Long-term outcome of chronic dialysis in children

Cardiovascular Risk in Pediatric Renal Transplant Recipients

BACKGROUND

The survival of pediatric chronic kidney disease (CKD) patients has improved in recent decades due to advances in dialysis and transplantation. However, cardiovascular disease (CVD) emerges as the main cause of mortality in patients with CKD.

OBJECTIVES

To estimate cardiovascular risk in children with CKD at least 1 year after kidney transplantation. In addition, the possible association of cardiovascular risk with classic biochemical markers and potential new markers of this outcome was investigated.

METHODS

An observational ambidirectional (retrospective capture of risk factors and prospective study of outcomes) research including 75 patients who underwent renal transplant between 2003 and 2013 with postoperative follow-up of at least 1 year was conducted. The outcome variables adopted were the LV mass Z-score and the presence of coronary calcification on computed tomography using calcium Agatston score.

RESULT

Only one patient had an elevated calcium score, and three children (4%) had an LV mass Z-score ≥ 2.0. After multivariable analysis, only gender, serum triglyceride, and serum renalase concentration remained significantly associated with LV mass.

CONCLUSION

The low incidence of cardiovascular changes in the population studied confirms the benefit of transplantation for the cardiovascular health of children. Nevertheless, long-term follow-up of these patients is recommended, given the limited duration of kidney function provided by transplantation and the high likelihood of further dialysis and kidney transplants being required in these children.

Reduced Blood Pressure Dipping Is A Risk Factor for the Progression of Chronic Kidney Disease in Children

Background: Elevated blood pressure and proteinuria are well-established risk factors for chronic kidney disease (CKD) progression in children. This study aimed to analyze risk factors for CKD progress, emphasizing detailed ambulatory blood pressure (ABPM) data. Methods: In 55 children with CKD II−V, observed for ≥1 year or until initiation of kidney replacement therapy, we analyzed ABPM, clinical, and biochemical parameters. Results: At the beginning, the glomerular filtration rate (eGFR) was 66 (interquartile range—IQR: 42.8−75.3) mL/min/1.73 m2, and the observation period was 27 (16−36) months. The mean eGFR decline was 2.9 ± 5.7 mL/min/1.73 m2/year. eGFR decline correlated (p < 0.05) with age (r = 0.30), initial proteinuria (r = 0.31), nighttime systolic and mean blood pressure (r = 0.27, r = 0.29), and systolic and diastolic blood pressure dipping (r = −0.37, r = −0.29). There was no relation between mean arterial pressure during 24 h (MAP 24 h Z-score) and eGFR decline and no difference in eGFR decline between those with MAP 24 h < and ≥50 th percentile. In multivariate analysis, systolic blood pressure dipping (beta = −0.43), presence of proteinuria (beta = −0.35), and age (beta = 0.25) were predictors of eGFR decline. Conclusions: Systolic blood pressure dipping may be a valuable indicator of CKD progression in children.

Introducing a New Technique for Fascial Closure to Avoid Renal Allograft Compartment Syndrome in Pediatric Recipients: The Use of Tutoplast® Fascia Lata

Introduction

Renal allograft compartment syndrome (RACS) is a complication that infrequently occurs after renal transplantation. Tight muscle closure may lead to RACS due to compression of renal parenchyma or kinking of the renal vessels. Many techniques have been proposed in an attempt to achieve tension-free closure, which can be specially challenging in child recipients. We present our experience with Tutoplast^® Fascia Lata (RTI Surgical Tutogen Medical GmbH Industriestrasse 6, 91077 Neunkirchen am Brand, Germany) closure.

Methods

All pediatric patients who underwent renal transplantation in our center between 2012 and 2021 were reviewed. Eight patients with Tutoplast^® Fascia Lata placed at the time of initial transplantation were identified. Donor and recipient characteristics, Doppler ultrasound findings, and overall patient and graft survival rates were analyzed.

Results

Doppler ultrasound was performed intra-operatively after abdominal wall closure. If any sign of vascular compromise was seen, the abdominal wall was opened and the graft was revised. The Tutoplast^® Fascia Lata implant was used to perform tension-free fascia closure and, afterwards, a Doppler ultrasound was performed to confirm the optimal renal artery perfusion and venous patency. Three of the renal transplantations were from a cadaver donor, with two of them en bloc. Living donor transplantation was performed in four cases. Among which, there was a case of auto-transplantation due to bilateral renal artery stenosis. None of the patients presented any complications of either short or long term that was derived from the abdominal closure with Tutoplast^® Fascia Lata. There was also no record of graft failure till datum.

Conclusions

Restricted volume of the recipient pelvic cavity and the size discrepancy between the recipient pelvic cavity space and the donor adult kidney may lead to RACS. Other situations that occur more infrequently, i.e., as en bloc or auto-transplantation, are prone to suffer the same problem. Tutoplast^® Fascia Lata is a safe option for these patients.

Kidney transplant outcomes in children and adolescents with systemic lupus erythematosus

BACKGROUND

Literature supports equivalent kidney transplant outcomes in adults with systemic lupus erythematosus (SLE) compared with those without SLE. However, there are conflicting and scant data on kidney transplant outcomes, as well as controversy over optimal timing of transplantation, in children and adolescents with SLE.

METHODS

Analysis included kidney-only transplant recipients aged 2-21 years from 2000 to 2017 enrolled in the Organ Procurement and Transplant Network (OPTN). The relationship between diagnosis (SLE n = 457, non-SLE glomerular disease n = 4492, and non-SLE non-glomerular disease n = 5605) and transplant outcomes was evaluated. The association between dialysis time and outcomes was analyzed in the SLE group only.

RESULTS

In adjusted models, SLE had higher mortality compared with non-SLE glomerular recipients (HR 1.24 CI 1.07-1.44) and non-glomerular recipients (HR 1.42 CI 1.20-1.70). SLE was associated with higher graft failure compared with non-SLE glomerular (HR 1.42 CI 1.20-1.69) and non-glomerular disease (HR 1.67 CI 1.22-2.28). SLE had a higher risk of acute rejection at 1 year compared with non-glomerular disease (HR 1.39 CI 1.03-1.88). There was a decreased risk of delayed graft function compared with non-SLE glomerular disease (HR 0.54, CI 0.36-0.82). There were no significant associations between dialysis time and transplant outcomes in the SLE group.

CONCLUSION

SLE in children and adolescents is associated with worse patient and graft survival compared with non-SLE diagnoses. Outcomes in children and adolescents with SLE are not associated with dialysis time. Further studies are needed to assess implications of potential earlier transplantation and shorter time on dialysis prior to transplantation.

Evaluation of Pupils' Knowledge about Kidney Health

The purpose of this study was to investigate the level of renal function knowledge of primary school pupils in Greece. We conducted a cross-sectional study with a convenience sample of 220 pupils, coming from the 5th and 6th grades of general education schools. A questionnaire consisting of 11 questions was developed from scratch. However, based on an analysis of Cronbach's alpha values obtained when individual questions were deleted, two questions were removed from the analysis, and only nine remained for analysis and participated in the calculation of the knowledge score. Moreover, the gender and daily habits of pupils regarding water consumption and frequency of urination were recorded. Pupils had a high percentage of correct knowledge about the number of kidneys (95.2%), whether a child may have problems with the kidneys (85.5%) and whether a person can survive with one kidney (68.5%). Low levels of knowledge were observed in the function and role of the kidneys (36.4%), as well as the part of the body where the kidneys are located (30.9%). The median (interquartile range (IQR)) total knowledge score was 6 (5-7), with no difference detected between genders (p = 0.135). A statistically significant difference between pupils of 5th and 6th grades was found but the difference did not seem to be clinically significant (p = 0.035). The present research demonstrates that pupils' knowledge of renal function and the protection of their kidneys needs improvement.

