ATS 2015, DENVER -- Caucasian and Hispanic children who undergo lung transplantation appear to be at greater risk for developing chronic kidney disease, or CKD, according to a small retrospective study conducted at Texas Children's Hospital.

The study, believed to be the first to look at CKD in children who have received lung transplants, also found that those children with high levels of tacrolimus, a powerful immunosuppressant given to fight organ rejection, circulating in the blood and those who experience at least one episode of acute kidney injury during their recovery also appear to be at greater risk for CKD.

"These results show tendencies that need to be explored further," said lead investigator Maria Gazzaneo, MD, who will present her research at ATS 2015, May 15-20, in Denver. "Still, we believe these results suggest pediatric lung transplantation patients can benefit from renal protective strategies."

At Texas Children's Hospital, where Dr. Gazzaneo is assistant professor of pediatric critical care and lung transplantation, the health care team now measures tacrolimus levels and kidney function twice a day. When possible, they try to reduce tacrolimus dosage, particularly in the first seven days post-surgery. The transplant team also involves nephrologists earlier in the care of any child who appears to be a risk for CKD.

Dr. Gazzaneo examined the medical records of 38 children who received a lung transplant at her hospital between 2012 and 2014. Two were excluded because they died within two months of the surgery. Of the 36 others, 5, or 13.8%, developed CKD within one year of transplantation based on criteria established by an international clinical guideline, Kidney Disease: Improving Global Outcomes (KDIGO).

Three of the children with CKD were Caucasian and two were Hispanic. Tacrolimus levels were elevated (15 ng/ml or higher) during the first seven post-operative days in 80% of those who developed CKD. All patients who developed CKD had at least one episode of acute kidney injury, or AKI. Among the children who did not develop CKD, the incidence of AKI was 71 percent.

Dr. Gazzaneo noted that CKD almost always presents a life-long challenge that can lead to many other complications, including hypertension, anemia, growth retardation and bone disease.

"The patients who developed CKD in our study were adolescents," she said. "If we could spare them this complication, it would greatly enhance their quality of life for the rest of their lives."

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* Please note that numbers in this release may differ slightly from those in the abstract. Many of these investigations are ongoing; the release represents the most up-to-date data available at press time.

Chronic Kidney Disease After Lung Transplantation: Incidence and Risk Factors in Pediatric Population: Retrospective Review

Type: Scientific Abstract

Category: 17.02 - Transplantation: Clinical (CP)

Authors: M.C. Gazzaneo1, A.A. Arikan1, O. Papadias2, M. Ebenbichler1,E. Melicoff-Portillo1, S. Kim1, N. Crews1, G. Mallory1; 1Texas Children's Hospital/Baylor College of Medicine - Houston, TX/US, 2Universidad Central Razetti - Caracas/VE

Abstract Body

Rationale: Chronic kidney Disease (CKD) is a potential complication following lung transplantation; however, the burden of this disease in pediatric population is not well-described. CKD is defined as abnormalities in kidney structure or function, present for > 3 months, with implications for health. The purpose of the study was to determine the incidence of CKD as well as risk factors for this condition after lung transplantation in a pediatric cohort.

Methods: This study retrospectively evaluated data on 38 patients who underwent lung transplantation in Texas Children's Hospital between 2012 and 2014. We excluded 2 patients; one died 2 months after transplant and the second one was within 30 days post-transplant. The primary outcome was CKD, defined and categorized according to the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. GFR was calculated using CKD-EPI equation. We also included age, race, and immunosuppressive drug levels as potential risk factors.

Results: Of a total of 36 patients, 13.8% (5) developed CKD within 1 year post-lung transplant. According to KDIGO Glomerular Filtration rate (GFR) categories in CKD 40% (2) were classified as mildly decreased (G2), 40% (2) were mildly to moderately decreased GFR (G3a), and 20% (1) was severely decreased (G4). Of patients who developed CKD the median age was 15.8 years (14-18), 60% (3) females and 40% (2) males. 60% (3) Caucasian and 40% (2) Hispanic. Tacrolimus levels were elevated during the first 7 post operative days in 80% (4) of patients who developed CKD within the first year after lung transplantation. All patients who developed CKD had at least one episode of AKI after lung transplant.

Conclusions: Children with CKD can develop many complications including hypertension, anemia, growth retardation, bone disease. Our study identifies a high-risk population for end-stage kidney disease; therefore targeting renoprotective strategies in earlier stages of kidney disease may decrease CKD related morbidity and mortality.

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NEW ORLEANS—Urinary tract infection (UTI) may predict higher stage bladder cancer and greater mortality among older patients, according to a research presented at the American Urological Association 2015 annual meeting.

Additionally, UTI appears to delay the diagnosis of bladder cancer in both sexes, but more notably in women.

For the study, investigators led by Kyle A. Richards, MD, of the University of Wisconsin School of Medicine and Public Health examined Medicare claims data linked to the Surveillance, Epidemiology, and End Results (SEER) cancer registry. They identified Medicare patients older than 66 years diagnosed with bladder cancer during 2007–2009, who presented initially with either hematuria or UTI. 

