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Nada T, Kamei K, Sato M, Nishi K, Ogura M, Ito S. Risk factors for early dialysate leakage around the exit site after catheter placement in pediatric peritoneal dialysis: a single-center experience. Clin Exp Nephrol 2023; 27:791-799. [PMID: 37289336 DOI: 10.1007/s10157-023-02365-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 05/27/2023] [Indexed: 06/09/2023]
Abstract
BACKGROUND Dialysate leakage, a major complication in peritoneal dialysis (PD), causes difficulty in continuing PD. However, literature evaluating risk factors for leakage in detail and the appropriate break-in period to avoid leakage in pediatric patients is scarce. METHODS We conducted a retrospective study on children aged < 20 years who underwent Tenckhoff catheter placement between April 1, 2002, and December 31, 2021, at our institution. We compared clinical factors between patients with and without leakage within 30 days of catheter insertion. RESULTS Dialysate leakage occurred in 8 of 102 (7.8%) PD catheters placed in 78 patients. All leaks occurred in children with a break-in period of < 14 days. Leaks were significantly more frequent in patients with low body weight at the catheter insertion, single-cuffed catheter insertion, a break-in period ≤ 7 days, and a long PD treatment time per day. Only one patient who had leakage with a break-in period > 7 days was neonate. PD was suspended in four of the eight patients with leakage and continued in the others. Two of the latter had secondary peritonitis, one of whom required catheter removal, and leakage improved in the remaining patients. Three infants had serious complications from bridge hemodialysis. CONCLUSIONS A break-in period of > 7 days and if possible 14 days is recommended to avoid leakage in pediatric patients. Whereas infants with low body weight are at high risk of leakage, their difficulty in inserting double-cuffed catheter, hemodialysis complications, and possible leakage even under long break-in period make prevention of leakage challenging.
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Affiliation(s)
- Taishi Nada
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan
- Department of Pediatrics, Yokohama City University Medical Center, 4-57 Urafune-Cho, Minami-ku, Yokohama, Kanagawa, 232-0024, Japan
| | - Koichi Kamei
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan.
| | - Mai Sato
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan
| | - Kentaro Nishi
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan
| | - Masao Ogura
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan
| | - Shuichi Ito
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan
- Department of Pediatrics, Yokohama City University Hospital, 3-9 Hukuura, Kanazawa-ku, Yokohama, Kanagawa, 236-0004, Japan
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Hirano D, Inoue E, Sako M, Ashida A, Honda M, Takahashi S, Iijima K, Hattori M. Survival analysis among pediatric patients receiving kidney replacement therapy: a Japanese nationwide cohort study. Pediatr Nephrol 2023; 38:1-7. [PMID: 35488903 DOI: 10.1007/s00467-022-05568-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 03/30/2022] [Accepted: 03/30/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND Limited data are available on the survival and causes of death in pediatric patients with chronic kidney disease (CKD) stage 5 receiving kidney replacement therapy (KRT) in Asia. METHODS Data were obtained from the Japanese nationwide cross-sectional CKD stage 5 survey on pediatric patients (<20 years of age) who started KRT from 2006 to 2013. The cohort was divided into three groups according to age at the start of KRT: <1, 1-5, and 6-19 years. RESULTS Among the 701 children who were included, 59.3% were boys. Peritoneal dialysis was the most common initial modality of KRT (60.3%). Median age at KRT initiation was 10.2 years. Infants (<1 year old) accounted for 16.0% of the total cohort. Overall survival at 1 and 5 years was 97.2% and 92.5%, respectively. Infants had significantly lower survival rates than the other groups (hazard ratio, 5.35; 95% CI, 2.60-11.03; P < 0.001). In contrast, after the age of 1 year, the survival rate improved and did not differ from that of other age groups. The most common causes of death were infection (35.9%) and sudden death (15.4%). CONCLUSIONS The overall survival rate of pediatric patients with CKD stage 5 in Japan is like that in other high-income countries. Age at initiation of KRT is an important factor affecting survival since the poorest survival rate was observed in infants. Further improvement in infant dialysis therapy is still needed to improve survival of the youngest children. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Daishi Hirano
- Department of Pediatrics, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-ku, Tokyo, 105-0003, Japan.
| | - Eisuke Inoue
- Showa University Research Administration Center, Showa University, Tokyo, Japan
| | - Mayumi Sako
- Department of Clinical Research Promotion, Clinical Research Center, National Center for Child Health and Development, Tokyo, Japan
| | - Akira Ashida
- Department of Pediatrics, Osaka Medical and Pharmaceutical University Hospital, Osaka, Japan
| | - Masataka Honda
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | | | - Kazumoto Iijima
- Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan.,Department of Advanced Pediatric Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Motoshi Hattori
- Department of Pediatric Nephrology, School of Medicine, Tokyo Women's Medical University, Tokyo, Japan
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3
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Chronic haemodialysis in infants and children less than 15 kg. Pediatr Nephrol 2021; 36:3725-3732. [PMID: 34043060 DOI: 10.1007/s00467-021-05146-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 05/09/2021] [Accepted: 05/18/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Peritoneal dialysis (PD) is the most commonly used kidney replacement therapy in infants and young children with chronic kidney disease (CKD) stage 5. Chronic haemodialysis (cHD) is the alternative treatment when PD is not possible for technical reasons; however, the difficulties that may be encountered are challenging and require clinicians with specialist training and experience. This study aims to describe the clinical history, complications and outcomes in children < 15 kg on cHD. METHODS A retrospective, descriptive study of the clinical records of patients weighing < 15 kg on cHD for more than 3 months. The reasons for CKD stage 5, age at start of treatment, duration of haemodialysis, anthropometric and metabolic variables, as well as vascular access, complications and clinical outcome were recorded. RESULTS Fifteen patients were included between 2006 and 2018 with a median age at start of cHD of 30 (interquartile range (IQR) 13, 39) months and median duration of 15 (IQR 7.5, 25.3) months. Five patients were younger than 2 years. The median weight at start of treatment was 11.2 (IQR 6.4, 12.8) kg. Forty-five tunneled catheters with a median survival of 106 days were used. The main cause of loss of vascular access was obstruction or displacement dysfunction (39%). The catheter-associated infection rate was 0.76 per 1000 catheter days. Ten patients received a successful kidney transplant, 4 were transferred to PD and one died from complications during abdominal surgery. CONCLUSIONS cHD can be successfully performed in children < 15 kg by addressing specific clinical and technical issues.