Hemodialysis (HD) dose and ultrafiltration rate are associated with survival in pediatric and adolescent patients on chronic HD-a large observational study with follow-up to young adult age

BACKGROUND

Hemodialysis (HD) dose targets and ultrafiltration rate (UFR) limits for pediatric patients on chronic HD are not known and are derived from adults (spKt/V>1.4 and <13 ml/kg/h). We aimed to characterize how delivered HD dose and UFR are associated with survival in a large cohort of patients who started HD in childhood.

METHODS

Retrospective analysis on a cohort of patients <30 years, on chronic HD since childhood (<19 years), having received thrice-weekly HD 2004-2016 in outpatient DaVita centers.

OUTCOME

Survival while remaining on HD.

PREDICTORS

(I) primary analysis: mean delivered dialysis dose stratified as spKt/V ≤1.4/1.4-1.6/>1.6 (Kaplan-Meier analysis), (II) secondary analyses: UFR and alternative dialysis adequacy measures [eKt/V, body-surface normalized Kt/BSA] on continuous scale (Weibull regression model).

RESULTS

A total of 1780 patients were included (age at the start of HD: 0-12y: n=321, >12-18y: n=1459; median spKt/V=1.55, eKt/V=1.31, Kt/BSA=31.2 L/m², UFR=10.6 mL/kg/h). (I) spKt/V<1.4 was associated with lower survival compared to spKt/V>1.4-1.6 (P<0.001, log-rank test), and spKt/V>1.6 (P<0.001), with 10-year survival of 69.3% (59.4-80.9%) versus 83.0% (76.8-89.8%) and 84.0% (79.6-88.5%), respectively. (II) Kt/BSA was a better predictor of survival than spKt/V or eKt/V. UFR was additionally associated with survival (P<0.001), with increased mortality <10/>18 mL/kg/h. Associations did not alter significantly following adjustment for demographic characteristics (age, etiology of kidney disease, and ethnicity).

CONCLUSIONS

Our results suggest usefulness of targeting Kt/BSA>30 L/m² for best long-term outcomes, corresponding to spKt/V>1.4 (>12 years) and >1.6 (<12 years). In contrast to adults, higher UFR of 10-18 ml/kg/h was not associated with greater mortality in this population.

An Integrated Transcriptomic Approach to Identify Molecular Markers of Calcineurin Inhibitor Nephrotoxicity in Pediatric Kidney Transplant Recipients

Calcineurin inhibitors are highly efficacious immunosuppressive agents used in pediatric kidney transplantation. However, calcineurin inhibitor nephrotoxicity (CNIT) has been associated with the development of chronic renal allograft dysfunction and decreased graft survival. This study evaluated 37 formalin-fixed paraffin-embedded biopsies from pediatric kidney transplant recipients using gene expression profiling. Normal allograft samples (n = 12) served as negative controls and were compared to biopsies exhibiting CNIT (n = 11). The remaining samples served as positive controls to validate CNIT marker specificity and were characterized by other common causes of graft failure such as acute rejection (n = 7) and interstitial fibrosis/tubular atrophy (n = 7). MiRNA profiles served as the platform for data integration. Oxidative phosphorylation and mitochondrial dysfunction were the top molecular pathways associated with overexpressed genes in CNIT samples. Decreased ATP synthesis was identified as a significant biological function in CNIT, while key toxicology pathways included NRF2-mediated oxidative stress response and increased permeability transition of mitochondria. An integrative analysis demonstrated a panel of 13 significant miRNAs and their 33 CNIT-specific gene targets involved with mitochondrial activity and function. We also identified a candidate panel of miRNAs/genes, which may serve as future molecular markers for CNIT diagnosis as well as potential therapeutic targets.

Identifying key predictors of mortality in young patients on chronic haemodialysis-a machine learning approach

BACKGROUND

The mortality risk remains significant in paediatric and adult patients on chronic haemodialysis (HD) treatment. We aimed to identify factors associated with mortality in patients who started HD as children and continued HD as adults.

METHODS

The data originated from a cohort of patients <30 years of age who started HD in childhood (≤19 years) on thrice-weekly HD in outpatient DaVita dialysis centres between 2004 and 2016. Patients with at least 5 years of follow-up since the initiation of HD or death within 5 years were included; 105 variables relating to demographics, HD treatment and laboratory measurements were evaluated as predictors of 5-year mortality utilizing a machine learning approach (random forest).

RESULTS

A total of 363 patients were included in the analysis, with 84 patients having started HD at <12 years of age. Low albumin and elevated lactate dehydrogenase (LDH) were the two most important predictors of 5-year mortality. Other predictors included elevated red blood cell distribution width or blood pressure and decreased red blood cell count, haemoglobin, albumin:globulin ratio, ultrafiltration rate, z-score weight for age or single-pool Kt/V (below target). Mortality was predicted with an accuracy of 81%.

CONCLUSIONS

Mortality in paediatric and young adult patients on chronic HD is associated with multifactorial markers of nutrition, inflammation, anaemia and dialysis dose. This highlights the importance of multimodal intervention strategies besides adequate HD treatment as determined by Kt/V alone. The association with elevated LDH was not previously reported and may indicate the relevance of blood-membrane interactions, organ malperfusion or haematologic and metabolic changes during maintenance HD in this population.

Long-term outcome of transplant ureterostomy in children: A National Review

BACKGROUND

CAKUT are the most common cause of end-stage renal failure in children (Pediatr Nephrol. 24, 2009, 1719). Many children with CAKUT have poor urinary drainage which can compromise post-transplant outcome. Identifying safe ways to manage anatomical abnormalities and provide effective urinary drainage is key to transplant success. Much debate exists regarding optimum urinary diversion techniques. The definitive formation of a continent urinary diversion is always preferable but may not always be possible. We explore the role of ureterostomy formation at transplantation in a complex pediatric group.

METHODS

We report six pediatric patients who had ureterostomy formation at the time of transplantation at the National Paediatric Transplant Centre in Dublin, Ireland. We compared renal function and burden of urinary tract infection to a group with alternative urinary diversion procedures and a group with normal bladders over a 5-year period.

RESULTS

There was no demonstrable difference in estimated glomerular filtration rate between the groups at 5-year follow-up. The overall burden of UTI was low and similar in frequency between the three groups.

CONCLUSIONS

Ureterostomy formation is a safe and effective option for temporary urinary diversion in children with complex abdominal anatomy facilitating transplantation; it is, however, important to consider the implications and risk of ureterostomy for definitive surgery after transplantation.

Long-term survival of children following acute peritoneal dialysis in a resource-limited setting

BACKGROUND

There is a paucity of data on long term-outcomes of children who undergo acute peritoneal dialysis (PD) in resource-limited settings. We reviewed the outcomes of children who underwent PD after 18 months of follow-up.

