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Opportunistic infections in children following renal transplantation
1Division of Nephrology, Children's Hospital, Boston, Massachusetts 02115.
Insights
Opportunistic infections pose a significant threat to children post-renal transplant. Advances in preventing and treating varicella, Pneumocystis carinii pneumonia (PCP), and cytomegalovirus (CMV) offer improved outcomes.
Area of Science:
- Pediatric Nephrology
- Transplant Infectious Diseases
- Immunocompromised Host Infections
Background:
- Opportunistic infections are a leading cause of morbidity and mortality in pediatric renal transplant recipients.
- Children face unique risks due to limited prior pathogen exposure.
- Key infections include varicella, Pneumocystis carinii pneumonia (PCP), and cytomegalovirus (CMV).
Purpose of the Study:
- To review recent advances in the prevention and treatment of common opportunistic infections in pediatric renal transplant patients.
- To highlight specific management strategies for varicella, PCP, and CMV.
- To discuss risk factors influencing infection incidence and severity.
Main Methods:
- Review of current literature on pediatric renal transplantation and opportunistic infections.
- Analysis of treatment protocols and prophylactic measures for varicella, PCP, and CMV.
- Discussion of risk factors including donor transmission, recipient immunity, and immunosuppression levels.
Main Results:
- Varicella is effectively treated with acyclovir without compromising graft survival.
- PCP prophylaxis with trimethoprim-sulfa is effective, though treatment guidelines need refinement.
- CMV disease, particularly in seropositive donor/seronegative recipient scenarios, can be mitigated by prophylactic immunoglobulin and oral acyclovir; ganciclovir shows promise for severe cases.
Conclusions:
- Advances in antiviral and antimicrobial therapies have significantly improved the management of opportunistic infections in pediatric renal transplant recipients.
- Prophylactic strategies and timely treatment are crucial for reducing severe morbidity and mortality.
- Further research is needed to establish clear guidelines for PCP prophylaxis and optimize CMV management.
Abstract:
Opportunistic infections following renal transplantation in children are a major cause of severe morbidity and mortality. These infections account for the majority of early post renal-transplant deaths in children. General risk factors which affect the incidence and severity of these infections include: transmission of the infectious agent by the donor organ; history of immunity in the recipient prior to transplantation; type and amount of immunosuppression including treatment for rejection episodes; availability of specific treatment for the infection. Children are at particular risk because of the lack of exposure to certain pathogens prior to transplantation. There have been recent advances in the prevention and treatment of important infections which occur in children following transplantation, including varicella, Pneumocystis carinii pneumonia (PCP) and cytomegalovirus (CMV) disease. Varicella is treatable with acyclovir, often without decreasing immunosuppression and placing the graft at risk. Prophylaxis against PCP may be achieved by provision of alternate-day trimethoprim sulpha, but clear guidelines for determining who should be treated are lacking. Treatment of this disease with high-dose trimethoprim sulfa or pentamidine is usually successful. CMV disease is frequently severe, especially when the donor is seropositive and the recipient seronegative. In these situations, prophylactic CMV immunoglobulin reduces the morbidity and the mortality of the disease and prophylactic oral acyclovir may decrease its incidence. Treatment of severe CMV disease with gancyclovir is promising.