It is not uncommon to see unilateral pulmonary emphysema compznsating for lobar collapse, or as a mechanical result of valvular obstruction of a bronchus. The clinical details of a case where neither of these factors was present, with a pathological report on the resected lung, form the subject of this paper.CLINICAL REPORTThe patient was a boy aged 6 years who came under observation after an attack of acute bronchitis in September, 1949. At the ages of 5 weeks, 2 years, and 3 years he had had bronchopneumonia, and since the age of 3 years he had been subject to recurrent attacks of bronchitis, which affected mainly the right lung.The boy was mentally normally developed, but slightly below standard height and weight for his age. Slight clubbing of the fingers was present. Chest expansion was poor on both sides, but more so on the right. Air entry on the right side was diminished with scattered crepitations throughout, and there were a few persistent crepitations at the left base. Other systems were apparently normal. A radiograph of the chest showed relative transradiancy of the right lung field compared with the left, with considerable decrease of vascular markings. The heart was slightly displaced to the right. The right hemithorax and lung were smaller than the left despite the increased transradiancy on the right (Fig. 1). Fluoroscopy showed movement of the heart to the right on inspiration and restricted excursion of the right diaphragm.Bronchography showed on the left side only slight dilatation of the posterior basic segmental bronchus of the lower lobe, and on the right a peculiar appearance because the peripheral bronchi failed to fill, with a sharp line of demarcation between the proximal filled and the peripheral unfilled parts (Figs. 2 and 3). Bronchoscopy showed that the main bronchi were normal with very little secretion present. Angiocardiography showed a normal heart with a right pulmonary artery much diminished in calibre, and confirmed the poor

Objective-Heavy post-transplant immunosuppression may contribute to long-term immunosuppression dependence by subverting tolerogenic mechanisms; thus, we sought to determine if this undesirable consequence could be mitigated by pretransplant lymphoid depletion and minimalistic post-transplant monotherapy.Study design-Lymphoid depletion in 17 unselected pediatric recipients of live (n = 14) or deceased donor kidneys (n = 3) was accomplished with antithymocyte globulin (ATG) (n = 8) or alemtuzumab (n = 9). Tacrolimus was begun post-transplantation with subsequent lengthening of intervals between doses (spaced weaning). Maintenance immunosuppression, morbidity, graft function, and patient/graft survival were collated.Results-Steroids were added temporarily to treat rejection in two patients (both ATG subgroup) or to treat hemolytic anemia in two others. After 16 to 31 months (mean 22), patient and graft survival was 100% and 94%, respectively. The only graft loss was in a nonweaned noncompliant recipient. In the other 16, serum creatinine was 0.85 ± 0.35 mg/dL and creatinine clearance was 90.8 ± 22.1 mL/1.73 m 2 . All 16 patients are on monotherapy (15 tacrolimus, one sirolimus), and 14 receive every other day or 3 times per week doses. There were no wound or other infections. Two patients developed insulin-dependent diabetes.Conclusion-The strategy of lymphoid depletion and minimum post-transplant immunosuppression appears safe and effective for pediatric kidney recipients.Until the late 1960s, renal transplantation in pediatric patients was a controversial service that was systematically provided in only a few centers. 1-4 Numerous ethical issues were raised at the outset, including risk to live donors, effects on family unity, mental health of well siblings, and doubts about the long-term prognosis.5 Some of these anxieties have been relieved with the passage of time. For example, complications associated with heavy steroid use have been progressively circumvented with better adjunct6 and/or baseline drugs7 -13 However, chronic immunodepression per se and drug-specific side effects (eg, nephrotoxicity) have remained the principal threats to the quality and duration of life of the pediatric recipient. 14 We report here an experience in 17 pediatric kidney recipients in whom the burden of longterm immunosuppression was lightened with a treatment regimen designed to avoid acute rejection while interfering minimally with natural tolerogenic mechanisms. 17 One principle of the strategy consisted of lymphoid depletion before renal allograft revascularization. In the first eight patients, the lymphoid depletion was done with antithymocyte globulin (ATG; Thymoglobulin R ). 18 In the next nine patients, alemtuzumab (Campath-1H ® )19 -23 was used. The second therapeutic principle consisted of the use of the least amount of post-transplant immunosuppression consistent with stable graft function. This was accomplished by beginning the postoperative course on tacrolimus monotherapy with subsequent attempts to reduce ...

We employed antibody pre-conditioning with alemtuzumab and posttransplant immunosuppression with low-dose tacrolimus monotherapy in 26 consecutive pediatric kidney transplant recipients between January 2004 and December 2005. Mean recipient age was 10.7 +/- 5.8 years, 7.7% were undergoing retransplantation, and 3.8% were sensitized, with a PRA >20%. Mean donor age was 32.8 +/- 9.2 years. Living donors were utilized in 65% of the transplants. Mean cold ischemia time was 27.6 +/- 6.4 h. The mean number of HLA mismatches was 3.3 +/- 1.3. Mean follow-up was 25 +/- 8 months. One and 2 year patient survival was 100% and 96%. One and 2 year graft survival was 96% and 88%. Mean serum creatinine was 1.1 +/- 0.6 mg/dL, and calculated creatinine clearance was 82.3 +/- 29.4 mL/min/1.73 m(2). The incidence of pre-weaning acute rejection was 11.5%; the incidence of delayed graft function was 7.7%. Eighteen (69%) of the children were tapered to spaced tacrolimus monotherapy, 10.5 +/- 2.2 months after transplantation. The incidence of CMV, PTLD and BK virus was 0%; the incidence of posttransplant diabetes was 7.7%. Although more follow-up is clearly needed, antibody pre-conditioning with alemtuzumab and tacrolimus monotherapy may be a safe and effective regimen in pediatric renal transplantation.

Introduction Urinary diversion in pediatric renal transplant candidates with bladders not amenable to primary reconstruction can be achieved by pre‐transplant ileal conduit creation. We performed cutaneous ureterostomies to limit pre‐transplant surgery, protect the peritoneum for dialysis, transplant patients sooner, and preserve ureter length for future surgical reconstruction. Methods We compared four pediatric transplant recipients with ureterostomies to four recipients with ileal conduits from 2009 to 2017. Results All patients with ileal conduits developed at least one urinary tract infection (UTI) within 1 year of transplant and three of four patients had recurrent UTIs within the first year. Two patients required ileal conduit revisions for redundant conduits and recurrent UTIs. Of the four ureterostomy patients, two patients had UTIs within one year of transplant. Two patients developed ureterostomy strictures requiring revision at the fascial level; one was associated with a UTI. Conclusion In our small case series, ureterostomy allowed for a single operative intervention with preservation of ureter length for later reconstruction. Ureterostomy is safe and recurrent UTI may be lower in the ureterostomy group. Long‐term evaluation of ureterostomy for urinary diversion in pediatric kidney transplant is warranted.