METHODS

We conducted a prospective cohort study in children with acute kidney injury (AKI) who underwent PD. Diagnosis of AKI was based on the 2012 Kidney Disease: Improving Global Outcomes definition. We assessed outcomes of in-hospital mortality, 18-month post-dialysis survival, factors associated with survival, and progression to chronic kidney disease (CKD).

RESULTS

Twenty-nine children with a median age of 6 (3 to 11) years underwent acute PD. In-hospital mortality was 3/29 (10.3%) and rose to 27.6% during follow-up. Seven (24.1%) children were lost to follow-up. Of the 14 remaining children, six (42.9%) experienced full recovery of renal function, while eight (57.1%) progressed to CKD. Among those who experienced full recovery, median (interquartile range) estimated glomerular filtration rate (eGFR) rose from 12.67 (7.05, 22.85) mL/min/1.73 m2 to 95.56 (64.50, 198.00) mL/min/1.73 m2, P = 0.031. No significant changes in median eGFR from baseline were observed among those who progressed to CKD (P = 0.383) or in non-survivors (P = 0.838). According to Kaplan-Meier curve analyses, 18-month survival during follow-up was 66.0% (95% CI, 45.0% to 86.5%). Age < 5 was associated with greater likelihood of survival (OR, 3.217; 95% CI, 1.240 to 8.342).

CONCLUSION

Progression of post-PD AKI to CKD occurred in more than half of survivors. Age < 5 was associated with greater likelihood of survival.

Extraperitoneal pediatric kidney transplantation of adult renal allograft using an en-bloc native liver and kidney mobilization technique

Background

We describe the safety and efficacy of performing pediatric kidney transplantation with a modified extraperitoneal approach that includes mobilization of the native liver and kidney.

Methods

We retrospectively identified pediatric renal transplants performed using this technique between 2015 and 2019. Data on patient demographics, surgical technique, and intraoperative details were collected. Outcomes were measured by morbidity and re-operation at 90 days, as well as serum creatinine, allograft survival, and overall survival at 1 year.

Results

Twenty-one patients with a median age of 5 (IQR 3–9) years, weighing 17.5 (IQR 14.5–24) kg were included. Median donor age was 24 (IQR 19–31) years. No intraoperative complications occurred. One child required a right native nephrectomy to allow sufficient space. Postoperatively, all patients had immediate graft function without urine leak or allograft thrombosis. 90-day morbidity and re-operation rates were zero. Both 1-year allograft and overall survival were 100% (on follow-up of all 21 patients through 1 year post-transplant), with a median serum creatinine of 0.58 (IQR 0.47–0.70) mg/dl at 1 year post-transplant.

Conclusions

Pediatric kidney transplantation of adult renal allografts using an extraperitoneal approach with native liver and kidney mobilization has promising allograft and patient survival outcomes that eliminates peritoneal violation and may diminish the need for native nephrectomy.

Nocturnal home hemodialysis in children: Advantages, implementation, and barriers

Chronic kidney disease and end-stage renal disease (ESRD) in children are major health concerns worldwide with increasing incidence and prevalence. Renal replacement therapies and kidney transplants have remarkably improved the management of patients with ESRD in both adult and pediatric populations. Kidney transplant has the best patient outcomes, but many a time it has a considerable waiting period. In the meantime, the majority of patients with pediatric ESRD are dependent on dialysis. The conventionally utilized hemodialysis regimen is the three times weekly, in-center hemodialysis. Many studies have demonstrated the unfavorable long-term morbidity associated with the conventional regimen. Intensified dialysis programs, which include extended nocturnal hemodialysis or short daily hemodialysis, are being increasingly advocated over the past two decades. In addition to having much better clinical outcomes as compared with the conventional regimen, the flexibility to provide dialysis at home serves as a great incentive. PubMed/Medline, Embase and Cochrane databases for literature on nocturnal home hemodialysis in children with ESRD were extensively searched. Contrary to the noticeable literature available on adult home hemodialysis, a small number of studies exist in the pediatric population. In this review, the benefits, implementation and associated barriers of nocturnal home hemodialysis in children were addressed.

Evaluation of administrative case definitions for chronic kidney disease in children

INTRODUCTION

Administrative data is increasingly used for chronic disease surveillance; however, its validity to define cases of chronic kidney disease (CKD) in children is unknown. We sought to evaluate the performance of case definitions for CKD in children.

METHODS

We utilized population-based administrative data from the Manitoba Center for Health Policy to evaluate the validity of algorithms based on a combination of hospital claims, outpatient physician visits, and pharmaceutical use over 1-3 years in children <18 years of age. Algorithms were compared with a laboratory-based definition (estimated glomerular filtration rate < 90 ml/min/1.73 m² and/or presence of proteinuria).

RESULTS

All algorithms evaluated had very low sensitivity (0.20-0.39) and moderate positive predictive value (0.52-0.68). Algorithms had excellent specificity (0.98-0.99) and negative predictive value (0.96-0.97). Receiver operating characteristic (ROC) curves indicate fair accuracy (0.60-0.68). Sensitivity improved with increasing years of data. One or more physician claims and one or more prescriptions over 3 years had the highest sensitivity and ROC.

CONCLUSIONS

The sensitivity of administrative data algorithms for CKD is unacceptably low for a screening test. Specificity is excellent; therefore, children without CKD are correctly identified. Alternate data sources are required for population-based surveillance of this important chronic disease.

Diagnostic and Management Challenges in Congenital Nephrotic Syndrome

Congenital Nephrotic Syndrome (CNS) is defined as nephrotic range proteinuria, hypoalbuminaemia and edema in the first three months of life. CNS is most commonly genetic in cause, with international variance in the incidence of causative mutations. Initially defined by the histopathological appearance, increasingly sophisticated and accessible genetic analyses now provide a body of evidence to suggest that there is a disparity between the histological appearance, the genotype of individuals and the severity of the clinical disease. Through the evolution of management approaches CNS has changed from being an invariably fatal condition to one with appreciable ongoing morbidity and mortality but comparably good outcomes to other causes of paediatric end-stage renal disease, especially following transplantation. This review briefly summarises the more commonly recognised genetic mutations leading to CNS, addresses common management decisions, and concludes with potential therapies for the future.

Good outcome of the single-center pediatric kidney transplant program in Abu Dhabi

Renal transplantation is the treatment of choice for ESRD in children. It is associated with better quality of life, growth of children, and improved long-term survival. The aim of the study was to evaluate the outcomes of pediatric renal transplantation at a tertiary care center in UAE. A retrospective chart review was undertaken for all the pediatric renal transplants performed at Sheikh Khalifa Medical City, Abu Dhabi, UAE, over the past 9 years. The study evaluated the demographic data, outcomes, and complications of pediatric renal transplantation. The post-transplantation outcomes including surgical complications, documented infections, graft rejection, graft and patient survival, effect on growth, and eGFR were reviewed. Between 2010 and 2018, 30 pediatric patients underwent renal transplantation. The follow-up period ranged from 1 to 9 years with a mean of 3.3 years. The mean age of the patients at the time of transplant was 9.8 years, and 56.7% were males. Prior to the transplantation, the majority of the recipients were on peritoneal dialysis (70.0%). Main source of renal donation at our center was from LRD, chiefly from parents. Patient survival at 1 and 5 years was 100% and 96.7%, respectively. Graft survival at 1 and 5 years was 96.7% and 83.3%, respectively. During the 9-year follow-up period, 5 (16.7%) recipients experienced rejection episode. This study demonstrates that during 5-year period, pediatric kidney transplantation program has achieved optimal patient (96.7%) and graft (83.3%) survival rates and is comparable to well-established centers.

