kidney transplanted children come of age

Kidney International, Vol. 55 (1999), pp. 1509–1517

Kidney transplanted children come of age

GISELA OFFNER, KAY LATTA, PETER F. HOYER, HANS-JURGEN BAUM, JOCHEN H.H. EHRICH,RUDOLF PICHLMAYR,1 and JOHANNES BRODEHL

Kinderklinik der Medizinischen Hochschule Hannover, and Klinik fur Abdominal-und Transplantationschirurgie,Kinderklinik der Medizinischen Hochschule Hannover, Hannover, Germany

Kidney transplanted children come of age. When the first pediatric kidney transplantations wereBackground. The aim of renal replacement therapy in chil- performed in the late 1960s [1], it was uncertain whether

dren is to restore their potential for normal growth and devel- there would be a realistic chance for children with end-opment in order to reach mature adulthood. Because pediatricstage renal failure to reach mature adulthood. In thekidney transplantation started in the late 1960s, it is now possi-subsequent 30 years, experience in pediatric kidneyble to document the progress and outcome of these patients

from transplantation in childhood to survival into adulthood. transplantation increased dramatically. The use of immu-Methods. In this single-center study, all 150 children born nosuppressive drugs improved to such an extent that

before December 1977 and having received a kidney transplanttoday kidney transplantation has become the treatmentbetween 1970 and 1993 were selected for long-term follow-up.of choice for children with end-stage renal failure [2–5].The mean age at transplantation was 12.1 years (range 3.2 to

16.7), and the mean follow-up was 13.1 years (range 2.0 to It has become obvious that the degree of medical and25.0). In December 1995, 124 grown-up patients with a mean psychosocial rehabilitation depends mainly on the qual-age of 25.4 years (range 18.4 to 40.3) were alive, 89 with a ity of graft function [6–8]. There are, however, only afunctioning graft. Fifty had the first graft functioning longer

few reports on the long-term results of patients whothan 10 years. The fate of all patients was traced, and thosereceived a renal transplantation in childhood and hadliving were analyzed in regard to their somatic and socioeco-

nomic states. reached adulthood [9–11]. We therefore evaluated theResults. The actuarial 25-year survival rate for the patients long-term results of children transplanted at our unit.

was 81%, and for the first graft it was 31%. The best graft Factors influencing graft survival, graft function longersurvival rates were observed after living related donation, pre-than 10 years, the final height, and the social rehabilita-emptive transplantation, and immunosuppression with cyclo-

sporine. The latter benefit, however, vanished after eight years. tion of the adult patients are analyzed.The mean creatinine clearance declined over the years from76 to 45 ml/min/1.73 m2, and the incidence of hypertensionincreased to more than 80% of the patients. Malignancies oc- METHODScurred in 2.6%. Final height was stunted in 44% of noncysti-

From 1970 to 1993, 150 children born before Decem-notic patients, whereas all patients with cystinosis were ex-ber 1977 received a total of 186 renal transplantations attremely growth retarded. Twenty-seven percent suffered from

additional disabilities. A majority of adult patients were reha- the Children’s Hospital of the Medical School Hannover.bilitated in regard to education and socioeconomic status, and The primary renal diseases leading to terminal renal14% were unemployed. failure is outlined in Table 1. Characteristics of all 150Conclusions. The results indicate that renal transplantation

patients, including these who died between 1975 andin children leads to a high degree of rehabilitation in adulthood.1995, and grafts are summarized in Table 2. The immuno-The life of a kidney transplant, however, is limited, which

points out the need for more specific immunosuppression with suppressive therapy between 1970 and 1982 consisted offewer side-effects in order to reach the goal of lifelong graft azathioprine (Aza) and high-dose prednisolone [12] andfunction.

between 1982 and 1995 of cyclosporine A (CsA) and low-dose prednisolone [13]. Twenty-seven transplantations