Researchers discovered that patients presenting with UTI were at the highest risk of adverse bladder cancer pathologic and oncologic outcomes compared to patients presenting with hematuria.  The odds of stage 2 or higher disease was 71% higher in men and 208% higher in women presenting with UTI. Likewise, bladder cancer-specific mortality was higher in men (50%) and women (37%) presenting with UTI. The chance of dying from any cause was similarly elevated by 39% to 47%.

When UTI claim was also considered as a presenting symptom in addition to hematuria,  time to diagnosis of bladder cancer was longer in women vs. men (72 vs. 59 days). Time to diagnosis, however, was not linked to worse pathology or mortality.  

“Symptoms of UTI in older patients might be a harbinger of bladder cancer and should prompt thorough evaluation if symptoms persist despite short-term conservative management,” Dr. Richards told Renal & Urology News. “Timely bladder cancer diagnosis and treatment may not always occur due to prolonged treatment for presumed UTI.”

According to the investigators, an alternate theory is that patients presenting with a true UTI might have different bladder tumor biology that leads to negative outcomes. Further studies may clarify the factors that lead to worse bladder cancer pathology and outcomes.  

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NEW ORLEANS, LA USA (UroToday.com) - Given the significance of training tools for physician education, the authors created three-dimensionally printed physical kidney models of renal malignancies. These models may aid trainees as well as patients by serving as a visual tool as well as for surgical simulation prior to a patient operation. Previous studies have demonstrated the use of three-dimensional printing technologies for developing anatomically correct models to be used as an education tool for training and skills acquisition.

The authors constructed high-fidelity physical 3D models of renal units with enhancing renal lesions using various 3D-printing techniques. Although each 3D-printing technique differed, all techniques used a similar process where successful layers of a material are cured, one atop another, until a final model was created.

The first technique used was colorjet printing. This process uses a core layer of plaster like powder to form a rigid, opaque model. The second technique used stereolithograph. This technique uses a liquid polymer that is cured by a UV laser to create a semi-translucent, rigid model. The last two techniques involved multijet printing. In this process various photopolymers are jetted through a print head in small droplets. This technique was also used to create a mold that could be used to make a kidney model using agarose gel.

The authors conclude that “pre-operative physical 3-D models using readily available printing techniques can be constructed and may potentially influence both the patients’ and trainees’ understanding of renal malignancies.” Further studies must be done to validate these models as a training tool and to determine whether they may improve patient outcomes.

Presented by Jonathan Silberstein at the American Urological Association (AUA) Annual Meeting - May 15 - 19, 2015 - New Orleans, LA USA

Tulane University, New Orleans, LA USA

Reported by Renai Yoon (University of California-Irvine), medical writer for UroToday.com

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NEW ORLEANS, LA USA (UroToday.com) - Percutaneous renal biopsy (PRB) under real-time ultrasound guidance is a routine procedure performed to diagnose renal mass histopathology. The indications for PRB have expanded, as there has been a substantial increase in the number of small renal masses (SRM) that are being diagnosed, and the acceptance of pre-treatment biopsy for SRM continues to expand. Additionally, imaging technologies continue to improve with higher quality ultrasound devices routinely being introduced into clinical practice.

Due to the percent of incidental renal tumors and localized tumors increasing, management of small renal masses (SRM) (renal cortical tumors ? 4 cm) is a frequent clinical problem. By traditional treatment strategies, which were designed to treat larger renal masses, all SRMs were managed as if they were malignant. Typically, management included ablative, open radical, or extirpative surgery. With technological advancement, urologists have several treatment modalities now available for management of SRMs, ranging from active surveillance to ablative techniques.

Dr. Landman emphasized that according to the AUA guidelines, 24% of histopathological staging of removed tumors are indicated as benign, thus indicating that the surgery was unnecessary.

Biopsy can be performed with sedation, but it can be successfully performed under local anesthesia. Dr. Landman’s technique has been described in the recent articles published in British Journal of Urology. Generally, access is obtained under the 12th rib and a spinal needle is used to anesthetize the tract. He recommends to work with the patient. Since the patient is awake, you have him breath normally up until you’re ready to do the biopsy, then request to have him hold his breath. In his series of 62 biopsied patients, there was a 19% benign tumor rate from partials, and cryoablation was reduced to a staggering 1.6%, meaning 12 patients avoided surgery.

He demonstrated a new ultrasound probe that has been developed by Hitachi-Aloka, and was tested in his lab, using a gel model with an olive inserted. Retrieving a green-red-green pattern, from the olive and a pimento center, indicated a successful biopsy.

Dr. Landman concluded that while surgical excision is preferred and the superior treatment option for aggressive RCC subtypes, some histopathological subtypes are successfully managed with alternative treatment options. Knowledge of tumor histopathology on preoperative evaluation allows for a more selective treatment approach, avoiding unnecessary surgery, and minimizing the need for aggressive surgical procedures. These factors have stimulated surgeons to look for preoperative factors and techniques to evaluate tumor histopathology. In terms of cost, although no surgical approach was taken, there is a significant level of savings,

Presented by Jaime Landman at the American Urological Association (AUA) Annual Meeting - May 15 - 19, 2015 - New Orleans, LA USA

University of California, Irvine, CA USA

Reported by Victor Huynh (University of California-Irvine), medical writer for UroToday.com

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