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Overman RE, Criss CN, Modi ZJ, Gadepalli SK. Early nephrectomy in neonates with symptomatic autosomal recessive polycystic kidney disease. J Pediatr Surg 2021; 56:328-331. [PMID: 32507635 DOI: 10.1016/j.jpedsurg.2020.03.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 03/14/2020] [Accepted: 03/26/2020] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Autosomal recessive polycystic kidney disease (ARPKD) is a rare cause of renal failure with a highly variable clinical course. Patients who are symptomatic early in life frequently require early nephrectomy and peritoneal dialysis. In these patients there are little data to guide clinicians on whether to select unilateral nephrectomy or bilateral nephrectomy at the initial operative intervention. We review our experience with this disease process. METHODS A retrospective review was performed of 11 patients at our institution with ARPKD symptomatic within the first month of life. Charts were reviewed for relevant clinical data, and patients were divided into groups based on undergoing either unilateral or bilateral nephrectomy at their initial intervention. The decision for unilateral versus bilateral nephrectomy was decided by the clinical team without any available guidelines. RESULTS Of the 11 patients reviewed, two patients died within the first two weeks from other complications. The remaining 9 all required nephrectomy, with 5 undergoing synchronous bilateral nephrectomy, and 4 undergoing initial unilateral nephrectomy. All four patients required removal of their contralateral kidney, a median of 25.5 days later. There was no difference in mortality, ventilator free days, or time to full feeds between the two groups, although the group undergoing initial unilateral nephrectomy had more TPN days than their counterparts (28 vs 17 days, p = 0.014). CONCLUSIONS In our cohort, there were few significant differences between the groups based on choice of initial unilateral or bilateral nephrectomy, and all children ultimately required removal of both kidneys. These data suggest that anesthetic exposures and other clinical outcomes might be optimized by initial bilateral nephrectomy. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Richard E Overman
- Division of Pediatric Surgery, Department of Surgery, University of Michigan 1540 E Hospital Dr., Rm 4972, Ann Arbor, MI 48109, United States.
| | - Cory N Criss
- Division of Pediatric Surgery, Department of Surgery, University of Michigan 1540 E Hospital Dr., Rm 4972, Ann Arbor, MI 48109, United States
| | - Zubin J Modi
- Division of Pediatric Nephrology, Department of Pediatrics, University of Michigan Medical Professional Building, Room D3202, Box: 5718, 1522 Simpson Road East, Ann Arbor, MI 48109-5718, United States; Susan B. Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan, 300 North Ingalls, Rm 6C11, Ann Arbor, MI 48109-5456, United States
| | - Samir K Gadepalli
- Division of Pediatric Surgery, Department of Surgery, University of Michigan 1540 E Hospital Dr., Rm 4972, Ann Arbor, MI 48109, United States
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5
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Rees L, Shaw V, Qizalbash L, Anderson C, Desloovere A, Greenbaum L, Haffner D, Nelms C, Oosterveld M, Paglialonga F, Polderman N, Renken-Terhaerdt J, Tuokkola J, Warady B, Walle JVD, Shroff R. Delivery of a nutritional prescription by enteral tube feeding in children with chronic kidney disease stages 2-5 and on dialysis-clinical practice recommendations from the Pediatric Renal Nutrition Taskforce. Pediatr Nephrol 2021; 36:187-204. [PMID: 32728841 PMCID: PMC7701061 DOI: 10.1007/s00467-020-04623-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 05/14/2020] [Accepted: 05/19/2020] [Indexed: 12/14/2022]
Abstract
The nutritional prescription (whether in the form of food or liquid formulas) may be taken orally when a child has the capacity for spontaneous intake by mouth, but may need to be administered partially or completely by nasogastric tube or gastrostomy device ("enteral tube feeding"). The relative use of each of these methods varies both within and between countries. The Pediatric Renal Nutrition Taskforce (PRNT), an international team of pediatric renal dietitians and pediatric nephrologists, has developed clinical practice recommendations (CPRs) based on evidence where available, or on the expert opinion of the Taskforce members, using a Delphi process to seek consensus from the wider community of experts in the field. We present CPRs for delivery of the nutritional prescription via enteral tube feeding to children with chronic kidney disease stages 2-5 and on dialysis. We address the types of enteral feeding tubes, when they should be used, placement techniques, recommendations and contraindications for their use, and evidence for their effects on growth parameters. Statements with a low grade of evidence, or based on opinion, must be considered and adapted for the individual patient by the treating physician and dietitian according to their clinical judgement. Research recommendations have been suggested. The CPRs will be regularly audited and updated by the PRNT.
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Affiliation(s)
- Lesley Rees
- The Biomedical Research Centre at Great Ormond Street Hospital for Children NHS Foundation Trust and Institute of Child Health, University College Londonfig, WC1N 3JH, London, UK.
