the development of PSC during the first posttransplant year. The severity of the PSC were correlated with time of onset and prednisone dosage. Four recipients in Group 1 required cataract extraction to obtain sufficient vision to facilitate school work.

Previous reports on the generation and nephritogenic capacity of post-transplant circulating immune complexes (CICs) are conflicting. To assess the pathogenicity of CICs in acute rejection (AR), 784 CIC determinations were performed on 392 serum samples from 27 pediatric renal allograft recipients using the C1q-solid phase assay (C1q-SPA) and the Raji cell radioimmunoassay (Raji-RIA). Serum samples from transplant recipients not undergoing rejection episodes and from normal subjects served as controls. Of the 784 CIC determinations, 723 (92.3%) were negative in both assays. CICs were present at some point post-transplant in eight (19.6%) recipients. Correlation of CIC levels with allograft rejection was found in only two patients with CIC levels responding to antirejection therapy; however, statistical analysis of data by chi 2 analysis failed to reveal a significant correlation of CICs with AR episodes. Allograft histology in three recipients demonstrated characteristic signs of AR. Immunofluorescent studies did not reveal significant deposition of immunoglobulin or complement. Sucrose density gradient ultracentrifugation studies confirmed the immune complex nature of materials reactive with the CIC assays. There was no immunological evidence supporting antithymocyte globulin (ATG) as an immunogen in patients demonstrating CICs post-transplant. CICs do not appear to be an important mediator of AR. Statistical analysis of data using the chi 2 test failed to reveal a positive correlation of CIC levels with AR or ultimate allograft outcome.

Blood transfusions (BT) administered prior to renal allograft transplantation are known to enhance allograft survival. One proposed mechanism for this effect is through the induction of antiidiotypic antibodies that modify the immune response to subsequently presented graft antigens. In an attempt to determine if antiidiotypic antibodies are generated post-BT, we studied sera from post-BT patients for the presence of antiidiotypic antibodies to anti-HLA class I IgG (i.e., anti-anti-HLA). Anti-HLA antiidiotypes were demonstrated by idiotype-specific inhibition of an enzyme immunoassay (EIA) for anti-HLA antibodies. Using this inhibition technique, test sera from 8 of 16 post-BT patients showed significant inhibition of the anti-HLA target sera (P less than 0.05). Sera from normal individuals showed no inhibition of the target sera, and test sera did not inhibit other antigen-antibody systems. Protein A absorption of test sera eliminated the inhibitory effect, suggesting that the antiidiotypic activity was limited to the IgG fraction of the sera. The EIA binding activity of F(ab')2 fragments of anti-HLA IgG was suppressed by sera from patients post-BT but not by sera from normal volunteers. Studies of serially obtained sera from a post-BT patient showed that anti-HLA antiidiotype levels fluctuate with time and transfusion status. These studies demonstrate that anti-HLA antiidiotypic antibodies are generated post-BT. Their importance in mediating the known allograft-enhancing effect of pretransplant BT remains to be clarified.

Over a 2 1/2-year period, prospective standard, T, and B lymphocyte crossmatches were performed in 45 cadaver renal transplants using the microlymphocytotoxicity technique. Twenty-three of the 45 recipients had a positive B lymphocyte crossmatch. Cumulative graft survival rates did not differ between recipients with a positive and negative B lymphocyte crossmatch. High levels of presensitization in routine lymphocytotoxic antibody screening or transplant number did not adversely affect graft survival in recipients with a positive B lymphocyte crossmatch. Five recipients had moderately positive standard crossmatches which were attributable to anti-B lymphocytotoxicity. Four of these five grafts are presently functioning with normal serum creatinine levels 9 to 14 months post-transplant. A positive B lymphocyte crossmatch is compatible with good long-term cadaveric renal allograft survival. In addition, a weakly positive standard crossmatch is not a contraindication to transplantation when the positive crossmatch is attributable to anti-B lymphocyte antibody.

Serial calculations of glomerular filtration rate were made in 31 pediatric liver transplant recipients surviving more than 1 year. GFR was computed from the Schwartz formula, (cGFR = KL/S Cr), before orthotopic liver transplantation, and at 3-6 monthly intervals thereafter. At the same time points, CsA dose/kg, CsA level, blood pressure, and liver functions were recorded. The mean difference between the pre-OLT cGFR and the most-current cGFR for all patients was -50 ml/min/1.73 m2 (P = less than 0.005). In 17/31 (55%), the current cGFR was less than 80 ml/min/1.73 m2, indicative of renal impairment. The cGFR continued to decrease in 24 patients followed beyond 1 year (26.8 ml/min/1.73 m2 per year decrease, P less than 0.005). More patients with a cGFR less than 80 ml/min/1.73 m2 had outpatient hypertension. There was no correlation of cGFR with CsA levels, CsA dose, or liver function. We conclude that a significant decrease in cGFR is seen in children treated with CsA for more than 1 year, which is progressive in the majority.