1 Deceased were performed pre-emptively. All but two patients hada minimum follow-up of at least four years. The mean

Key words: pediatric kidney transplantation, living related organ dona-time was 13.1 years (range 2 to 25 years).tion, creatinine clearance, growth, immunosuppression, graft function,

end-stage renal failure. In December 1995, 124 patients were alive, with amean age of 25.4 years (range 18 to 40 years). Twenty-Received for publication March 3, 1998two died at a mean age of 16.5 years (range 6.0 to 32.2and in revised form November 3, 1998

Accepted for publication November 5, 1998 years), and four were lost to follow-up. Fifty patientswere living with the first graft functioning longer than 1999 by the International Society of Nephrology

1509

Offner et al: Kidney transplanted children come of age1510

Table 2. Characteristics of all transplanted children (RTx)Table 1. Primary renal diseases in 150 children (aged 3.2 to 16.7years) born before 1977 and transplanted between 1970–1993 born before 1977

with the potential to reach adulthood (age . 18 years)Patients 150after first kidney transplantation

Age of RTx years 12.163.2aCongenital/inherited N 5 104 Acquired N 5 46

Male/female 74/76(69%) (31%)Number of grafts 1861/2/3/4 grafts 150/29/6/1Nephronophthisis N 5 28 FSGS N 5 13

Dysplasia/hypoplasia N 5 21 HUS N 5 10 LRD/CD (1st grafts) 35/115Aza/CsA (1st grafts) 79/71Obstructive uropathy N 5 20 Henoch-Schonlein nephritis N 5 6

Cystinosis N 5 19 MPGN N 5 6 Preemptive transplantation 27 (18%)Patients alive at December 1995 124 (83%)Alport’s syndrome N 5 9 IgA nephritis N 5 1

Hyperoxaluria type I N 5 3 RPGN N 5 1 Age of living patients 25 644.4a

Follow-up time after RTx of living patients years 13.164.5aARPKD N 5 2 Undefined glomerulonephritis N 5 3Congenital NS N 5 2 Other N 5 6 a Data are mean 6 sd

The different immunosuppressive regimens consisted either of azathioprineAbbreviations are: ARPKD, autosomal recessive polycystic kidney disease;and high dose prednisolone (Aza), or cyclosporine and low dose prednisoloneNS, nephrotic syndrome; FSGS, focal segmental glomerulosclerosis; HUS, hemo-(CsA). Abbreviations are: LRD, living related donors; CD, cadaveric donors.lytic uremic syndrome; MPGN, membranoproliferative glomerulonephritis;

RGN, rapid progressive glomerulonephritis; other, unilateral Wilm’s tumor andkidney trauma, amyloidosis in juvenile rheumatoid arthritis, hypersensitive vas-culitis, membranous glomerulonephritis.

thereafter (Fig. 2). A comparison between living relateddonor (LRD) grafts (N 5 35) and cadaveric (CD) grafts

10 years. Twenty-five patients with a mean age of 21.3 (N 5 115) demonstrated a slightly, but insignificantly,years (range 18.4 to 29.7 years) were still under the care better outcome of LRD grafts (Fig. 3). The outcome ofof the Pediatric Transplantation Unit of the Children’s pre-emptively transplanted grafts (N 5 27), regardlessHospital, Medical School of Hannover, and 99 patients of LRD (N 5 12) or CD (N 5 15), was at least as goodwere transferred to adult nephrological care at a mean as for those grafted with prior dialysis (Fig. 4).age of 26.8 years (range 19.1 to 40.3 years). For socioeco-nomic evaluation, 120 patients were contacted by tele- A 10-year follow-up of patients living with first graftphone, whereas four could not be reached. The final Fifty adult patients transplanted in childhood had theadult height was available in 100 patients. first graft functioning longer than 10 years. Thirty-five of

