About

Sandra Amaral, MD, MHS, is an Associate Professor of Pediatrics (Nephrology) at the Children's Hospital of Philadelphia. She holds additional roles as an Associate Fellow at the Center for Health Behavior Research and as a Senior Scholar at the Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine. Dr. Amaral is also the Medical Director of the Pediatric Kidney Transplant Program and the Hand Transplant Program (Vascular Composite Allograft Program) at Children's Hospital of Philadelphia. Her research and clinical work focus on pediatric nephrology, with particular expertise in kidney transplantation and vascularized composite allografts. She is actively involved in academic and clinical leadership, contributing to advancing pediatric transplant medicine and health behavior research.

Research topics

• Physical therapy
• Intensive care medicine
• Internal medicine
• Nursing
• Medicine

Selected publications

• Children as Living Solid Organ Donors: Ethical Discussion and Model Hospital Policy Statement

  The Journal of Clinical Ethics · 2025-02-10 · 2 citations

  articleOpen accessSenior author

  AbstractIn recent years, more attention has been paid to living donation as a means to reduce the suffering of individuals with end-stage kidney or liver disease. Implicated ethical issues include medical risk and risk of coercion, counterbalanced by improved medical outcomes and the benefits of saving a life. Living donation becomes particularly ethically complicated with the prospect of child donation, given the child's developing autonomy and uniquely dependent status. We outline four broad ethical considerations pertinent to living child organ donation: (1) beneficence, (2) respect for the family as a moral unit, (3) respect for the child as a person, and (4) justice. We conclude that it can be ethical for a healthy child to donate a kidney or liver lobe to a close relative who has exhausted other options provided that certain protections are put into place. Ideally, these donations will be rare. Lastly, we construct a model transplant center donation policy.

  PublisherOA PDFDOI

• Tacrolimus IPV Group Membership Does Not Consistently Track With Electronically Monitored or Self-reported Adherence in Adolescent and Young Adult Kidney Transplant Recipients

  Transplantation Direct · 2025-05-12 · 2 citations

  articleOpen access

  Background. High intrapatient variability (IPV) of tacrolimus trough concentrations (SD ≥ 2, coefficient of variation (CV%) ≥ 30) is associated with rejection and graft loss and may indicate nonadherence. However, the association between tacrolimus IPV and electronically monitored or self-reported adherence is unknown. Methods. This secondary analysis of the TAKE-IT (Teen Adherence in Kidney Transplant Effectiveness of Intervention Trial) compared electronically monitored and self-reported adherence between participants with high and low tacrolimus IPV among 103 adolescent and young adult kidney transplant recipients (mean age = 15.18 y, 59% male, 60% White, 65% >1-y posttransplant). Results. Electronically monitored daily taking and timing adherence were not significantly associated with tacrolimus IPV group in binomial generalized linear mixed effects models: Participants with tacrolimus SD ≥ 2 or CV% ≥ 30 were no less likely to take each daily dose than those below these cutoffs (SD < versus ≥ 2: odds ratio [OR]; 0.84, 95% confidence interval [CI], 0.48-1.47; P = 0.54 and CV% < versus ≥ 30: OR, 0.72; 95% CI, 0.43-1.21; P = 0.22). Participants with tacrolimus SD ≥ 2 or CV% ≥ 30 were no less likely to take each daily dose on time than those below these cutoffs (SD < versus ≥ 2: OR, 0.70; 95% CI, 0.40-1.23; P = 0.21 and CV% < versus ≥ 30: OR, 0.68; 95% CI, 0.40-1.16; P = 0.15). Electronically monitored averages of doses taken, doses taken early/late, and differences from expected dose time were associated with tacrolimus IPV ( P < 0.05) but were poor classifiers of IPV group membership (area under the curve < 0.70). Self-reported adherence was not associated with tacrolimus IPV. Conclusions. Tacrolimus IPV group membership does not consistently track with behavioral adherence measures. Relying on tacrolimus IPV group membership may misidentify nonadherence in adolescent and young adult kidney transplant recipients.

  PublisherDOI

• 1163-P: Disparities in Glucagon-Like Peptide 1 Receptor Agonist (GLP-1RA) Utilization in Pediatric Type 2 Diabetes (T2D)