| | - Vanessa Shaw
- grid.83440.3b0000000121901201The Biomedical Research Centre at Great Ormond Street Hospital for Children NHS Foundation Trust and Institute of Child Health, University College Londonfig, WC1N 3JH, London, UK ,grid.11201.330000 0001 2219 0747University of Plymouth, Plymouth, UK
| | - Leila Qizalbash
- Great Northern Children’s Hospital, Upon Tyne, Newcastle, UK
| | - Caroline Anderson
- grid.430506.4Southampton Children’s Hospital, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - An Desloovere
- grid.410566.00000 0004 0626 3303University Hospital Ghent, Ghent, Belgium
| | - Laurence Greenbaum
- grid.428158.20000 0004 0371 6071Emory University and Children’s Healthcare of Atlanta, Atlanta, USA
| | - Dieter Haffner
- grid.10423.340000 0000 9529 9877Children’s Hospital, Hannover Medical School, Hannover, Germany
| | - Christina Nelms
- grid.24434.350000 0004 1937 0060PedsFeeds LLC, University of Nebraska, Lincoln, USA
| | - Michiel Oosterveld
- grid.414503.70000 0004 0529 2508Emma Children’s Hospital, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Fabio Paglialonga
- grid.414818.00000 0004 1757 8749Fondazione IRCCS Ca’Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Nonnie Polderman
- grid.414137.40000 0001 0684 7788British Columbia Children’s Hospital, Vancouver, Canada
| | - José Renken-Terhaerdt
- grid.7692.a0000000090126352Wilhelmina Children’s Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jetta Tuokkola
- grid.7737.40000 0004 0410 2071Children’s Hospital and Clinical Nutrition Unit, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Bradley Warady
- grid.239559.10000 0004 0415 5050Children’s Mercy, Kansas City, USA
| | - Johan Van de Walle
- grid.410566.00000 0004 0626 3303University Hospital Ghent, Ghent, Belgium
| | - Rukshana Shroff
- grid.83440.3b0000000121901201The Biomedical Research Centre at Great Ormond Street Hospital for Children NHS Foundation Trust and Institute of Child Health, University College Londonfig, WC1N 3JH, London, UK
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Hemodialysis Catheters in Infants: A Retrospective Single-Center Cohort Study. J Vasc Interv Radiol 2020; 31:778-786. [PMID: 32305244 DOI: 10.1016/j.jvir.2020.01.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 12/11/2019] [Accepted: 01/22/2020] [Indexed: 01/10/2023] Open
Abstract
PURPOSE Evaluate technical aspects and outcomes of insertion/maintenance of hemodialysis (HD) central venous catheter (CVC) during infancy. MATERIALS AND METHODS Single-center retrospective study of 29 infants who underwent 49 HD-CVC insertions between 2002 and 2016. Demographics, procedural, and post-procedural details, interventional radiology (IR) maintenance procedures, technical modifications, complications, and outcomes were evaluated. Technical adjustments during HD-CVC placement to adapt catheter length to patient size were labeled "modifications." CVCs requiring return visit to IR were called IR-maintenance procedures. Mean age and weight at HD-CVC insertion were 117 days and 4.9 kg. RESULTS Of the 29 patients, 13 (45%) required renal-replacement-therapy (RRT) as neonates, 10 (34%) commenced RRT with peritoneal dialysis (PD), and 19 (66%) with HD. Fifteen nontunneled and 34 tunneled HD-CVCs were inserted while patients were ≤1 year. Technical modifications were required placing 25/49 (51%) HD-CVCs: 5/15 (33%) nontunneled and 20/34 (59%) tunneled catheters (P = .08). Patients underwent ≤6 dialysis-cycles/patient during infancy (mean 2.3), and a mean of 4.1 and 49 HD-sessions/catheter for nontunneled and tunneled HD-CVCs, respectively. Mean primary and secondary device service, and total access site intervals for tunneled HD-CVCs were 75, 115, and 201 days, respectively. A total of 26 of 49 (53%) patients required IR-maintenance procedures. Nontunneled lines had greater catheter-related bloodstream infections per 1,000 catheter-days than tunneled HD-CVCs (9.25 vs. 0.85/1,000 catheter days; P = .02). Nineteen patients (65%) survived over 1 year. At final evaluation (December 2017): 8/19 survived transplantation, 5/19 remained on RRT, 2/19 completely recovered, 1/19 lost to follow-up, and 3 died at 1.3, 2, and 10 years. CONCLUSIONS Placement/maintenance of HD-CVCs in infants pose specific challenges, requiring insertion modifications, and IR-maintenance procedures to maintain function.
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End-stage kidney disease in infancy: an educational review. Pediatr Nephrol 2020; 35:229-240. [PMID: 30465082 PMCID: PMC6529305 DOI: 10.1007/s00467-018-4151-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 11/05/2018] [Accepted: 11/12/2018] [Indexed: 12/15/2022]
Abstract
An increasing number of infants with end-stage kidney disease (ESKD) are surviving and receiving renal replacement therapy (RRT). Unique clinical issues specific to this age group of patients influence their short- and long-term outcomes. This review summarizes current epidemiology, clinical characteristics, ethical dilemmas, management concerns, and outcomes of infants requiring chronic dialysis therapy. Optimal care during infancy requires a multidisciplinary team working closely with the patient's family. Nutritional management, infection prevention, and attention to cardiovascular status are important treatment targets. Although mortality rates remain higher among infants on dialysis compared to older pediatric dialysis patients, outcomes have improved over time. Most importantly, infants who subsequently receive a kidney transplant are now experiencing graft survival rates that are comparable to older pediatric patients.
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Ta A, Saxena S, Badru F, Lee ASE, Fitzpatrick CM, Villalona GA. Laparoscopic Peritoneal Dialysis Catheter Placement with Chest Wall Exit Site for Neonate with Stoma. Perit Dial Int 2019; 39:405-408. [PMID: 31501290 DOI: 10.3747/pdi.2018.00213] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 03/22/2019] [Indexed: 11/15/2022] Open
Abstract
Neonates requiring peritoneal dialysis (PD) catheters have been shown to have complication rates up to 70%. The presence of a concurrent stoma significantly increases the risk of peritonitis, exit-site infection, and catheter failure. As such, multiple techniques have been proposed to reduce these risks, including a chest wall exit site. In this case, the patient was born with bilateral hypoplastic kidneys and an anorectal malformation, requiring a colostomy soon after birth. At 4 weeks of life, he required placement of a PD catheter for dialysis. Given the high risk of infection, a laparoscopic-assisted PD catheter placement with a chest wall exit remote from the colostomy was performed. This report describes the operative technique including omentectomy, placement of a percutaneous stitch between the catheter cuffs, and fibrin glue injection around the catheter. The patient had no catheter-related infections. Laparoscopic-assisted PD catheter placement with chest wall exit site is a safe alternative in patients with any type of abdominal stoma.