Concentrations of representative uraemic toxins in a healthy versus non-dialysis chronic kidney disease paediatric population

Background

Chronic kidney disease (CKD) in childhood is poorly explained by routine markers (e.g. urea and creatinine) and is better depicted in adults by other uraemic toxins. This study describes concentrations of representative uraemic toxins in non-dialysis CKD versus healthy children.

Methods

In 50 healthy children and 57 children with CKD Stages 1-5 [median estimated glomerular filtration rate 48 (25th-75th percentile 24-71) mL/min/1.73 m2; none on dialysis], serum concentrations of small solutes [symmetric and asymmetric dimethyl-arginine (SDMA and ADMA, respectively)], middle molecules [β2-microglobuline (β2M), complement factor D (CfD)] and protein-bound solutes [p-cresylglucuronide (pCG), hippuric acid (HA), indole-acetic acid (IAA), indoxyl sulphate (IxS), p-cresyl sulphate (pCS) and 3-carboxy-4-methyl-5-propyl-furanpropionic acid (CMPF)] were measured. Concentrations in the CKD group were expressed as z-score relative to controls and matched for age and gender.

Results

SDMA, CfD, β2M, IxS, pCS, IAA, CMPF and HA concentrations were higher in the overall CKD group compared with controls, ranging from 1.7 standard deviations (SD) for IAA and HA to 11.1 SD for SDMA. SDMA, CfD, β2M, IxS and CMPF in CKD Stages 1-2 with concentrations 4.8, 2.8, 4.5, 1.9 and 1.6 SD higher, respectively. In contrast, pCS, pCG and IAA concentrations were only higher than controls from CKD Stages 3-4 onwards, but only in CKD Stage 5 for ADMA and HA (z-score 2.6 and 20.2, respectively).

Conclusions

This is the first study to establish reference values for a wide range of uraemic toxins in non-dialysis CKD and healthy children. We observed an accumulation of multiple uraemic toxins, each with a particular retention profile according to the different CKD stages.

Management of Denys-Drash syndrome: A case series based on an international survey

Denys-Drash syndrome (DDS), a condition caused by mutations in the tumor-suppressor gene WT-1, is associated with a triad of disorders: ambiguous genitalia, nephrotic syndrome leading to end-stage renal disease (ESRD), and Wilms’ tumor. Given the variable disease course, management is challenging. We aimed to describe the evolution of DDS and the range of management strategies by summarizing the clinical courses of cases collected from a questionnaire sent to the international pediatric nephrology community. 15 respondents provided information on 23 patients; 21 DDS cases were confirmed and analyzed. At DDS diagnosis, 6 patients had a Wilms’ tumor (group A) and 15 had no Wilms’ tumor (group B). Three group A patients had unilateral nephrectomy. Two of these still had renal function, with no second tumor, at 36 months and 16 years of age, and 1 progressed to ESRD. Three had bilateral nephrectomy before ESRD. Eight group B patients progressed to ESRD, all of whom later had all renal tissue removed. Two group B patients subsequently developed a unilateral Wilms’ tumor and had bilateral nephrectomy pre-ESRD. Three had bilateral nephrectomy prior to reaching ESRD without ever having a Wilms’ tumor. Two group B patients remained tumor-free with renal function at last follow-up. Two main management approaches were taken: pre-emptive nephrectomy prior to ESRD and conservative surveillance. Based on the known risks associated with ESRD in infants and young children, the variable course of DDS, and the relatively good prognosis associated with Wilms’ tumor, a guiding principle of preservation of renal function is most logical. Most would advocate bilateral prophylactic nephrectomy after ESRD is reached due to the high tumor risk, which is likely heightened after transplant.

Mortality Risks among Various Primary Renal Diseases in Children and Adolescents on Chronic Dialysis

There is little information available on the association between primary renal disease (PRD) and long-term mortality in the pediatric dialysis population. The objective of this study was to explore mortality risks in children and adolescents on chronic dialysis, specifically focused on the risk of various PRDs. The study cohort included children and adolescents with end-stage renal disease (ESRD) (aged < 20 years) who had received dialysis for at least 90 days between 2000 and 2014 and were identified from Taiwan's National Health Insurance medical claims. A total of 530 children and adolescents were included in the study. The median age of the included patients was 13.6 years and 305 (57.5%) patients were males. One hundred and seven patients died during the follow-up period and the median survival time was 6.0 years. Mortality was highest in the youngest patients. For patients with the following PRDs, mortality was significantly higher than that in patients with primary glomerulonephritis: secondary glomerulonephritis (adjusted hazard ratio (aHR): 2.50; 95% confidence interval (CI): 1.03⁻6.08), urologic disorder (aHR: 4.77; 95% CI: 1.69⁻13.46), and metabolic diseases (aHR: 5.57; 95% CI: 1.84⁻16.85). Several kinds of PRDs appear to have high mortality risks in the pediatric dialysis population. These differences in mortality risk highlight the importance of the focused clinical management of these high-risk subgroups.

Impact of the kidney allocation system on young pediatric recipients

The kidney allocation system (KAS) altered pediatric candidate prioritization. We determined KAS's impact on pediatric kidney recipients by examining delayed graft function (DGF) rates from 2010 to 2016. A propensity score-matched pediatric recipients pre- and post-KAS. A semiparametric decomposition analysis estimated the contributions of KAS-related changes in donor characteristics and dialysis time on DGF rate. The unadjusted odds of DGF were 69% higher post-KAS for young (<10 years at listing) recipients (N = 1153, P = .02) but were not significantly increased for older pediatric (10-17 years at listing) recipients (N = 2624, P = .48). Post-KAS, young recipients received significantly fewer pediatric (<18 years) donor kidneys (21% vs 32%, P < .01) and had longer median pretransplant dialysis time (603 vs 435 days, P < .01). After propensity score matching, post-KAS status increased the odds of DGF in young recipients 71% (OR 1.71, 95% CI 1.01-2.46). In decomposition analysis, 24% of the higher DGF rate post-KAS was attributable to donor characteristics and 19% to increased recipient dialysis time. In a confirmatory survival analysis, DGF was associated with a 2.2 times higher risk of graft failure (aHR2.28, 95% CI 1.46-3.54). In conclusion, KAS may lead to worse graft survival outcomes in children. Allocation changes should be considered.

Accumulation of uraemic toxins is reflected only partially by estimated GFR in paediatric patients with chronic kidney disease

BACKGROUND

Chronic kidney disease (CKD) in childhood is characterised by the accumulation of uraemic toxins resulting in a multisystem disorder that has a negative impact on quality of life. Childhood CKD is predominantly defined by a decrease in glomerular filtration rate, estimated (eGFR) by a single serum measurement of endogenous biomarkers, e.g. creatinine. The objective of this study was to evaluate how accurately eGFR predicts the concentration of uraemic toxins in a paediatric CKD cohort.

