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Of 2213 primary transplants reported to NAPRTCS between 1/1/87 and 10/31/92, 581 (26.3%) were performed without prior dialysis. The rate of pre‐emptive transplantation (PET) differed by donor source, 35.7% LD and 16.1% CD (p<0.001); gender, 29.6% male and 21.1% female (p<0.001); race, 30.1% white, 16.1% black, 19.5% hispanic, and 20.2% other (p<0.001); recipient age, 0‐1 yr 18.7%, 2‐5 yr 27.9%, 6‐12 yr 30.5%, and 13‐17 yr 22.8% (p<0.001). The graft survival rate was significantly better for both the LD (p<0.01) and CD (p=0.01) grafts in the pre‐emptive group; however, the differences were not significant after adjustment for other variables. The major reasons for pre‐emptive transplantation were the parents' desire to avoid dialysis and the recommendation of the nephrologist/surgeon. The data indicate that preemptive transplantation does not adversely impact on transplant outcome and that the desire to avoid dialysis is the primary motivating factor.

With improved renal graft survival, rehabilitation and growth post‐transplantation are the major challenges to pediatric nephrologists. Recent data from the pediatric renal transplant registry shows that children undergoing renal transplantation have a significant statural height deficit which does not improve in the 1st year after receiving a transplant. Two strategies can be developed to optimize growth post‐transplantation. Using the steroid‐sparing effect of cyclosporine, withdrawal of corticosteroids may be possible in 30‐40% of children, enabling them to grow. Recombinant growth hormone adminstered every other day can be utilized in children who continue to need steroid therapy to improve their growth velocity. This review discusses the mode of action of steroids in inhibiting growth, the methodology of steroid withdrawal post‐transplantation, the measurement of stimulated growth hormone levels, and the use of recombinant growth hormone.

• We studied serum osmolality in 167 consecutive infants admitted for gastroenteritis with 5% or more dehydration. Osmolality was determined by the freezing-point method in a 0.2-mL sample of serum immediately on admission. Forty-one patients (24.6%) had hypo-osmolar dehydration, with a mean osmolality of 257 mOsm/kg (range, 234 to 270 mOsm/kg). Eleven patients (6.5%) had hyperosmolar dehydration, with a mean osmolality of 329 mOsm/kg (range, 312 to 369 mOsm/kg). Simultaneous serum and CSF osmolalities were determined in 14 patients with hypo-osmolar and eight with hyperosmolar dehydration. In patients with hyperosmolar dehydration, serum osmolality correlated well with CSF osmolality, but a poor correlation was seen between serum and CSF sodium levels. Convulsions occurred in two patients in whom the CSF osmolality was greater than the serum osmolality by more than 10 mOsm/kg. Convulsions also occurred in two patients with hypo-osmolar dehydration in whom the CSF osmolality was lower than the serum osmolality by more than 13 mOsm/kg.(Am J Dis Child 1981;135:1000-1005)

• Meningitis and epiglottitis are the clinical manifestations of severe Haemophilus influenzae serotype b infection. Compared with meningitis, epiglottitis occurs in older children. When secondary cases occur within the family, the type of clinical manifestation produced by this serotype is generally similar in siblings. This report concerns the unusual occurrence of meningitis developing in the older child and epiglottitis developing in the younger one. We discuss the possible explanations for this unusual pattern. We also survey the spread of H influenzae both within and outside the family unit and review the present status of histocompatibility antigens and Haemophilus disease.(Am J Dis Child 131:778-781, 1977)

We reviewed the long-term outcome of 25 boys born with posterior urethral valves who were followed longitudinally. Patient age at diagnosis varied from 7 months intrauterine to 7 years postnatal, and the mean duration of followup was 9 years. Of the children 40 per cent had retardation of growth by the end of the followup period and 44 per cent had end stage renal disease. Of the various factors delay in diagnosis and the association of persistent vesicoureteral reflux seem to predict eventual end stage status. In 18 of 25 children the diagnosis of posterior urethral valves was made before they were 2 years old. Only 5 of these children have reached end stage disease status. In comparison, of 7 children whose diagnosis was delayed beyond 2 years 6 have end stage disease (p less than 0.01). Similarly, 7 of 9 children with persistent reflux had end stage disease compared to 4 of 16 who did not have persistent reflux (p less than 0.01). Since end stage renal disease status was reached at widely varying intervals a prolonged followup of children with this anomaly is necessary.