  Diabetes · 2025-06-13 · 1 citations

  articleSenior author

  Introduction and Objective: Disparities in GLP-1 RA use by race/ethnicity and socioeconomic status are documented in adult T2D. To assess if similar disparities occur in pediatric T2D, the association between GLP-1 RA prescriptions and race/ethnicity amongst Medicaid-insured youths with T2D was examined. Methods: A cross-sectional study of youths aged 10-17 years (y) with T2D (2021-2022) was conducted using the Merative MarketScan Medicaid Database. Multivariable logistic regression was used to assess associations of GLP-1 RA prescription ever prescribed (yes/no) with race/ethnicity and potential confounders (age, sex, obesity, co-morbidities, and use of metformin or insulin). Results: Among 4000 youths (57.7 % female, 33.1% NH White, 47.2% NH Black, 13.0% Hispanic, 6.7% Other, mean age: 14.9 y [SD 1.9]), GLP-1 RAs were prescribed in 23.3% (liraglutide 17.5%, dulaglutide 4.4%, exenatide 2.3%, semaglutide 2.2%) and less frequently than metformin (73.8%) and insulin (64.0%). After covariate adjustment, Hispanic ethnicity, but not Black race, was associated with lower odds of GLP-1 RA prescription compared to NH White (OR 0.57 [95% CI 0.43, 0.76], p < 0.001) (Figure 1). Conclusion: Among Medicaid-insured youths with T2D, Hispanic youths were less likely to be prescribed GLP-1 RAs. Developing strategies to ensure equitable access to novel treatments in pediatric T2D are needed. Disclosure P.Y. Chu: None. A. Kelly: None. M. Vajravelu: None. S. Hennessy: Consultant; Novo Nordisk, AstraZeneca, Urovant Sciences, i2o Therapeutics, Basilea, Eli Lilly and Company, Balance Opthalmics, Inc, Applied Therapeutics, GlaxoSmithKline plc, Lycos Therapeutics. S. Amaral: Consultant; Bristol-Myers Squibb Company. Funding National Institute of Diabetes and Digestive and Kidney Diseases (F32DK138739); National Institute of General Medical Sciences (T32GM075766)

  PublisherDOI

• Large Scale Urinary Metabolomic Screening in the Prospective Multicenter VIRTUUS Children's Study

  American Journal of Transplantation · 2025-08-01

  article
  PublisherDOI

• Polygenic Risk Scores and HLA Class II Variants are Biomarkers of Corticosteroid Response in Childhood Nephrotic Syndrome

  medRxiv · 2025-08-07 · 1 citations

  preprintOpen access

  Abstract Introduction Nephrotic syndrome (NS), a common glomerular disease in children, is classified based on response to corticosteroid therapy as either steroid-sensitive nephrotic syndrome (SSNS), or steroid-resistant nephrotic syndrome (SRNS). However, there are currently no reliable predictors of therapy response at initial clinical presentation. Methods We conducted genome-wide association studies, developed polygenic risk scores (PRS) for therapy response and analyzed classical HLA alleles in 1,997 (994 discovery and 1,003 replication/validation cohorts) previously unstudied children with NS and 3,558 ancestry-matched controls. Results A significant association with HLA loci defined by variants in HLA-DQB1, HLA-DRB1 , and HLA-DQA1 were found for SSNS (but not SRNS), along with a second immune-related SSNS locus: CLEC16A . A PRS that discriminates between SSNS and SRNS was validated in two independent cohorts. The HLA haplotype HLA-DRB1*07:01∼DQA1*02:01∼DQB1*02:02 was associated with ∼4 times the risk of developing SSNS. A model incorporating HLA haplotype, PRS score, and age at onset of the disease was the best predictor of steroid responsiveness with an AUC of 0.68-0.70 and an overall classification accuracy of SSNS versus SRNS of 67-71%. Conclusions Our findings confirm that SSNS (unlike SRNS) is an immune-mediated HLA-associated disorder. The PRS for therapy response and HLA haplotype can serve as biomarkers and provide a foundation for more accurate diagnoses and tailored and individualized treatment. Translational statement To identify biomarkers of pattern of steroid responsiveness in childhood-onset nephrotic syndrome, we carried out a case-control study that included over 4,000 samples, including 994 patients with NS in the discovery phase and an additional 1,003 cases from two independent replication cohorts. We identified significant risk of steroid-sensitive NS (SSNS) at HLA class II genes and CLEC16A (a gene important in the regulation of T and B lymphocytes). The HLA haplotype DRB1*07:01∼DQA1*02:01∼DQB1*02:02 was associated with four-fold increased odds of SSNS. A model incorporating HLA haplotype, polygenic risk score, and age at onset of the disease was the best predictor of steroid responsiveness providing useful delineation of steroid sensitivity from steroid resistance. In conclusion, age at onset of disease, HLA class II variants and polygenic risk scores are useful biomarkers of corticosteroid response in childhood NS and may serve as useful clinical decision support tools to guide treatment. Abstract Figure Graphical Abstract

  PublisherOA PDFDOI

• Diffusion Tensor Imaging ( <scp>DTI</scp> ) as a Non‐Invasive Tool for Assessing Pediatric Kidney Transplants: A Feasibility Study