The immunological events mediated by, and antigen specificity of, allograft-bound lymphocytes (ABLs) are poorly understood. To further define the role of antibody-mediated rejection, a rejected allograft from a patient with primary anti-TBM disease was sterilely minced and pressed through a microscreen. The ABLs were isolated by density gradient centrifugation. Using this technique, 8.5 X 10(6) ABLs were isolated. Then 1 X 10(6) washed ABLs/ml were suspended in RPMI 1640 with 20% fetal calf serum and cultured in microtiter plates with media only, or with pokeweed mitogen (PWM) (100 micrograms/culture). The cells were incubated for 7 days and supernatants were collected and assayed for total IgG and IgM by a solid-phase enzyme immunoassay (EIA) and reactivity with normal human kidney targets by indirect immunofluorescence (IF) and immunoperoxidase (IP) techniques. Total IgG production was 500 ng/ml for both spontaneous and PWM stimulated cells. No IgM production was detected. IF and IP studies demonstrated IgG-anti-TBM antibodies in the spontaneous supernatants only. IgG antibodies reactive with peritubular capillaries (anti-PTC) were also noted. IgG-anti-TBM anti-bodies and antibodies reactive with arterioles were subsequently demonstrated by direct immunofluorescence techniques in the rejected allograft. Analysis of serum samples obtained at the time of allograft rejection showed no IF or IP reactivity with the kidney targets. Subsequent analysis of anti-TBM production by the patient's peripheral blood mononuclear cells (PBMs) showed IgM-anti-TBM only. These studies suggest that the IgG-anti-TBM and IgG-anti-PTC antibodies reactive with the allograft resulted from in situ antibody production by ABLs; the role of anti-TBM antibodies in mediating the AR is unclear, but their presence suggests recurrence of the original disease in the allograft. Anti-PTC antibodies could be important in mediation of the vascular AR.

Patients with steroid-resistant nephrotic syndrome and focal segmental glomerulosclerosis (FGS) who develop end-stage renal disease are at risk for recurrence of the disease following renal transplantation. Recurrence of the nephrotic syndrome in renal allografts of two children with primary FGS was successfully controlled by plasma exchange. This report suggests that plasma exchange instituted early in the course of recurrent nephrotic syndrome may be beneficial in some patients with steroid-resistant nephrotic syndrome and FGS.

In 33 renal allograft recipient-donor pairs, B and T lymphocyte complement-dependent cytotoxicity crossmatches and mixed lymphocyte culture (MLC) blocking experiments were performed and the results were correlated with graft outcome. MLC blocking particularly in the unidirectional culture against donor-stimulating cells, was highly correlated with the presence of complement-dependent cytotoxicity antibodies against donor B lymphocytes. Grafts in both MLC blocking and B lymphocyte crossmatch-positive groups fared equally as well as those without positive tests. No difference in graft outcome was noted when the presence or absence of MLC blocking was examined in relationship to positive or negative B lymphocyte complement-dependent cytotoxicity crossmatching.

Serial HBs Ag determinations were performed on 98 renal allograft recipients with functioning grafts for 6 to 108 months, 85 of whom were followed from the initiation of dialysis. Twenty-six (27%) recipients had HBs antigenemia following transplantation. Thirteen (50%) of the 26 recipients were HBs Ag positive during the period of dialysis and 13 developed HBs antigenemia 1 to 44 months following transplantation. Seventeen (65%) of the 26 HBs Ag positive patients had hepatic dysfunction which was detected by biochemical surveillance and not associated with clinical symptomatology. There was no evidence of progressive hepatic insufficiency. HBs Ag persisted in 24 (92%) recipients for 6 to 49 months. Clearing of antigenemia occurred in only two patients, both of whom ultimately rejected their grafts. The presence of HBs Ag had no adverse effect on graft function. Temporary reduction in azathioprine dosage with hepatic dysfunction was not associated with rejection episodes. The major hazard posed by the HBs Ag positive recipient is the potential reservoir for spread to the general population because of the persistence of antigenemia.

Both magnetic resonance imaging (MRI) and ultrasound (US) have been reported to be useful in differentiating between acute allograft rejection and other causes of graft dysfunction in renal transplantation. The aim of this study was to evaluate the comparative usefulness of these techniques in the assessment of patients with acutely rising serum creatinine levels. Seventeen patients with 19 episodes of acute serum creatinine elevations were evaluated for the presence of acute rejection. The ultimate diagnoses of acute rejection were based on either renal pathological findings, or the response to standard antirejection therapy. Clinical, US and MRI diagnoses were assessed independently, without knowledge of the results of the other evaluation techniques. We found that US alone was useful in diagnosing acute rejection (x2 = 4.95, P less than 0.05), and when taken in the clinical setting was an added advantage (x2 = 6.68, P less than 0.01). MRI did not increase the diagnostic accuracy significantly.

Total rosette-forming cells (TRFCs) and percentage of rosette-forming cell (RFC) levels were measured in patients undergoing dialysis and in recipients following renal transplantation. The percentage of RFCs of the dialysis patients was not different from the percentage of RFCs of normal subjects, whereas the TRFCs were significantly lower in the dialysis patients. After transplantation, the percentage of RFCs and TRFCs was significantly lower in recipients treated with antithymocyte globulin (ATG) than in those of the control group; however, there was no difference in allograft survival between the ATG-treated and control recipients when using ATG in the dose by rosette protocol.