For statistical analysis, PC-Statistik 3.0 (Lambda, Top-these were treated with Aza and high-dose prednisolone,

soft, Graz, Hannover, 1993) was used. Actuarial survivaland 15 patients were treated with CsA and low-doserates calculated according to Kaplan and Meier [14] wereprednisolone. Complete data of renal function and bloodcompared by the Mantel-Haenszel x2 test. The death ofpressure were available for 40 patients. Glomerular fil-a patient was computed as graft loss even though thetration rate (GFR), calculated by serum creatinine andgraft was still functioning. The Mann–Whitney and Fisherheight [17], deteriorated over the years in both immuno-tests were used for comparison of unpaired groups. Dif-suppressive groups (Table 3). The mean initial GFR wasferences were defined as significant by a P of less thanhigher in the Aza group than in the CsA group (86 vs.0.05. Height was expressed by standard deviation scores67 ml/min/1.73 m2, P , 0.03). After 10 years, the differ-(SDS) in correlation to the height of age- and sex-ence of GFR between both groups was not significantmatched children of Germany [15]. The socioeconomic(50 vs. 41 ml/min/1.73 m2). With the deterioration ofstatus of the German population in the age group from 25GFR, the rate of hypertension increased in the Azato 35 years was drawn from the 1994 statistics of the Sta-group from 54% at time of transplantation to 89% aftertistisches Bundesamt (85180 Wiesbaden, Germany) [16].10 years, and in the CsA group from 58% to 83%. Thedifference between mean GFR at six weeks after trans-

RESULTS plantation of all 10-year graft survivors (79 ml/min/1.73m2) and those who did not survive 10 years (52 ml/min/Survival rates1.73 m2) was significant (P , 0.001).The actuarial survival rate of the 150 children after 25

years was 81%, and the survival rate of the first graftsGraft failurewas 31% (Fig. 1). The calculated half-life of a first graft

During the 25 years of observation, 90 first grafts andfunctioning is therefore 10.5 years. Among those who26 regrafts were lost. Most of the graft failures occurredlost their grafts, 36 retransplantations were performed,during the first decade, especially in the first year afterwhich had a worse outcome with a half-life of 7.5 years. Atransplantation because of acute rejection episodes, vas-comparison of the results under Aza immunosuppressioncular complications, primary nonfunction, recurrence of(N 5 79) and CsA immunosuppression (N 5 71) re-primary disease, cytomegalovirus infection, and CsAvealed a significant superiority of CsA over Aza during

the first seven years after transplantation, which vanished toxicity (Fig. 5). Graft failures after 10 years were rare

Offner et al: Kidney transplanted children come of age 1511

Fig. 1. Survival rates according to Kaplanand Meier of 150 patients (s), 150 first grafts( ), and 36 regrafts (m).

Fig. 2. Survival rates according to Kaplanand Meier of 150 first renal grafts comparingbetween azathioprine (Aza) immunosuppres-sion (N 5 79; j) and cyclosporine A (CsA)immunosuppression (N 5 79; s). P values atone, five, and eight years after transplantationwere 0.0007, 0.022, and 0.107, respectively.

Fig. 3. Survival rates according to Kaplanand Meier of 150 first renal grafts comparingbetween living related donor grafts (LRD 535; s) and cadaveric grafts (CD 5 115; j).The P value is 0.293.


Fig. 4. Survival rates according to Kaplanand Meier of 150 first renal grafts comparingbetween pre-emptive transplantation (N 5 27;s) and transplantation after prior dialysis(N 5 123; j). The P value is 0.13.

Table 3. Glomerular filtration rate (GFR) and hypertension (%) Patient deathsin adult patients transplanted in childhood with 10 year

graft function Twenty-two patients died, seven of whom in the firstyear after transplantation (Fig. 5). Four patients died6 weeks after RTx 5 years after 10 yearswith uremia after their graft failed after the decision not

GFR ml/min/1.73 m2

to re-establish dialysis treatment. In the first decade ofAza (N 5 28) 86626 65 618 50625CsA (N 5 12) 67615 49 615 41621 kidney transplantation, the most frequent cause of death

Percentage of patients with was an infection related to high-dose immunosuppres-arterial hypertension

sive treatment with glucocorticoids. Cardiovascular com-Aza (N 5 28) 54% 82% 89%CsA (N 5 12) 58% 67% 83% plications accounted for 23% of deaths. Beyond 10 years,The comparison is between Aza and CsA immunosuppression. six patients died, two from complications of retrans-

plantation, one each from a T-cell lymphoma, cerebralinsult caused by cystinosis, cardiovascular complication,and suicide after the fourth graft failure (Table 4).