  Pediatric Transplantation · 2025-06-11 · 2 citations

  articleOpen access

  BACKGROUND: Pediatric kidney transplant recipients require periodic biopsy for active surveillance to prolong allograft half-life, and non-invasive MR imaging markers are needed but understudied. Here we aimed to determine the feasibility of MR diffusion tensor imaging (DTI) on pediatric kidney transplant recipients, compare transplanted kidneys DTI values to healthy controls, and correlate DTI values with allograft histopathology. METHODS: Single-center prospective study of pediatric (< 18 years of age) kidney transplant recipients undergoing biopsies and healthy controls between February 2020 and October 2023. MRI DTI-derived metrics (fractional anisotropy [FA] and track length) of the kidney cortex were obtained for all participants. Transplant recipients versus controls, rejection versus non-rejection, and high chronic allograft damage index (CADI) versus low were compared using two-sample t-test or Wilcoxon rank-sum test. RESULTS: Fifteen transplant recipients (4F/11M, median 16 [IQR 13-18] years old) and 15 healthy controls (9F/6M, median 15 [IQR 12-22] years old, 30 kidney units) were evaluated. DTI was technically appropriate in all cases. Smaller FA values and longer track length were found in allografts (FA in allografts (median [IQR]: 0.25 [0.25-0.28]) vs. controls (0.28 [0.27-0.33], p = 0.003) and track length in allografts (mean: 19.36 ± 5.21) vs. controls (12.80 ± 3.34, p-value < 0.001). FA and track length between allografts with and without rejection, and/or with high vs. low CADI score were not significantly different. CONCLUSION: DTI in pediatric kidney transplants is feasible and showed differences in FA and track length values when compared to controls. However, in our limited dataset, DTI did not find differences within the allograft group.

  PublisherOA PDFDOI

• A Case Report of Successful Use of Phenytoin/Fosphenytoin in a Pediatric Kidney Transplant Recipient With Nirmatrelvir/Ritonavir‐Induced Tacrolimus Allograft Injury

  Pediatric Transplantation · 2025-03-26

  articleOpen access

  BACKGROUND: Paxlovid, a fixed combination nirmatrelvir and ritonavir (NIM-RTV), is a potent inhibitor of cytochrome P450 3A4 (CYP3A4) isoenzyme. It is approved for the treatment of mild to moderate COVID-19 infections in patients at risk for serious infection. The metabolism of tacrolimus, a CYP3A4 substrate, is significantly reduced in those receiving NIM-RTV. Coadministration of NIM-RTV without tacrolimus dose reduction may result in toxicity. CYP3A4-inducing medications, including phenytoin, fosphenytoin or rifampin, may reverse toxicity while achieving rapid clearance. CASE PRESENTATION: A 14-year-old, 66.5 kg African American female with a history of chronic kidney disease stage 5 secondary to collapsing focal segmental glomerulosclerosis (FSGS) underwent an uncomplicated deceased donor kidney transplant at 12 years of age. Approximately 2.5 years after transplant, she tested positive for COVID-19. NIM-RTV was prescribed through a local pharmacy. She presented 3.5 days later with nausea, vomiting, fatigue, and oligo-anuria with acute kidney injury (AKI) and creatinine of 2.6 mg/dL from baseline of 0.7 mg/dL. Tacrolimus level was > 60 ng/mL. Phenytoin/fosphenytoin was initiated to induce tacrolimus clearance due to sustained AKI and neurological risk. Within 36 h, her tacrolimus level was 38 ng/mLwith improved urine output. After 3 days, her tacrolimus level 11.9 ng/mL and serum creatinine was near baseline. CONCLUSIONS: To our knowledge, this is the first report of a pediatric kidney transplant patient with tacrolimus toxicity secondary to NIM-RTV therapy utilizing phenytoin/fosphenytoin to induce tacrolimus metabolism and prevent further toxicity. Heightened awareness of this interaction is paramount to reduce allograft injury and promote patient safety.

  PublisherOA PDFDOI

• Consent to Receive Offers for Kidneys From Donors With Hepatitis C Among Pediatric Kidney Transplant Candidates in the United States