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Affiliation(s)
- Anh Ta
- Saint Louis University School of Medicine, St. Louis, MO, USA
| | - Saurabh Saxena
- SSM Health Cardinal Glennon Children's Hospital, St. Louis, MO, USA
| | - Faidah Badru
- SSM Health Cardinal Glennon Children's Hospital, St. Louis, MO, USA
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9
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Katsoufis CP, DeFreitas MJ, Infante JC, Castellan M, Cano T, Safina Vaccaro D, Seeherunvong W, Chandar JJ, Abitbol CL. Risk Assessment of Severe Congenital Anomalies of the Kidney and Urinary Tract (CAKUT): A Birth Cohort. Front Pediatr 2019; 7:182. [PMID: 31139603 PMCID: PMC6527773 DOI: 10.3389/fped.2019.00182] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 04/18/2019] [Indexed: 01/16/2023] Open
Abstract
Recent advances in the early diagnosis of fetal CAKUT with an increase in fetal surgical interventions have led to a growing number of neonatal survivors born with severe renal dysfunction. This, in turn, has required the development of multi-disciplinary treatment paradigms in the individualized management of these infants with advanced stage kidney disease from birth. Early multi-modal management includes neonatal surgical interventions directed toward establishing adequate urine flow, respiratory support with the assessment of pulmonary hypoplasia, and establishing metabolic control to avoid the need for dialysis intervention. The development of specialized imaging to assess for residual renal mass with non-invasive 3-dimensional techniques are rapidly evolving. The use of non-radioactive imaging offers improved safety and allows for early prognostic-based planning including anticipatory guidance for progression to end stage renal disease (ESRD). The trajectory of kidney function during the neonatal period as determined by peak and nadir serum creatinine (SCr) and cystatin C (CysC) during the first months of life provides a guide toward individualized prospective management. This is a single center experience based on a birth cohort of 42 subjects followed prospectively from birth for an average of 6.1 ± 2.8 years at the University of Miami/Holtz Children's Hospital during the past decade. There was an 8:1 male: female ratio. The birth cohort was divided into 3 subgroups according to CKD Stages at the current age: CKD 1-2 (Group 1) (eGFR ≥ 60 ml/min/1.73 m2) (N = 15), CKD stage 3-5 (Group 2) (eGFR ≤ 59 ml/min/1.73 m2) (N = 12), and ESRD-Dialysis and/or Transplantation (Group 3) (N = 15). A neonatal CysC >3.0 mg/L predicted progression to ESRD while a nadir SCr >0.6 mg/dL predicted progression to CKD 3-5 with the highest specificity and sensitivity by ROC-AUC analysis (P < 0.0001). Medical management was directed toward nutritional support with novel formula designs, early introduction of growth hormone and strict control of mineral bone disorder. One of the central aspects of the management was to avoid dialysis for as long as feasible with a primary goal toward pre-emptive transplantation.
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Affiliation(s)
- Chryso P. Katsoufis
- Division of Pediatric Nephrology, Department of Pediatrics, Miller School of Medicine, University of Miami, Miami, FL, United States
- Holtz Children's Hospital, Jackson Health System, Miami, FL, United States
| | - Marissa J. DeFreitas
- Division of Pediatric Nephrology, Department of Pediatrics, Miller School of Medicine, University of Miami, Miami, FL, United States
- Miami Transplant Institute, Jackson Health System, Miami, FL, United States
| | - Juan C. Infante
- Holtz Children's Hospital, Jackson Health System, Miami, FL, United States
- Department of Radiology, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Miguel Castellan
- Holtz Children's Hospital, Jackson Health System, Miami, FL, United States
- Pediatric Urology, Nicklaus Children's Health System, Miami, FL, United States
| | - Teresa Cano
- Holtz Children's Hospital, Jackson Health System, Miami, FL, United States
| | | | - Wacharee Seeherunvong
- Division of Pediatric Nephrology, Department of Pediatrics, Miller School of Medicine, University of Miami, Miami, FL, United States
- Holtz Children's Hospital, Jackson Health System, Miami, FL, United States
| | - Jayanthi J. Chandar
- Miami Transplant Institute, Jackson Health System, Miami, FL, United States
- Department of Pediatrics, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Carolyn L. Abitbol
- Division of Pediatric Nephrology, Department of Pediatrics, Miller School of Medicine, University of Miami, Miami, FL, United States
- Holtz Children's Hospital, Jackson Health System, Miami, FL, United States
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10
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Dufek S, Ylinen E, Trautmann A, Alpay H, Ariceta G, Aufricht C, Bacchetta J, Bakkaloglu S, Bayazit A, Caliskan S, do Sameiro Faria M, Dursun I, Ekim M, Jankauskiene A, Klaus G, Paglialonga F, Pasini A, Printza N, Conti VS, Schmitt CP, Stefanidis C, Verrina E, Vidal E, Webb H, Zampetoglou A, Edefonti A, Holtta T, Shroff R. Infants with congenital nephrotic syndrome have comparable outcomes to infants with other renal diseases. Pediatr Nephrol 2019; 34:649-655. [PMID: 30374605 DOI: 10.1007/s00467-018-4122-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 10/12/2018] [Accepted: 10/18/2018] [Indexed: 01/18/2023]
Abstract
BACKGROUND Children with congenital nephrotic syndrome (CNS) commonly develop end stage renal failure in infancy and require dialysis, but little is known about the complications and outcomes of dialysis in these children. METHODS We conducted a retrospective case note review across members of the European Society for Pediatric Nephrology Dialysis Working Group to evaluate dialysis management, complications of dialysis, and outcomes in children with CNS. RESULTS Eighty children (50% male) with CNS were identified form 17 centers over a 6-year period. Chronic dialysis was started in 44 (55%) children at a median age of 8 (interquartile range 4-14) months. Of these, 17 (39%) were on dialysis by the age of 6 months, 30 (68%) by 1 year, and 40 (91%) by 2 years. Peritoneal dialysis (PD) was the modality of choice in 93%, but 34% switched to hemodialysis (HD), largely due to catheter malfunction (n = 5) or peritonitis (n = 4). The peritonitis rate was 0.77 per patient-year. Weight and height SDS remained static after 6 months on dialysis. In the overall cohort, at final follow-up, 29 children were transplanted, 18 were still on dialysis (15 PD, 3 HD), 19 were in pre-dialysis chronic kidney disease (CKD), and there were 14 deaths (8 on dialysis). Median time on chronic dialysis until transplantation was 9 (6-18) months, and the median age at transplantation was 22 (14-28) months. CONCLUSIONS Infants with CNS on dialysis have a comparable mortality, peritonitis rate, growth, and time to transplantation as infants with other primary renal diseases reported in international registry data.