Transplanted children becoming adults

In December 1995, 124 patients who were transplantedin childhood lived to a mean age of 25.4 years (range 18to 40 years). Their medical profile is summarized in Table5. Eighty-nine lived with a functioning graft, 60 with thefirst graft. Thirty-five were waiting for retransplantationon dialysis, 24 on hemodialysis, 11 on peritoneal dialysis.Twenty-five patients were still under the care of thetransplant team of the Children’s Hospital, whereas 99had been transferred to adult nephrological clinics.

Seventy-eight percent of the patients with functioninggraft and 73% of patients on dialysis needed antihyper-

Fig. 5. Number of renal graft failures (N 5 90; ) and patient deathstensive medications. There was a significant correlation(N 5 22; j) in correlation to the time after kidney transplantation.between serum creatinine and hypertension in the pa-tients with functioning grafts (P 5 0.0027). Sixty-fourpatients with hypertension had a mean serum creatinineand were largely due to chronic graft failure. In a fewof 150 6 86 mmol/liter, and 18 patients with normal bloodcases, acute rejection caused by noncompliance, recur-pressure showed a normal graft function with a meanrence of membranoproliferative glomerulonephritis, ma-serum creatinine of 98 6 37 mmol/liter.lignancy (T-Non-Hodgkin lymphoma), de novo glomeru-

Twenty-nine out of 108 patients developed additionallopathy, and death with functioning graft led to graftfailures even after 10 years post-transplantation (Table 4). disabilities, which were in the main part of their primary


Table 4. Causes for 90 graft failures and 22 patient deaths

Grafts N 5 90 Patients N 5 22

Causes N Years after RTx N Years after RTx

Acute rejection 14 2.0 (0.01–11.7) 2c 0.3 and 1.0Chronic rejection 48 6.2 (0.7–14.5) 2c 3.4 and 4.0Cardiovascular complications 7 0.7 (0.01–4.0) 6b 7.6 (1.9–17.1)Severe infection 5 2.6 (0.01–6.9) 7a 4.2 (0.01–14.2)Primary non-function 3 0 — —Surgical complications 3 0 2 0 and 8.6CsA toxicity 1 0 — —T cell lymphoma 1 11.0 1 11.2Recurrence of renal disease 5 3.5 (0.01–14.2) — —De novo glomerulonephritis 2 2.3 and 15.1 — —Cerebral insult 1 13.5 1 13.5Suicide — — 1 12.2

Data are mean (range).a Four and b 2 patients died with functioning graftsc Dialysis not re-established following graft failure

Table 5. Medical profile of adult patients who received a kidney transplantation in childhood and were alive on December 1995

Patients’ number Tx/dialysis Patients with functioning grafts Patients with dialysis

Actual age yearsa

at children’s hospital 24/1 21.3 (18.4–29.7) 20.3at adult nephrology 65/34 27.5 (19.1–40.3) 25.7 (20.4–35.0)

Serum creatinine lmol/literb 84/35 139681 .800Serum cholesterol mg/dl b 62/11 219653 215646Serum triglycerides mg/dl b 59/11 159676 2686120Hypertensionc 82/22 63/82 (78%) 16/22 (73%)Additional disabilities 80/28 21/80 (26%) 8/28 (29%)

Tx is transplantation.a Mean values (range)b Mean values 6 sdc Patients with antihypertensive medications, diuretics not included

Table 6. Final height of 84 non-cystinotic and 16 cystinotic patientsdisease. Diabetes mellitus (N 5 2), visual impairmentwith kidney transplantation in childhood, separated by

(N 5 5), muscle weakness (N 5 2), and neurological immunosuppressive therapydisorders (N 5 4) occurred in patients with cystinosis

Aza CsA P valueand nephronophthisis. A hearing defect (N 5 3) occurredNon-cystinotic patientsin patients with Alport’s syndrome. There was an impair-

Number of patients 35 49ment of liver function (N 5 4) in patients with ARPKD, Age of RTx yearsa 12.262.9 13.8 62.5 0.029