METHODS

In 65 children (10.8 [5.1; 14.7] years) with CKD (eGFR 44 [20; 64] mL/min/1.73 m²), serum concentrations were determined of small solutes (uric acid [UA], urea, symmetric dimethylarginine [SDMA], asymmetric dimethylarginine [ADMA]), middle molecules (β2-microglobulin [β2M], complement factor D [CfD]) and protein-bound solutes (p-cresylglucuronide [pCG], hippuric acid, indole acetic acid, indoxyl sulphate [IxS], p-cresylsulfate [pCS] and 3-carboxy-4-methyl-5-propyl-furanpropionic acid [CMPF]). Spearman's correlation coefficients (r) were calculated to correlate uraemic toxin concentrations with three different eGFR equations, based on either serum creatinine or β2M.

RESULTS

Updated Schwartz eGFR was correlated reasonably well with concentrations of creatinine (r = -0.98), urea (r_s = -0.84), SDMA (r = -0.82) and middle molecules CfD and β2M (both r_s = -0.90). In contrast, poor correlation coefficients were found for CMPF (r_s = -0.32), UA (r_s = -0.45), ADMA (r_s = -0.47) and pCG (r_s = -0.48). The other toxins, all protein-bound, had r_s between -0.75 and -0.57. Comparable correlations were found between the three evaluated eGFR equations and uraemic toxin concentrations.

CONCLUSIONS

This study demonstrates that eGFR poorly predicts concentrations of protein-bound uraemic toxins, UA and ADMA in childhood CKD. Therefore, eGFR only partially reflects the complexity of the accumulation pattern of uraemic toxins in childhood CKD.

A propensity-matched comparison of hard outcomes in children on chronic dialysis

Data concerning outcomes of children on hemodialysis (HD) and peritoneal dialysis (PD) are scarce and frequently derived from single-center experiences. We sought to compare survival and transplantation rates in a large cohort of PD and HD patients. We extracted all patients initiating dialysis under 16 years of age between 2004 and 2013 from the Italian Registry of Pediatric Chronic Dialysis. Patients on PD were propensity-matched to those on HD based on gender, age, primary cause of ESRD, and the number of co-morbidities. Stratified Cox proportional hazard models were used to compare outcomes by dialysis modality. Three hundred ten patients were matched from 452 incident patients. In the unmatched cohort, PD patients were younger, more likely to be diagnosed with CAKUT, and had a higher urine output than HD patients. In the propensity-matched cohort, covariates were balanced between the two groups. At 2 years, the cumulative hazard ratio for death was similar (CHR 0.95, 95% CI 0.17-5.20) for HD relative to PD patients; and at 5 years, the CHR was lower for HD patients (0.22 95% CI 0.16-0.29). The cumulative incidence of transplantation at 3 years after dialysis initiation was 60.9% in HD patients and 59.7% in PD patients, with a CHR of 1.03 (95% CI 0.73-1.45).

CONCLUSIONS

Pediatric PD and HD patients have distinct characteristics. After controlling for treatment-selection biases, children selected to start on PD or HD exhibit a similar mortality risk during the first 2 years on treatment, after which this risk increases in PD children. What is Known: • Few studies have compared hard outcomes in children on maintenance dialysis. • Children started on different dialysis modalities have distinct characteristics that impact on survival. What is New: • After controlling for treatment-selection biases, children selected to start dialysis on PD or HD exhibit a similar mortality risk during the first 2 years on treatment, after which this risk appears to be increased in PD children. • An "integrative care" approach should be used in children on PD, switching them to HD when PD-related morbidity tends to increase.

Dietary Intake, Nutritional Status, and Body Composition in Children With End-Stage Kidney Disease on Hemodialysis or Peritoneal Dialysis

OBJECTIVE(S)

This study aimed to demonstrate that dietary intake, anthropometric indicators, and body composition in children with end-stage kidney disease differs between those on peritoneal dialysis (PD) and those on hemodialysis (HD).

METHODS

This was a cross-sectional and consecutive study that included 55 children and adolescents with end-stage kidney disease who were undergoing replacement therapy (22 PD patients and 33 HD patients). Two 24-hour dietary recall surveys were conducted for each patient. Anthropometric, biochemical, and body composition indicators were estimated. A Student's t-test and a Mann-Whitney U test were used for the parametric variables, whereas association tests were estimated for the nonparametric variables (i.e., χ², Fisher exact test, and odds ratio). Regression models were designed to predict dietary intake on anthropometric and body composition indicators.

RESULTS

The mid-upper arm circumference was greater on the patients undergoing HD than on the PD patients (odds ratio = 15.8 [95% confidence interval (CI): 2.9, 85.1], P < .001); the arm muscular area was greater in the HD patients than in the PD patients (P = .07). Children on PD had significantly greater creatinine concentration (8.4 ± 3.0 mg/dL vs. 4.6 ± 1.2 mg/dL, P < .001), urea (101 ± 27 mg/dL vs. 50 ± 17 mg/dL, P < .001), and glucose (87 ± 14.4 mg/dL vs. 77 ± 10.2 mg/dL, P = .003). Children on PD had lower lipid intake (31.2 ± 15.8 vs. 40.9 ± 19.1 g/day, P = .032), lower percentage of adequacy of vitamin C (128 ± 66 vs. 146 ± 70, P = .046), and lower sodium (62 ± 43 vs. 79 ± 42, P = .044) than children on HD. Dietary intake predicted 40% to 80% of the variability in the nutritional status in children on PD and 28% to 60% in children on HD.

CONCLUSIONS

Nutritional status is affected in most patients on dialysis treatment, which differs significantly among those who are undergoing PD or HD.

Prolonged respiratory disorder predicts adverse prognosis in infants with end-stage kidney disease

BACKGROUND

Among comorbidities, pulmonary hypoplasia (PH) is known as a significant risk factor for mortality in infants with end-stage kidney disease (ESKD). However, the final outcomes of infants with both ESKD and PH are still not well defined, as the diagnosis modality, and definition of PH severity remain ambiguous.

METHODS

Children initiating peritoneal dialysis during infancy from 1990 to 2015 were followed until death, date of last contact, or the end of 2015. We examined the long-term outcome of children with congenital pulmonary disorders by studying infants with prolonged respiratory disorders of greater than 28 days duration after birth and evaluated risk factors for mortality.

RESULTS

Forty-six children were followed (median follow-up, 9.23 years), and classified as children without (n = 38; Group A) or with (n = 8; Group B) a prolonged respiratory disorder. Overall actuarial 5 year survival rate in this cohort was 79.5 %. The survival curve in Group B showed a significant decline compared with Group A. Prolonged respiratory disorder was significantly associated with mortality by multivariate analysis (hazard ratio, 8.32).

CONCLUSIONS

Infants who initiate peritoneal dialysis complicated by prolonged respiratory disorders have increased adverse risk factors for mortality; therefore, withholding aggressive treatment should be considered.

Timing of first arteriovenous fistula cannulation in children on hemodialysis

BACKGROUND

Due to lower complication rates in comparison to central venous catheter (CVC) arteriovenous fistulas (AVFs) are now the preferred hemodialysis access. Recommendations for the first access cannulation range from 6 to 12 weeks, which could lead to temporary or even permanent preference for CVC while awaiting the maturation of the newly created AVF. The aim of this study was to evaluate the influence of first cannulation of AVFs on primary (PP) and secondary (SP) patency rates in children on hemodialysis (HD).