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MESH Headings
- Age Factors
- Child, Preschool
- Disease Progression
- Europe
- Female
- Humans
- Infant
- Infant, Newborn
- Kidney Failure, Chronic/diagnosis
- Kidney Failure, Chronic/etiology
- Kidney Failure, Chronic/mortality
- Kidney Failure, Chronic/therapy
- Kidney Transplantation/adverse effects
- Kidney Transplantation/mortality
- Male
- Nephrotic Syndrome/congenital
- Nephrotic Syndrome/diagnosis
- Nephrotic Syndrome/mortality
- Nephrotic Syndrome/therapy
- Peritoneal Dialysis
- Renal Dialysis/adverse effects
- Renal Insufficiency, Chronic/diagnosis
- Renal Insufficiency, Chronic/etiology
- Renal Insufficiency, Chronic/mortality
- Renal Insufficiency, Chronic/therapy
- Retrospective Studies
- Risk Factors
- Time Factors
- Treatment Outcome
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Affiliation(s)
- Stephanie Dufek
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK
| | - Elisa Ylinen
- University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Agnes Trautmann
- Center for Pediatric and Adolescent Medicine, Heidelberg, Germany
| | - Harika Alpay
- School of Medicine, Marmara University, Istanbul, Turkey
| | - Gema Ariceta
- Hospital Universitari Vall d'Hebron. Universitat Autonoma de Barcelona, Barcelona, Spain
| | | | | | | | | | | | | | | | | | | | | | - Fabio Paglialonga
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Andrea Pasini
- Azienda Ospedaliero-Universitaria Sant'Orsola-Malpighi, Bologna, Italy
| | - Nikoleta Printza
- 1st Pediatric Department, Aristotle University, Thessaloniki, Greece
| | | | | | | | | | | | - Hazel Webb
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK
| | | | - Alberto Edefonti
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Tuula Holtta
- University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Rukshana Shroff
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK.
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11
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Sanderson KR, Yu Y, Dai H, Willig LK, Warady BA. Outcomes of infants receiving chronic peritoneal dialysis: an analysis of the USRDS registry. Pediatr Nephrol 2019; 34:155-162. [PMID: 30141177 PMCID: PMC6289046 DOI: 10.1007/s00467-018-4056-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 08/09/2018] [Accepted: 08/13/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Outcome data for infants on chronic peritoneal dialysis (CPD) is limited and has been based primarily on the analyses of voluntary entry registry data. In contrast, the United States Renal Data Systems (USRDS) collects data on all infants with end-stage kidney disease (ESKD) on chronic dialysis in the USA. We aimed to describe the clinical characteristics of this population and to determine the associated patient mortality. METHODS The USRDS database was reviewed retrospectively for data on infants who initiated CPD at ≤ 12 months of age from 1990 to 2014. Infants were categorized into four groups, CPD initiation age (≤ 1 month of age or neonates and > 1-12 months of age or older infants) and initiation era (1990-1999 and 2000-2014). RESULTS A total of 1723 infants (574 neonates and 1149 older infants) were identified. Overall, 20.9% of infants (147 neonates and 213 older infants) died on dialysis during the follow-up. The most commonly identified causes of death on dialysis were cardiorespiratory disease (25.8%) and infection (22.8%). There was an increased risk for mortality in all infants who initiated CPD in the earlier initiation era (1990-1999) vs the later era (2000-2014) (aHR of 1.95), for females vs males (aHR 1.43), and for those with a primary diagnosis of cystic kidney diseases vs congenital anomalies of the kidney and urinary tract (CAKUT) (aHR 1.84). In 2000-2014, patient survival at 1 and 5 years was 86.8% and 74.6% for those who initiated CPD as neonates and 89.6% and 79.3% for those who did so as older infants. CONCLUSIONS In this large cohort of infants who received chronic peritoneal dialysis over more than two decades, the probability of survival after initiating CPD in the first year of life has significantly improved. There is no difference in the probability of death for neonates compared to older infants. However, the mortality rate remains substantial in association with multiple risk factors.
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Affiliation(s)
- Keia R. Sanderson
- University of North Carolina Department of Medicine-Nephrology, 7024 Burnett-Womack, CB 7155, Chapel Hill, NC 27599, USA
| | - Yichun Yu
- University of North Carolina Department of Medicine-Nephrology, 7024 Burnett-Womack, CB 7155, Chapel Hill, NC 27599, USA
| | - Hongying Dai
- Children’s Mercy Hospitals and Clinics, Kansas City, Kansas City, MO, USA
| | - Laurel K. Willig
- Children’s Mercy Hospitals and Clinics, Kansas City, Kansas City, MO, USA
| | - Bradley A. Warady
- Children’s Mercy Hospitals and Clinics, Kansas City, Kansas City, MO, USA
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12
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Imani PD, Carpenter JL, Bell CS, Brandt ML, Braun MC, Swartz SJ. Peritoneal dialysis catheter outcomes in infants initiating peritoneal dialysis for end-stage renal disease. BMC Nephrol 2018; 19:231. [PMID: 30217181 PMCID: PMC6137733 DOI: 10.1186/s12882-018-1015-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Accepted: 08/24/2018] [Indexed: 12/16/2022] Open
Abstract
Background End-stage renal disease (ESRD) although rare among infants presents many management challenges. We sought to evaluate factors associated with PD catheter failure among infants initiated on chronic PD. Methods A retrospective chart review of all children under two years of age who had PD catheters placed for initiation of chronic PD from 2002 to 2015. Data was extracted for catheter related events occurring within 12 months of catheter placement. Cox and Poisson regression models were used to delineate factors associated catheter complications. Results Twenty-five infants with median age 18 days had PD catheters placed for chronic dialysis. Common complications included leakage around the exit site (31%), blockage (26%), migration or malposition (23%), catheter-related infections (18%), and other complications (2%). Predictors of initial PD catheter failure were age less than one month at catheter placement (hazard ratio (HR) 7.77, 95% CI, 1.70–35.39, p = 0.008), use of catheter within three days of placement (HR 5.67, 95% CI, 1.39–23.10, p = 0.015) and presence of a hernia (HR 8.64, 95% CI, 1.19–62.36, p = 0.033). In an adjusted Poisson regression model, PD catheter use within three days of placement was the only predictor of any catheter complication over the12 months of follow up. Conclusions Use of PD catheters within three days of placement was associated with catheter failure. We recommend that when possible, catheters should be allowed to heal for at least three days prior to use to reduce risk of complications and improve catheter survival.