Height SDS at RTxa 21.5561.52 21.6661.42 0.342and hyperoxaluria was found in one patient who neededYears with graft functiona 12.067.1 7.5 63.1 0.0002a liver transplant. Three patients with uropathy requiredFinal height SDSa 22.2061.53 21.6361.70 0.046

an ileum conduit. Bone disease (N 5 3) was not specific D height SDS 20.65 10.03 0.038Cystinotic patientsto primary disease. Gout (N 5 2) was considered as a

Number of patients 11 5side-effect of CsA. In one patient suffering from polyar-Age of RTx years 9.661.7 10.661.9 0.145

thritis complicated by amyloidosis, the disease continued Height SDS at RTxa 25.7861.91 25.0461.14 0.223Years with graft functiona 9.366.3 6.4 64.5 0.187after transplantation.Final height SDSa 26.1561.64 24.1661.46 0.018D height SDS 20.37 10.88 0.267Adult heightAbbreviations are: Aza, azathioprine; CsA, cyclosporine; RTx, renal trans-The final height was evaluated in 100 patients (84 plantation; SDS, standard deviation score.a Data are mean 6 sdnoncystinotic and 16 cystinotic patients) and compared

with the immunosuppressive therapy. This is detailed inTable 6. Noncystinotic males (N 5 41) reached a meanfinal height of 168.7 6 9.9 cm, and noncystinotic females

was 140.8 6 7.7 cm. The percentage of patients with(N 5 43) reached a mean final height of 158.5 6 8.0 cm.stunted final height (height SDS below 22.0) was 44%The mean final height of cystinotic males (N 5 6) was

147.5 6 13.6 cm, and that of cystinotic females (N 5 10) in noncystinotic patients and 100% in cystinotic patients.


Table 8. Professional profile of 61 adult patients with renalTable 7. Socioeconomic status of 120 adult patients (age $ 18 years)with renal transplantation in childhood transplantation in childhood

Occupation NSocial condition

At parental home Alone Partnership Public service 18Office worker 16Occupation N 5 54 (45%) N 5 41 (34%) N 5 25 (21%)Healthcare professional (1 physician) 6

School/university 10 8 — Manual laborer 5Vocational training 17 6 — Craftsman 1Employed 19 22 15 Tailor, housekeeper 2Unemployeda 5 4 4 Unskilled worker (3 included from sheltered workshops) 8Unable to work 3 1 1 Housewife 5Housewife — — 5b

a The rate of unemployment was 14% compared to 9% of the German popula-tion in the age group between 25 and 35 years 1994

b Three mothers had given birth to healthy children

port them into becoming adults. Often evaluation ofoutcome is hampered by the fact that adolescents aretransferred to adult units. This may be why only a fewSeven patients were treated with recombinant humanreports exist on the long-term outcome of children withgrowth hormone (rhGH) late in puberty, three noncysti-end-stage renal failure into adulthood. Most reports re-notic patients and four cystinotic patients (three Aza,garding long-term results are focused on graft functionone CsA). The noncystinotic patients treated with rhGH[7, 18, 19], and less is known about other factors thatreached a mean final height SDS of 21.88, and the cysti-determine the lifestyle of young adults who receivednotic patients with rhGH reached a mean final heighttransplants during childhood [9, 20]. In our study, weSDS of 26.77.could follow the majority of children transplanted at

Malignancy our unit during the 25 years and evaluate them intoadulthood.Four adult patients (2.6%) transplanted in childhood

The mortality rate of pediatric kidney transplantationdeveloped malignant tumors (one neoplasm per 491 pa-is low. In our study, 22 patients died either in childhoodtient years). As already mentioned, one patient withor at adult age. The main causes of death were cardiovas-T-cell lymphoma 11 years after transplantation diedcular complications or severe infections, as described bywithout chemotherapy. Two patients with carcinoma ofothers [21]. In accordance to the observation by Reiss,the thyroid gland and uterine cervix each survived withWingen and Scharer [22], death can occur at any timesurgical removal of the tumor, but lost their grafts someafter transplantation. Single-center reports [2–4] as wellyears later because of chronic rejection. One patient with

a testicular tumor was successfully operated and is still as cooperative registries in Europe (European Dialysisliving with the first graft functioning after 20 years. and Transplant Association) [23] and North America