METHODS

This was a retrospective cohort study of 42 pediatric patients with a median age of 14 (range 7-17) years. At the time of surgical AVF creation 21 patients (end-stage renal disease) were still on HD via CVC or peritoneal catheter, while 21 were pre-emptive with initiation of HD expected within a few weeks. All patients received an AVF by the same experienced surgeon between February 1993 and May 2014. Primary failure (PF) was defined as the inability to use the AVF even once due to absent maturation or occlusion within 4 weeks after creation. PP was defined as the interval from time of access placement to any intervention designed to maintain or reestablish patency, to access thrombosis or the time of measurement of patency, while SP was defined as the total lifespan from creation to access abandonment, end of follow-up or loss.

RESULTS

Primary failure was observed in six (14.3 %) of 42 AVFs (all radiocephalic fistulas) within the first 10 days after cannulation. Excluding PF, the PP/SP rates at 1, 3, 6, 12, 18 and 24 months were 100/100, 91/99, 86/98, 76/95, 55/85 and 44/77 %, respectively. There was a significant decrease in PP when first cannulation was performed within the first 30 days after creation compared to first cannulation performed after 30 days (p = 0.004). In terms of PP/SP outcome and timing of the first cannulation, there was no significant difference in thee outcome of PP/SP between first cannulation within the first 45 days after creation and that after 45 days (p = 0.091/0.883).

CONCLUSIONS

The findings suggest that cannulation of AVF within 30 days after surgical creation reduces PP, while SP may be influenced less by time until cannulation. We also found no significant differences in PP after maturing periods of >45 days.

Arginine dimethylation products in pediatric patients with chronic kidney disease

Background

arginine and its metabolites have been linked to pediatric chronic kidney disease (CKD). We aimed to estimate serum levels of argninine (Arg), asymmetric dimethylarginine (ADMA) and symmetric dimethylarginine (SDMA) in pediatric CKD patients and its relation to altered kidney function.

Patients and methods

132 pediatric patients with CKD and 120 healthy age and sex matched controls were compared regarding; serum Arg, ADMA and SDMA levels.

Results

In comparison to their values in control subjects, serum Arg levels were significantly lower; serum ADMA levels were non-significantly higher, but serum SDMA levels were significantly higher in CKD patients (p values: < 0.000; = 0.054; <0.000, respectively).

Calculated Arg/ADMA and Arg/SDMA ratios were significantly higher in patients compared to controls (p values: 0.001, and <0.000, respectively). However ADMA/SDMA ratio was significantly lower in patients compared to controls (p = 0.001. Serum Arg levels showed positive significant correlation, while serum ADMA and SDMA levels showed negative significant correlation with eGFR. Moreover, Arg/ADMA ratio showed negative significant correlation, while ADMA/SDMA ratio showed positive significant correlation with eGFR of patients. Regression analysis defined high serum SDMA level as persistently significant predictor for low eGFR.

Conclusion

Disturbed serum levels of arginine and its dimethyl derivatives may underlie development and/or progression of CKD. Elevated serum SDMA level is strongly correlated with impaired kidney functions and could be considered as a predictor for kidney functions deterioration and CKD progression.

•

The underlying pathogenic mechanisms for pediatric CKD are multiple and interlocking.

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Disturbed serum levels of Arg and its dimethyl derivatives may underlie development and/or progression of CKD.

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Elevated serum SDMA level is strongly correlated with impaired kidney functions.

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Elevated SDMA level can be a predictor for kidney functions deterioration and CKD progression.

Long-term hemodialysis therapy in neonates and infants with end-stage renal disease: a 16-year experience and outcome

BACKGROUND

Peritoneal dialysis is the preferred mode of renal replacement therapy in infants with end-stage renal disease (ESRD). Hemodialysis (HD) is seldom used in neonates and infants due to the risk of major complications in the very young.

METHODS

Demographic, clinical, laboratory, and imaging data on all infants younger than 12 months with ESRD who received HD in our Pediatric Dialysis Unit between January 1997 and June 2013 were analyzed.

RESULTS

Eighteen infants (n = 6 male) with ESRD (median age 3 months; median weight 4.06 kg) received HD through a central venous catheter (CVC) for a total of 543 months (median duration per infant 16 months). Seven of the infants (39%) were neonates, and five (28%) had serious comorbidities. There were five episodes of CVC infection, which is a rate of 0.3/1000 CVC days. Median catheter survival time was 320 days. Most infants had good oral intake, and only four (22%) required a gastric tube; 14 (78%) infants displayed normal growth. Fourteen (78%) infants had hypertension, of whom four (22%) had severe cardiac complications; eight (44%) showed delayed psychomotor development. Eleven (61%) of the infants, including six (86%) of the neonates, survived. Five (28%) infants underwent renal transplantation; 10-year graft survival was 80%.

CONCLUSIONS

Based on these results, long-term HD in neonates and infants with ESRD is technically feasible, can be implemented without major complications, carries a very low rate of CVC infection and malfunction, and results in adequate nutrition, good growth, as well as good kidney graft and patient survivals. Future efforts should aim to prevent hypertension and its cardiac sequelae, improve neurodevelopmental outcome, and lower mortality rate in these infants.

Obsessive Compulsive Inventory-Child Version (OCV-CI) to Evaluate Obsessive Compulsive Disorder in Children With Early Stages of Chronic Kidney Disease: A Case Control Study

Background:

Chronic kidney disease (CKD) is a common medical condition among children and obsessive-compulsive disorder (OCD) is a frequent, chronic, costly, and disabling disorder among them.

Objectives:

The aim of this study was to investigate obsessive-compulsive disorder (OCD) in children with early stages of CKD, and to compare it with the occurrence of OCD in healthy children.

Patients and Methods:

In this case-control study, we evaluated 160 children aged 7 to 17 years old who were visited in the pediatric clinics of Amir-Kabir hospital, Arak, Iran. The control group consisted of 80 healthy children and the case group included 80 children with Stage 1 to 3 CKD. The ages and sex of the children in the two groups were matched. OCD in children was evaluated using the obsessive compulsive inventory-child version (OCI-CV).

Results:

The mean scores of doubting/checking (case: 3.52 ± 2.54, control: 2.5 ± 2.32, P = 0.007) and ordering (case: 2.59 ± 1.81, control: 1.5 ± 2.56, P = 0.005) in the children with CKD was significantly higher than in the healthy ones. Moreover, the mean total scores for the OCI-CV of the children with CKD at 15.32 ± 7.69 was significantly higher than the scores of the healthy ones at 11.12 ± 2.54 (P = 0.021). There was a significant correlation between the CKD duration and doubting/checking (P = 0.004, correlation coefficient (CC): 0.4), obsessing (P = 0.06, CC: 0.02), washing (P = 0.031, CC: 0.8), ordering (P = 0.001, CC: 0.2), and the total scores of the OCI-CV questionnaire (P = 0.04, CC: 0.4).

Conclusions:

The risk of OCD in children with CKD is significantly higher than that in healthy children. Although the results seem to suggest that psychiatric intervention can be helpful in treating OCD in children with CKD, further investigation into the medical condition is required so as to obtain more definitive conclusions.

Do children with end-stage renal disease live shorter? Analysis of mortality on the basis of data from the Polish Registry of Renal Replacement Therapy in Children

PURPOSE

The mortality of patients with end-stage renal disease (ESRD) is much higher than that of the general population. To date no data has been published on the mortality of children with ESRD in Poland. The aim of this study was to compare the risk of death for pediatric patients on renal replacement therapy (RRT) with that of the general pediatric population and to identify the risk factors of death.