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Affiliation(s)
- Peace D Imani
- Renal Section, Department of Pediatrics, Texas Children's Hospital/Baylor College of Medicine, 1102 Bates Avenue, Suite 245, Houston, TX, 77030, USA.
| | - Jennifer L Carpenter
- Department of Surgery, Texas Children's Hospital/Baylor College of Medicine, 6621 Fannin St, Houston, TX, 77030, USA
| | - Cynthia S Bell
- Division of Pediatric Nephrology and Hypertension, McGovern Medical School at UTHealth, 6431 Fannin St, MSB 3.121, Houston, TX, 77030, USA
| | - Mary L Brandt
- Department of Surgery, Texas Children's Hospital/Baylor College of Medicine, 6621 Fannin St, Houston, TX, 77030, USA
| | - Michael C Braun
- Renal Section, Department of Pediatrics, Texas Children's Hospital/Baylor College of Medicine, 1102 Bates Avenue, Suite 245, Houston, TX, 77030, USA
| | - Sarah J Swartz
- Renal Section, Department of Pediatrics, Texas Children's Hospital/Baylor College of Medicine, 1102 Bates Avenue, Suite 245, Houston, TX, 77030, USA
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13
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Vidal E. Peritoneal dialysis and infants: further insights into a complicated relationship. Pediatr Nephrol 2018; 33:547-551. [PMID: 29218436 DOI: 10.1007/s00467-017-3857-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 11/24/2017] [Accepted: 11/24/2017] [Indexed: 01/23/2023]
Abstract
Peritoneal dialysis (PD) in infants represents one of the greatest challenges for pediatric nephrologists. Over recent years, positive outcome data described by several multicenter experiences and registry studies have increased the amount of information available to help determine whether to initiate a dialysis program in this high-risk patient population. There is no doubt that the rigorous implementation of strategies aimed at preventing infectious complications may have contributed to reducing the morbidity rate of these patients. However, the complex nature of infants with end-stage renal disease and the presence of multiple comorbidities still represent hallmarks that significantly impact on outcome. Although the rigorous application of improved scientific techniques can still contribute to enhancing PD results in infants, we have to acknowledge that the severity of illness in infants, especially at dialysis initiation, represents an undeniable and nonmodifiable factor.
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Affiliation(s)
- Enrico Vidal
- Pediatric Nephrology, Dialysis and Transplantation Unit, Department of Woman's and Child's Health, University Hospital of Padua, Via Giustiniani 3, 35128, Padua, Italy.
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14
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Bérody S, Heidet L, Gribouval O, Harambat J, Niaudet P, Baudouin V, Bacchetta J, Boudaillez B, Dehennault M, de Parscau L, Dunand O, Flodrops H, Fila M, Garnier A, Louillet F, Macher MA, May A, Merieau E, Monceaux F, Pietrement C, Rousset-Rouvière C, Roussey G, Taque S, Tenenbaum J, Ulinski T, Vieux R, Zaloszyc A, Morinière V, Salomon R, Boyer O. Treatment and outcome of congenital nephrotic syndrome. Nephrol Dial Transplant 2018; 34:458-467. [DOI: 10.1093/ndt/gfy015] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 12/24/2017] [Indexed: 11/13/2022] Open
Affiliation(s)
- Sandra Bérody
- Hôpital Necker-Enfants malades, Néphrologie pédiatrique, Assistance Publique des Hôpitaux de Paris, Université Paris Descartes-Sorbonne Paris-Cité, Paris, France
| | - Laurence Heidet
- Hôpital Necker-Enfants malades, Néphrologie pédiatrique, Assistance Publique des Hôpitaux de Paris, Université Paris Descartes-Sorbonne Paris-Cité, Paris, France
- Centre de référence des Maladies Rénales Héréditaires de l'Enfant et de l'Adulte (MARHEA), Centre de référence du syndrome néphrotique idiopathique de l'enfant et de l'adulte, Hôpital Necker-Enfants Malades, Paris, France
- Inserm U1163, Imagine Institute, Paris, France
| | | | - Jérome Harambat
- Centre Hospitalier Universitaire de Bordeaux, Néphrologie pédiatrique, Bordeaux, France
| | - Patrick Niaudet
- Hôpital Necker-Enfants malades, Néphrologie pédiatrique, Assistance Publique des Hôpitaux de Paris, Université Paris Descartes-Sorbonne Paris-Cité, Paris, France
- Centre de référence des Maladies Rénales Héréditaires de l'Enfant et de l'Adulte (MARHEA), Centre de référence du syndrome néphrotique idiopathique de l'enfant et de l'adulte, Hôpital Necker-Enfants Malades, Paris, France
- Inserm U1163, Imagine Institute, Paris, France
| | - Veronique Baudouin
- Centre de référence des Maladies Rénales Héréditaires de l'Enfant et de l'Adulte (MARHEA), Centre de référence du syndrome néphrotique idiopathique de l'enfant et de l'adulte, Hôpital Necker-Enfants Malades, Paris, France
- Hôpital Universitaire Robert Debré, Néphrologie pédiatrique, Paris, France
| | | | | | | | | | - Olivier Dunand
- CHU Felix Guyon, Pédiatrie, Saint-Denis, La Reunion, France
| | | | - Marc Fila
- Centre Hospitalier Regional Universitaire de Montpellier, Néphrologie pédiatrique, Montpellier, France
| | - Arnaud Garnier
- Centre Hospitalier Universitaire de Toulouse, Néphrologie pédiatrique, Toulouse, France
| | | | - Marie-Alice Macher
- Hôpital Universitaire Robert Debré, Néphrologie pédiatrique, Paris, France
| | - Adrien May
- Centre Hospitalier Sud Francilien, Pédiatrie, Corbeil-Essonnes, France
| | | | | | | | | | - Gwenaëlle Roussey
- Centre Hospitalier Universitaire de Nantes, Néphrologie pédiatrique, Nantes, France
| | - Sophie Taque
- Centre Hospitalier Universitaire de Rennes, Pédiatrie, Rennes, France
| | - Julie Tenenbaum