(North American Pediatric Renal Transplant Coopera-Socioeconomic status tive Study) [24] confirm more or less excellent survivals

One hundred and twenty patients could be contacted (more than 80%) of children with end-stage renal failureto evaluate their socioeconomic status as defined by com- following kidney transplantation. As a result of this, themunity of life, schooling, and employment (Table 7). number of young adults living with renal replacementThree housewives gave birth to three children, and one therapy increases continuously.male recipient became a father. The professional profile Graft survival is influenced by several factors such asof the 61 patients with employment is listed in Table 8. histocompatibility, ischemia time, immunosuppression,The economic profile of the transplanted patients was and graft quality (for example, donor age, and living orquite similar to the general German population of the cadaveric sources) [24]. In our population, the best graftage between 25 and 35 years, in which 9% were regis- survival rates were observed after living related dona-tered as unemployed in 1995 [16]. Ten of 35 patients tion, CsA immunosuppression, and pre-emptive trans-(29%) requesting dialysis postgraft failure were unem- plantation. The benefit of CsA versus Aza immunosup-ployed or unable to work, compared with 8 of 89 patients pression is statistically significant only for the first seven(9%) with functioning grafts. This was a significant differ- years after transplantation. Thereafter, the superior graftence in the levels of unemployment (P 5 0.0045). Other survival under CsA disappeared. It is noteworthy thatfactors, such as the year of transplantation, did not influ-

under Aza, no further graft loss was observed after 15ence the socioeconomic outcome.years. The disappointing long-term results of CsA couldbe caused either by CsA toxicity or chronic rejection.

DISCUSSION Sutherland et al showed the evidence of CsA toxicity[25], which was not confirmed by Burke et al [26]. Non-The aim of treatment in chronic diseased children is

always to alleviate symptoms of their illness and to sup- compliance is another important risk factor of late rejec-


tion with graft failure especially in adolescent recipients demonstrate that CsA and low-dose prednisolone reveala tendency to normalize final height in noncystinotic[27, 28]. We also observed an increase of graft loss 10

years after transplantation, which could be due to noncom- patients. Most reports with long-term results, which usu-ally used higher steroid dosages, showed more pro-pliance in the age group between 15 and 20 years. How-

ever, no special investigations concerning noncompliance nounced growth retardation [18, 41]. Only seven of ourpatients were treated with recombinant human growthwere performed. The superiority of living related trans-

plantation over cadaveric grafts was not significant. This hormone (rhGH), because in the early years, the treat-ment was not available. Growth hormone after kidneyis in contrast to earlier reports from our own center [2]

and other cooperative studies [24], but confirms the data transplantation is effective and is often necessary espe-cially if graft function is reduced, but there is still afrom the Collaborative Transplant Study by Opelz [29].

The role of pre-emptive transplantation is discussed certain risk for graft rejection even in those with long-term stable graft function [42].controversially in the literature [30, 31]. Our results indi-

cate that pre-emptive transplantation had no adverse in- The risk of malignancy is a well-known complicationafter organ transplantation, which is related to the inten-fluence on transplant outcome, but rather showed better

graft survival rates. This could not be explained by the sity of immunosuppression [43]. In the Cincinnati Trans-plant Tumor Registry, a total of 316 tumors in 308 pediat-higher rates of LRD grafts in the pre-emptive group, as

a matched-pair analysis of our patients demonstrated [32]. ric transplant recipients was reported by Penn in 1996[44]. A German registry reported 18 tumors after kidneyThis was also observed by Fine, Tejani and Sullivan [33].