MATERIAL/METHODS

Data of 779 children with ESRD registered in the Polish Registry of Children on RRT was analyzed. The relative risk of death was calculated as the ratio of the mortality rate in ESRD patients to the mortality rate in age-adjusted general population.

RESULTS

The mortality rate of children with ESRD was 74-fold higher than that of the age- and gender-adjusted general pediatric population (4.05 vs. 0.05/100 person-years). The highest mortality rate (4.53/100 patient-years) was found in the youngest age group. Younger age and duration of dialysis therapy were identified as mortality risk factors. The major causes of death in ESRD patients were infections and cardiovascular complications, whereas deaths in general child population were mainly due to accidents or congenital defects.

CONCLUSIONS

The mortality in Polish children with ESRD is 74-fold higher than that of the general pediatric population. Infections, followed by cardiovascular complications, constitute the main causes of mortality in children subjected to RRT. The risk of death is the highest among children who started RRT at a younger age and in those subjected to long-term dialysis treatment.

Attention deficit hyperactivity disorder in children with early stages of chronic kidney disease

BACKGROUND

Attention Deficit Hyperactivity Disorder (ADHD) is the most common childhood neurological disorder. This disorder is more prevalent in some chronic diseases. The aim of this study was to investigate ADHD in children with early stages of chronic kidney disease (CKD) and to compare it with healthy children.

METHODS

Seventy five 5-16-year-old children with early stages of CKD (stage 1, 2 and 3) and 75 healthy children without CKD were included in this case - control study as case and control groups, respectively. The participants were selected from those children who were referred to the pediatric clinic of Amir Kabir Hospital of Arak (Iran) in the form of simple probability and based on inclusion and exclusion criteria. ADHD was diagnosed using Conner's Parent Rating Scale - 48 (CPRS-48) and DSM-IV criteria and was confirmed by a psychologist consultant. Data were analyzed by Binomial test in SPSS18.

RESULTS

ADHD inattentive type was observed in 8 cases (10.6%) with CKD and 2 controls (2.6%) (p= 0.109). Moreover, in the case and control groups, 7 (9.3%) and 6 (8%) children were affected by ADHD hyperactiveimpulsive type (p= 0.997), and 9 (12%) and 12 (16%) children were affected by ADHD mixed type (p= 0.664), respectively.

CONCLUSION

No differences were found between the prevalence of ADHD in the children with early stages of CKD and the control group. However, due to the importance of the relationships between different types of psychiatric disorders and CKD and lack of enough evidence concerning the relationship between ADHD and different stages of CKD in children, conducting further studies in this field is recommended.

Maintenance dialysis in developing countries

Patients with end-stage renal disease require renal replacement therapy with maintenance hemodialysis or chronic peritoneal dialysis while awaiting transplantation. In addition to economic issues and limited state funding for advanced health care, the lack of trained medical personnel contributes to scarce dialysis facilities for children in developing countries. The establishment and operation of a hemodialysis unit with multidisciplinary facilities is both cost- and labor-intensive. Hemodialysis is usually carried out three times a week in a hospital setting and affects the curricular and extracurricular activities of the patient. Chronic ambulatory or cyclic peritoneal dialysis is technically simpler and allows better nutrition and growth, but is expensive for the majority of patients who must pay out of their own pocket. Multiple initiatives to enhance the training of pediatricians and nurses in skills related to initiating and managing patients on maintenance dialysis have resulted in the improved survival of children with end-stage renal disease. Support from state governments and philanthropic institutions have helped in establishing pediatric nephrology units that are equipped to provide renal replacement therapy for children.

Experience with continuous venovenous hemodiafiltration in four newborns: A case series and review of the literature

When conventional methods for treating complicated problems such as acute and chronic renal failure or metabolic diseases fail, the therapy of choice is peritoneal dialysis (PD) in neonatal period. However, in cases that involve technical difficulties, such as bulky lesions in the abdomen or complications from previous abdominal surgeries, it is not always possible to place a peritoneal catheter. In such situations, continuous venovenous hemodiafiltration (CVVHDF) can be effective. This case series presents our experience in 2013 with the administration of CVVHDF to four patients in our neonatal intensive care unit who could not undergo PD for various reasons.

Children and adolescents on hemodialysis: attributes associated with quality of life


The aim of this study was to estimate the prevalence and factors associated with the occurrence of incidents related to medication, registered in the medical records of patients admitted to a Surgical Clinic, in 2010. This is a cross-sectional study, conducted at a university hospital, with a sample of 735 hospitalizations. Was performed the categorization of types of incidents, multivariate analysis of regression logistic and calculated the prevalence. The prevalence of drug-related incidents was estimated at 48.0% and were identified, as factors related to the occurrence of these incidents: length of hospitalization more than four days, prescribed three or more medications per day and realization of surgery intervention. It is expected to have contributed for the professionals and area managers can identify risky situations and rethink their actions.


Implementation of clinical pharmacy services in a pediatric dialysis unit

BACKGROUND

End-stage renal disease patients on hemodialysis are on complex drug regimens consisting of multiple medications, many of which are administered in several doses per day. Consequently, such patients are at high risk for developing drug therapy-related problems (DTRPs). The aim of this study was to detect DTRPs in children undergoing hemodialysis and to assess and evaluate the impact of interventions by the clinical pharmacist on the clinical outcome of children undergoing hemodialysis.

METHODS

Fifty hemodialysis outpatients were randomly divided into two groups (25 each): the control group and the test group. During the 9-month study period, patients in the control group received the usual medical care, and those in the test group received pharmaceutical care 3 times weekly in addition to the usual medical care.

RESULTS

After 9 months of pharmaceutical care implementation, the test group showed a significant decline in systolic and diastolic blood pressure (p = 0.0001), serum phosphorus level (p = 0.006) and parathyroid hormone level (p = 0.001) versus their baseline values and versus the control. The serum Ca*P product level of the test group decreased (p = 0.001) after intervention versus baseline. Serum calcium level significantly increased in test group (p = 0.02) and decreased in the control group (p = 0.001) versus the respective baseline values. Satisfaction with the renal treatment significantly improved in the test group (p = 0.0001) versus the control group after 9 months of pharmaceutical care implementation based on Renal Treatment Satisfaction Questionnaire scores.

CONCLUSIONS

Pharmacist-initiated pharmaceutical care improved the satisfaction and biochemical findings of patients on hemodialysis.

Parent-child and spousal relationships in families with a young child with end-stage renal disease

BACKGROUND

End-stage renal disease (ESRD) leads to the need for dialysis and renal transplantation (Tx). Peritoneal dialysis (PD) of young children is normally performed at home by the parents and affects the whole family. We studied the coping of families with a young child with ESRD by interviewing the parents of 19 children.

METHODS

The spousal and parent-child relationships were assessed by using the Psychosocial Assessment of Childhood Experiences (PACE) and the Brief Measure of Expressed Emotion, respectively. A control group of 22 families with a healthy child was used for the parent-child relationship evaluation.