- Centre Hospitalier Regional Universitaire de Montpellier, Néphrologie pédiatrique, Montpellier, France
| | - Tim Ulinski
- Centre de référence des Maladies Rénales Héréditaires de l'Enfant et de l'Adulte (MARHEA), Centre de référence du syndrome néphrotique idiopathique de l'enfant et de l'adulte, Hôpital Necker-Enfants Malades, Paris, France
- Hôpital Armand-Trousseau, Néphrologie pédiatrique, Paris, France
| | - Rachel Vieux
- Centre Hospitalier Universitaire de Nancy, Pédiatrie, Nancy, France
| | | | | | - Rémi Salomon
- Hôpital Necker-Enfants malades, Néphrologie pédiatrique, Assistance Publique des Hôpitaux de Paris, Université Paris Descartes-Sorbonne Paris-Cité, Paris, France
- Centre de référence des Maladies Rénales Héréditaires de l'Enfant et de l'Adulte (MARHEA), Centre de référence du syndrome néphrotique idiopathique de l'enfant et de l'adulte, Hôpital Necker-Enfants Malades, Paris, France
- Inserm U1163, Imagine Institute, Paris, France
| | - Olivia Boyer
- Hôpital Necker-Enfants malades, Néphrologie pédiatrique, Assistance Publique des Hôpitaux de Paris, Université Paris Descartes-Sorbonne Paris-Cité, Paris, France
- Centre de référence des Maladies Rénales Héréditaires de l'Enfant et de l'Adulte (MARHEA), Centre de référence du syndrome néphrotique idiopathique de l'enfant et de l'adulte, Hôpital Necker-Enfants Malades, Paris, France
- Inserm U1163, Imagine Institute, Paris, France
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15
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Chesnaye NC, van Stralen KJ, Bonthuis M, Harambat J, Groothoff JW, Jager KJ. Survival in children requiring chronic renal replacement therapy. Pediatr Nephrol 2018; 33:585-594. [PMID: 28508132 PMCID: PMC5859702 DOI: 10.1007/s00467-017-3681-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Revised: 03/21/2017] [Accepted: 04/12/2017] [Indexed: 01/19/2023]
Abstract
Survival in the pediatric end-stage renal disease (ESRD) population has improved substantially over recent decades. Nonetheless, mortality remains at least 30 times higher than that of healthy peers. Patient survival is multifactorial and dependent on various patient and treatment characteristics and degree of economic welfare of the country in which a patient is treated. In this educational review, we aim to delineate current evidence regarding mortality risk in the pediatric ESRD population and provide pediatric nephrologists with up-to-date information required to counsel affected families.
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Affiliation(s)
- Nicholas C Chesnaye
- ESPN/ERA-EDTA Registry, Department of Medical Informatics, Academic Medical Center, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, The Netherlands.
| | | | - Marjolein Bonthuis
- ESPN/ERA-EDTA Registry, Department of Medical Informatics, Academic Medical Center, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, The Netherlands
| | - Jérôme Harambat
- Department of Pediatrics, Bordeaux University Hospital and INSERM U1219, Bordeaux, France
| | - Jaap W Groothoff
- Department of Pediatric Nephrology, Emma Children's Hospital AMC, Amsterdam, Netherlands
| | - Kitty J Jager
- ESPN/ERA-EDTA Registry, Department of Medical Informatics, Academic Medical Center, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, The Netherlands
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16
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Wightman A. Management dilemmas in pediatric nephrology: time-limited trials of dialysis therapy. Pediatr Nephrol 2017; 32:615-620. [PMID: 27942955 DOI: 10.1007/s00467-016-3545-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 10/24/2016] [Accepted: 10/26/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Time-limited trials of dialysis have been proposed as a third option in addition to initiation of treatment and comfort-care only in the setting of high uncertainty or discordance between the treating team and child/family or among the treating team. CASE-DIAGNOSIS/TREATMENT The index case was noted antenatally to have severe kidney disease and pulmonary hypoplasia. In light of the guarded, but uncertain prognosis and a lack of consensus among the treating team, as well as between the treating team and the family, a time-limited trial of dialysis was initiated. Six days later the child developed bacteremia due to infection of the dialysis catheter. The treating team felt this was a failure of the trial and that future dialysis should be withheld, the family disagreed. CONCLUSION A time-limited trial is a problematic option. Providers may be better suited by returning to the dichotomous choice of withholding or initiating treatment. KEY MANAGEMENT POINTS • Time-limited trials offer potential benefits in terms of alleviating the burden of decision-making in the setting of uncertainty, offering an opportunity to forecast a poor prognosis, help avoid interprofessional conflict, and providing support for patients, their families, and staff. • Time-limited trials have important limitations, including the use of time limits, difficulty in determining clear, meaningful endpoints, and different interpretations of a trial of therapy between parents and providers. • Decisions regarding the initiation, withholding, and withdrawal of dialysis should be made based on regular assessments of the benefits and burdens of the intervention for the child. • Pediatric nephrologists are better served to abandon the concept of time-limited trials.
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Affiliation(s)
- Aaron Wightman
- Division of Nephrology, Department of Pediatrics, University of Washington School of Medicine, 4800 Sand Point Way NE, Seattle, WA, 98105, USA.