The data base of the North American Pediatric Renal Transplant Cooperative Study (NAPRTCS) was used to examine the effect of primary diagnosis on the outcome of renal transplantation in children. The relative risk of graft failure for eight diagnostic groups was determined, with patients with congenital and structural anomalies of the urinary tract serving as the reference group. Covariate analysis was used to control for the effects of age, race and transfusion history in recipients of living-related donor kidneys, and for age, donor age, antilymphocyte prophylaxis, prior transplantation, prior dialysis and cold ischemia time in recipients of cadaver kidneys. In recipients of living-related donor kidneys, the lowest graft failure rates were associated with the diagnoses of cystinosis, familial nephritis and hemolytic uremic syndrome (HUS), while the highest failure rates were observed in patients with a primary diagnosis of congenital nephrotic syndrome (CNS) or focal segmental glomerulosclerosis (FSGS). In cadaver allograft recipients, the lowest graft failure rates were associated with primary diagnoses of glomerulonephritis, congenital/structural disease and cystinosis, while patients with FSGS, HUS and CNS had the highest graft failure rates. This study suggests that patients with a primary diagnosis of cystinosis have superior outcomes, while the diagnoses of FSGS and CNS carry with them the highest risks of graft failure.

From January 1987 to January 1992 the North American pediatric Renal Transplant Cooperative Study registered and followed 2,037 children and adolescents 17 years of age or less who received 2, 197 renal transplants at 75 participating centers in the United States and Canada. The cumulative experience over 5 years of data collection demonstrated trends in renal transplantation practice for pediatric patients. The percentage of live donor organ recipients receiving donor-specific blood transfusions decreased from 40% in 1987 to less than 12% in 1991; random blood transfusions also were used less frequently during the most recent 2 years of the study. Immunosuppressive therapy on posttransplant day 0 or 1 with polyclonal and monoclonal antilymphocyte agents was used in over 40% of transplants. There was also a notable preference for the combined use of prednisone, azathioprine and cyclosporine as maintenance immunosuppression. The percentage of live donor source graft recipients receiving cyclosporine increased from 78% in 1987 to 90% in the most recent year, and considered together, nearly 90% of live donor and cadaver organ recipients received cyclosporine. The observed graft survival probabilities for live donor grafts were 88%, 83%, 81% and 76% at years 1–4 post transplantation, respectively. The 1st through 4th year graft survival probabilities for cadaver grafts were 74%, 68%, 63% and 58%, respectively. The five most common causes of pediatric end-stage renal disease have remained as: hypoplastic-dysplastic kidney, obstructive uropathy, focal segmental glomerulosclerosis, reflux nephropathy and systemic immunological diseases throughout the 5 years of this study. There has been a decrease in children 2 years of age or less undergoing transplant surgery. On average, 50% of graft failures were due to the various forms of rejection. Vascular thrombosis (14%) and recurrence of primary renal disease (7%) were the next most frequently encountered causes of graft failure. Poor linear growth was identified as a problem affecting the majority of children both before and after transplantation. Post transplant linear growth was best among recipients less than 6 years of age at transplantation and recipients of all ages who received alternate-day prednisone. A total of 16 malignancies were reported during the 5 years of study. A total of 105 deaths were reported, with infection (41%) the most common primary cause of death. The 2-year patient survival probabilities were 95.5% and 93% for recipients of live donor and cadaver grafts, respectively.

• We studied the long-term outcome of lupus nephritis in 23 black and Hispanic children. The follow-up period ranged from two to 16.5 years, with a mean follow-up of 5.4 years. The mean age at onset was 10.1 years, which is younger than that described in recent series of children with lupus nephritis. All patients had renal involvement, including four normotensive patients with normal renal function and normal urinary sediment. When children whose disease started before the age of 10 years were compared with patients older at onset, there were no significant differences regarding the type of lesion or duration of therapy, but a higher incidence of renal death (.02&lt;P&lt;.05) was noted in younger children. Overall, 25% of our patients have died of renal causes, and another 25% have been undergoing dialysis, receiving transplants, or in chronic renal failure. The mortality in our series was higher than that reported in other series of children with lupus nephritis in recent years. Age and race may be acting synergistically to produce the higher mortality and morbidity.(Am J Dis Child 1983;137:481-483)

In Reply.—Dr Sawyer's second patient falls in the category that we prefer to call coprimary rather than secondary. In our review of intrafamily spread of Haemophilus influenzae infection in confirmed cases, the time interval between the disease in the index case and siblings ranged from 24 hours to two months, with a mean time interval being 8.5 days. Our present policy is to diagnose H influenzae meningitis expediently by smear (80% to 85% positive) and counterimmunoelectrophoresis (90% to 95% positive). Once a diagnosis is made, we ask the parents to bring in the siblings. Cultures are taken from all siblings, and those under 3 years of age are given ampicillin, 100 mg/kg/day orally, for ten days. Using this regimen, we have not seen a secondary or coprimary case in two years. Siblings over 3 years of age, if culture positive, are also treated; the rationale here is to reduce