RESULTS

The spousal relationship at the start of PD was good or fairly good in most of the families and remained good in half of the families following renal Tx. Lack of support from close relatives and renal Tx were associated with a poorer relationship quality. Almost all parents expressed much or fairly much emotional warmth towards the child throughout the study, but there was a trend towards increased criticism over time. No differences in the degree of expressed warmth or criticism were noted between the index parents and controls.

CONCLUSIONS

Overall, the study families appeared to cope well despite the serious illness of their child and the demands of the treatments.

Haemodialysing babies weighing <8 kg with the Newcastle infant dialysis and ultrafiltration system (Nidus): comparison with peritoneal and conventional haemodialysis

BACKGROUND

To compare the efficacy of the Newcastle infant dialysis and ultrafiltration system (Nidus) with peritoneal dialysis (PD) and conventional haemodialysis (HD) in infants weighing <8 kg.

METHODS

We compared the urea, creatinine and phosphate clearances, the ultrafiltration precision, and the safety of the Nidus machine with PD in 7 piglets weighing 1-8 kg, in a planned randomised cross-over trial in babies, and in babies for whom no other therapy existed, some of whom later graduated to conventional HD.

RESULTS

Two babies entered the randomised trial; 1 recovered rapidly on PD, the other remained on the Nidus as PD failed. Additionally, 9 babies were treated on the Nidus on humanitarian grounds: 3 because of failed PD, and 3 with permanent kidney failure later converted to conventional HD. We haemodialysed 10 babies weighing between 1.8 and 5.9 kg for 2,475 h during 354 Nidus sessions without any clinically important incidents, and without detectable haemolysis. Single-lumen vascular access was used with no blood priming of circuits. The urea, creatinine and phosphate clearances using the Nidus were around 1.5 to 2.0 ml/min in piglets and babies, and were consistently higher than PD clearances, which ranged from about 0.2 to 0.8 ml/min (p ≤ 0.0002 for each chemical). Ultrafiltration was achieved to microlitre precision by the Nidus, but varied widely with PD. Fluid removal using conventional HD was imprecise and resulted in some hypovolaemic episodes requiring correction.

CONCLUSION

The Nidus can provide HD in the Pediatric Intensive Care Unit (PICU) and outpatient intermittent HD without blood priming for babies weighing <8 kg, It generates higher dialysis clearances than PD, and delivers more precise ultrafiltration control than either PD or conventional HD.

Clinical practice recommendations for the care of infants with stage 5 chronic kidney disease (CKD5)

BACKGROUND

To provide recommendations for the care of infants with stage 5 chronic kidney disease (CKD5).

SETTING

European Paediatric Dialysis Working Group.

DATA SOURCES

Literature on clinical studies involving infants with CKD5 (end stage renal failure) and consensus discussions within the group.

RECOMMENDATIONS

There has been an important change in attitudes towards offering RRT (renal replacement therapy) to both newborns and infants as data have accumulated on their improved survival and long-term outcomes. The management of this challenging group of patients differs in a number of ways from that of older children. The authors have summarised the basic recommendations for treating infants with CKD5 in order to support the multidisciplinary teams who endeavour on this difficult task.

Pediatric renal transplantation: results and prognostic factors

BACKGROUND/OBJECTIVE

As renal transplantation may increase survival rates and improve quality of life for children with end-stage renal disease, we investigated the long-term outcomes and prognostic factors of pediatric renal transplantation.

METHODS

A retrospective study was conducted to review 25 pediatric renal transplantations, either from live or deceased donors, in our hospital from 1995 to 2008. The cumulative graft survival rate was calculated using the Kaplan-Meier method. Log rank tests were employed to identify categorical prognostic factors for graft survival of the pediatric renal transplantations, and Cox regression analysis for numeric factors.

RESULTS

The mean age of our study subjects was 11.63±3.76 years, and the mean follow-up period was 49.24±33.72 months. The 12-month and 36-month graft survival rates were 92% and 82.14%, respectively. The rejection-free survival rates were 88% and 72.88% in the first and third years, respectively. All of the patients were alive during the follow-up period. Acute rejection (p=0.0175) and male sex (p=0.0384) were found to be significant factors for graft survival.

CONCLUSION

For pediatric patients, we found that renal transplantation is now a safe and effective surgical procedure for children with end-stage renal disease. Acute rejection and male gender were identified as prognostic factors for poor graft survival.

Management and outcome of children with end-stage renal disease in northwest Iran

Outcome of end-stage renal disease (ESRD) in children has considerably improved since the development of dialysis and kidney transplantation. This study was conducted to evaluate the management and outcome of ESRD children in a referral pediatric center in northwest Iran. A cross-sectional study of medical records of ESRD children (glomerular filtration rate less than 15 ml/min/1.73 m(2)) younger than 16 years who were admitted in Children's Hospital of Tabriz between October 1999 and October 2009 was performed. Ninety-four children with ESRD including 51 boys (54.3%) and 43 girls (45.7%) with a mean age of 7.9 ± 3.49 years were studied. Parents of nine patients (7.8%) refused treatment. Eighty patients underwent renal replacement therapy (RRT) and were followed for a mean period of 4.86 ± 2.77 years. Initial modality of RRT was hemodialysis in 81.25%, continuous ambulatory peritoneal dialysis in 16.25%, and preemptive kidney transplantation in 2.5%. Thirty-two patients (34%) underwent renal transplantation. The mean duration of staying on dialysis before transplantation was 12.4 ± 11 months. Twenty-nine of kidney donors (90.6%) were living unrelated donors. The 1-and 3-year graft survival rates were 81.2% and 68.8% and the 1- and 3-year patient survival rates were 96.9% and 93.8%, respectively. Thirty-one patients died (33%). The mortality of girls was significantly higher than boys (P=0.04). There was a significant negative correlation between age and mortality (P=0.01). Heart failure and infections were the most common cause of death. This study showed that ESRD children in our area have a poor outcome in comparison with developed countries.

Survival and transplantation outcomes of children less than 2 years of age with end-stage renal disease

BACKGROUND

Young children with end-stage renal disease (ESRD) requiring renal replacement therapy (RRT) have traditionally experienced high rates of morbidity and mortality; however, detailed long-term follow-up data is limited.

METHODS

Using a population-based retrospective cohort with data from a national organ failure registry and administrative data from Canada's universal health care system, we analysed the outcomes of 87 children starting RRT (before age 2 years) and followed them until death or date of last contact [median follow-up 4.7 years, interquartile range (IQR) 1.4-9.8). We assessed secular trends in survival and the influence of: (1) age at start of RRT and (2) etiology of ESRD with survival and time to transplantation.

RESULTS

Patients were mostly male (69.0 %) with ESRD predominantly due to renal malformations (54.0 %). Peritoneal dialysis was the most common initial RRT (83.9 %). Fifty-seven (65.5 %) children received a renal transplant (median age at first transplant: 2.7 years, IQR 2.0-3.3). During 490 patient-years of follow-up, there were 23 (26.4 %) deaths, of which 22 occurred in patients who had not received a transplant. Mortality was greater for patients commencing dialysis between 1992 and 1999 and among the youngest children starting RRT (0-3 months). Children with ESRD secondary to renal malformations had better survival than those with ESRD due to other causes. Among the transplanted patients, all but one survived to the end of the observation period.

CONCLUSION

Children who start RRT before 3 months of age have a high risk of mortality. Among our paediatric patient cohort, mortality rates were much lower among children who had received a renal transplant.