  Pediatric Transplantation · 2025-09-11 · 1 citations

  articleOpen access

  BACKGROUND: Changes to the calculation of the Kidney Donor Profile Index (KDPI) have lowered the KDPI of hepatitis C (HCV+) donor kidneys; therefore, increasing the proportion of pediatric-prioritized kidneys that are HCV+. We aimed to study consent rates for HCV+ kidneys among pediatric kidney transplant candidates. METHODS: We identified pediatric candidates waitlisted from 2019 to 2024 and excluded those who received a living donor transplant. We used logistic regression to identify candidate characteristics associated with HCV+ offer consent and Cox proportional hazards models to determine the association between HCV+ offer consent and the rate of deceased donor transplantation. RESULTS: Among 3202 candidates included in the analysis, 124 (4%) consented to receive HCV+ deceased donor kidney offers, and 3077 (96%) did not. In adjusted logistic regression, higher candidate age (OR 1.09 per year, 95% CI 1.03-1.15, p = 0.002) and high PRA status (OR 2.76, 95% CI 1.42-5.37, p = 0.003) were associated with a higher odds of consenting to receive HCV+ donor offers, whereas Hispanic ethnicity was associated with lower odds (OR 0.44, 95% CI 0.28-0.72, p = 0.001) of consenting to receive these offers. 2773 candidates (87%) received a transplant. There was no significant association between HCV+ donor offer consent status and transplant rate after adjusting for candidate characteristics. Only 1 received a kidney from a HCV+ donor. CONCLUSIONS: Consent to receive HCV+ donor kidney offers was rare among pediatric kidney transplant candidates. Allocation changes that increase the proportion of pediatric-prioritized kidneys that are HCV+ may decrease access to transplant for pediatric candidates.

  PublisherOA PDFDOI

• Donor-Derived Epstein-Barr Virus Infection Among Pediatric Kidney Transplant Recipients

  JAMA · 2025-09-17 · 1 citations

  articleOpen access

  This study uses US national data to examine Epstein-Barr virus–seronegative donor kidney use among Epstein-Barr virus–seronegative children.

  PublisherOA PDFDOI

• Socioeconomic Disparities in Preemptive Kidney Transplant Rates in Children

  Kidney360 · 2025-04-07 · 3 citations

  articleOpen access

  Key Points Pediatric preemptive kidney transplantation rates in the United States vary by socioeconomic status (SES). The HOUsing-based index of SES, an individual-level SES measure derived from residential addresses, effectively predicts pediatric preemptive kidney transplant rates. Background Preemptive kidney transplantation in children is associated with better patient and graft survival compared with transplants after dialysis. However, preemptive kidney transplantation rates in children remain low. This study aimed to evaluate the effect of socioeconomic status (SES) on preemptive transplantation in children. Methods Our study included 173 Minnesota-resident pediatric kidney transplant recipients (younger than 18 years) transplanted at the University of Minnesota from 2010 to 2020. Using the HOUsing-based index of SES (HOUSES) index, a validated, individual SES measure based on housing units categorized into quartiles (Q1: lower SES; Q2–Q4: higher SES), we applied mixed-effects multivariable logistic models to examine the effects of HOUSES on preemptive kidney transplants and pretransplant dialysis duration. Results Of 173 pediatric kidney transplant recipients, 46 (26.6%) received a preemptive transplant, and of 109 recipients with dialysis duration data, 39 (35.8%) received dialysis for &gt;1 year. After adjusting for age at kidney failure, sex, donor type, insurance type, and underlying cause of kidney failure, we observed significantly lower odds of preemptive transplantation among Q1 recipients compared with Q2–4 recipients (adjusted odds ratio, 0.31; 95% confidence interval, 0.11 to 0.90; P = 0.03). Conclusions Using the HOUSES index, we found significant socioeconomic disparities in preemptive kidney transplantation rates among children.

  PublisherDOI

Recent grants

• Does geographic access to care impact pediatric ESRD outcomes?

  NIH · $184k · 2014–2017

• Reaching Equity for Adults and CHildren in Transplant (REACH-TRANSPLANT)

  NIH · $3.5M · 2019–2026

• Urological and Renal Disease Engaging Adolescents in Adherence Collaborative Trial

  NIH · $3.5M · 2016–2022

• VIRTUUS Children's Study: Validating Injury to the Renal Transplant Using Urinary Signatures in Children

  NIH · $3.4M · 2017–2024

• Assessing an adherence intervention for adolescents with kidney transplants

  NIH · $861k · 2011–2017

Frequent coauthors

• L. Scott Levin

  University of Pennsylvania

  48 shared

• Susan L. Furth

  Children's Hospital of Philadelphia

  43 shared

• Debra S. Lefkowitz

  Children's Hospital of Philadelphia

  21 shared

• Sudha Kilaru Kessler

  Children's Hospital of Philadelphia

  20 shared

• Benjamin L. Laskin

  Children's Hospital of Philadelphia

  19 shared

• Andrea Kelly

  Children's Hospital of Philadelphia

  17 shared

• Timothy P. L. Roberts

  Children's Hospital of Philadelphia

  17 shared

• Rachel E. Patzer

  Indiana University – Purdue University Indianapolis

  17 shared

Labs

• Sandra Amaral LabPI

Education

• Fellow, Pediatric Nephrology, Pediatrics

  Johns Hopkins University

  2006

• Resident, Pediatrics

  Medical College of Wisconsin

  2003

• MD

  Med Coll of PA- Hahnemann Univ.

  2000