Serum creatinine at six months after successful kidney transplantation [45]. In both studies, lymphomas werethe most common tumors. We observed a mixture oftransplantation was postulated to be the best predicting

factor for long-term graft function [34, 35]. Our patients tumor types but no skin cancers, unlike the CincinnatiTransplant Tumor Registry [44].with 10 or more years graft survival had a significantly

higher GFR at six weeks after transplantation than survi- Another aim of this study was to evaluate whetherchildren after renal transplantation have a realisticvors below 10 years.

Hypertension is reported to be a further predictor of chance to reach mature adulthood with good rehabilita-tion. The inquiry of 120 adult recipients, living in Decem-long-term function [34]. In transplanted children, the

reported percentage of hypertension is high, about 70 to ber 1995, exemplified an almost normal social rehabilita-tion after renal transplantation. Although most of the80% [36, 37]. There was a significant correlation between

serum creatinine and hypertension in our adult recipients young adults in this study were still living with theirparents, this seems to be characteristic for young adultstransplanted in childhood. Patients with a normal blood

pressure had a normal serum creatinine concentration with chronic renal failure [46], in contrast to the Germanpopulation of the same age group [16]. The percentagebelow 100 mmol/liter, whereas the others showed ele-

vated serum creatinines. of employment is comparable with the age-matched pop-ulation. Unemployment of 14% is very low consideringHyperlipidemia is a further risk factor for cardiovascu-

lar complications [38]. In our analysis, serum cholesterol the background of chronic illness, frequent hospitaliza-tions, clinic visits, and dialysis. Thirty percent of thewas increased in both transplanted and dialyzed grown-

up patients (Table 5). Triglycerides were raised in only patients suffered from additional disabilities. Data fromthe EDTA registry and from a single center describeddialyzed patients. Until now, our treatment of hyperlip-

idemia consisted of only dietetic recommendations, but unemployment of young adults with renal transplanta-tion to range between 25 and 65%, depending on thethis approach needs re-evaluation in the context of more

effective lipid-lowering drugs [39]. presence of concomitant disabilities, that is, hearing,sight, or motor deficits [9, 47]. Successful pregnanciesOne major effect of renal failure in children is growth

retardation [40]. Our study confirms this in long-term sur- are convincing indications of an adequate rehabilitation.A questionnaire from EDTA concerning this topic gath-vivors on renal replacement therapy. With CsA immuno-

suppression combined with low-dose prednisolone, growth ered 820 successful pregnancies, with marked differencesbetween the several countries [48]. In Germany, the per-retardation could be reduced significantly when compared

with Aza and a high-dose prednisolone regimen (P 5 centage of pregnancies was low as compared with GreatBritain, which is confirmed by our experience with only0.038). In fact, the Aza prednisolone combination even

deteriorated height SDS (D height SDS 20.65), whereas three pregnancies in 72 female recipients and one off-spring from a male transplant recipient.CsA and low-dose prednisolone showed a slight increase

from childhood to final height in adulthood (D height In conclusion, the long-term survival rates of childrenafter renal transplantation and their degree of rehabilita-SDS 10.03). Although the number of cystinotic patients

is small, the effect of the two immunosuppressive regi- tion is encouraging, although the long-term graft func-tion is still limited. Most of the long-term survivors havemens was similar. These findings highlight the influence

of high-dose steroids on growth in children, but also experienced a declining graft function or even graft fail-


derived from body length and plasma creatinine. Transplantationures. The positive impact of renal transplantation on43:489–493, 1987

quality of life is obvious and highlighted by our findings 18. Hokken-Koelega ACS, Van Zaal MAE, Van Bergen W, Deof patient survival into adulthood. By improving graft Ridder MAJ, Stijnen T, Wolff ED, De Jong RCJW, Doncker-

wolcke RA, Keizer-Schrama SM, Drop SLS: Final height andsurvival and function, and aiming for lifelong graft toler-its predictive factors after renal transplantation in childhood. Pedi-ance, these benefits could be sustained further. atr Res 36:323–328, 1994

19. Chavers B, Kim E-M, Matas AJ, Gillingham KJ, Najarian JS,Mauer SM: Causes of kidney allograft loss in a large pediatricACKNOWLEDGMENTSpopulation at a single center. Pediatr Nephrol 8:57–61, 1994

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