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17
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Twichell SA, Fiascone J, Gupta M, Prendergast M, Rodig N, Hansen A. A Regional Evaluation of Survival of Infants with End-Stage Renal Disease. Neonatology 2017; 112:73-79. [PMID: 28359062 PMCID: PMC5931204 DOI: 10.1159/000456647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 01/16/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Information regarding morbidity and mortality of infants born with end-stage renal disease (ESRD) requiring dialysis early in life is critical to optimize patient care and better counsel families. OBJECTIVE We evaluated outcomes of infants born regionally with ESRD, and those within our broader catchment area referred for dialysis. STUDY DESIGN We screened deaths at 5 regional referral hospitals, identifying infants with ESRD who did not survive to transfer for dialysis. We also screened all infants <8 weeks old seen at our institution over a 7-year period with ESRD referred for dialysis. We evaluated factors associated with survival to dialysis and transplant. RESULTS We identified 14 infants from regional hospitals who died prior to transfer and 12 infants at our institution who were dialyzed. Because of the large burden of lethal comorbidities in our regional referral centers, overall survival was low, with 73% dying at birth hospitals. Amongst dialyzed infants, 42% survived to transplant. CONCLUSION This study is unusual in reporting survival of infants with ESRD including those not referred for dialysis, which yields an expectedly lower survival rate than reported by dialysis registries.
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Affiliation(s)
- Sarah A Twichell
- Division of Nephrology, Department of Medicine, Boston Children's Hospital, Boston, MA, USA
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18
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Vidal E, van Stralen KJ, Chesnaye NC, Bonthuis M, Holmberg C, Zurowska A, Trivelli A, Da Silva JEE, Herthelius M, Adams B, Bjerre A, Jankauskiene A, Miteva P, Emirova K, Bayazit AK, Mache CJ, Sánchez-Moreno A, Harambat J, Groothoff JW, Jager KJ, Schaefer F, Verrina E. Infants Requiring Maintenance Dialysis: Outcomes of Hemodialysis and Peritoneal Dialysis. Am J Kidney Dis 2016; 69:617-625. [PMID: 27955924 DOI: 10.1053/j.ajkd.2016.09.024] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 09/01/2016] [Indexed: 01/27/2023]
Abstract
BACKGROUND The impact of different dialysis modalities on clinical outcomes has not been explored in young infants with chronic kidney failure. STUDY DESIGN Cohort study. SETTING & PARTICIPANTS Data were extracted from the ESPN/ERA-EDTA Registry. This analysis included 1,063 infants 12 months or younger who initiated dialysis therapy in 1991 to 2013. FACTOR Type of dialysis modality. OUTCOMES & MEASUREMENTS Differences between infants treated with peritoneal dialysis (PD) or hemodialysis (HD) in patient survival, technique survival, and access to kidney transplantation were examined using Cox regression analysis while adjusting for age at dialysis therapy initiation, sex, underlying kidney disease, and country of residence. RESULTS 917 infants initiated dialysis therapy on PD, and 146, on HD. Median age at dialysis therapy initiation was 4.5 (IQR, 0.7-7.9) months, and median body weight was 5.7 (IQR, 3.7-7.5) kg. Although the groups were homogeneous regarding age and sex, infants treated with PD more often had congenital anomalies of the kidney and urinary tract (CAKUT; 48% vs 27%), whereas those on HD therapy more frequently had metabolic disorders (12% vs 4%). Risk factors for death were younger age at dialysis therapy initiation (HR per each 1-month later initiation, 0.95; 95% CI, 0.90-0.97) and non-CAKUT cause of chronic kidney failure (HR, 1.49; 95% CI, 1.08-2.04). Mortality risk and likelihood of transplantation were equal in PD and HD patients, whereas HD patients had a higher risk for changing dialysis treatment (adjusted HR, 1.64; 95% CI, 1.17-2.31). LIMITATIONS Inability to control for unmeasured confounders not included in the Registry database and missing data (ie, comorbid conditions). Low statistical power because of relatively small number of participants. CONCLUSIONS Despite a widespread preconception that HD should be reserved for cases in which PD is not feasible, in Europe, we found 1 in 8 infants in need of maintenance dialysis to be initiated on HD therapy. Patient characteristics at dialysis therapy initiation, prospective survival, and time to transplantation were very similar for infants initiated on PD or HD therapy.
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Affiliation(s)
- Enrico Vidal
- Department of Women's and Children's Health, University-Hospital of Padova, Padova, Italy
| | | | | | - Marjolein Bonthuis
- ESPN/ERA-EDTA Registry, Academic Medical Center, Amsterdam, the Netherlands.
| | - Christer Holmberg
- Children's Hospital, Helsinki University Central Hospital, Helsinki, Finland
| | - Aleksandra Zurowska
- Department of Nephrology and Hypertension for Children and Adolescents, Medical University of Gdańsk, Gdańsk, Poland
| | | | | | - Maria Herthelius
- Karolinska Institutet-Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Brigitte Adams
- Queen Fabiola Children's University Hospital, Brussels, Belgium
| | - Anna Bjerre
- Department of Pediatrics, Oslo University Hospital-Rikshospitalet, Oslo, Norway
| | | | - Polina Miteva
- University Hospital for Active Treatment of Pediatric Diseases, Sofia Medical University, Sofia, Bulgaria
| | - Khadizha Emirova
- Moscow State University of Medicine and Dentistry, Moscow, Russia
| | - Aysun K Bayazit
- Department of Pediatric Nephrology, Çukurova University, Adana, Turkey
| | | | | | - Jérôme Harambat
- Department of Pediatrics, Bordeaux University Hospital, Bordeaux, France
| | - Jaap W Groothoff
- Departmnent of Pediatric Nephrology, Emma Children's Hospital AMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Kitty J Jager
- ESPN/ERA-EDTA Registry, Academic Medical Center, Amsterdam, the Netherlands; ERA-EDTA Registry, Academic Medical Center, Amsterdam, the Netherlands
| | - Franz Schaefer
- Division of Pediatric Nephrology, University of Heidelberg, Center for Pediatrics and Adolescent Medicine, Heidelberg, Germany
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19
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Wightman AG, Freeman MA. Update on Ethical Issues in Pediatric Dialysis: Has Pediatric Dialysis Become Morally Obligatory? Clin J Am Soc Nephrol 2016; 11:1456-1462. [PMID: 27037272 PMCID: PMC4974893 DOI: 10.2215/cjn.12741215] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Improvements in pediatric dialysis over the past 50 years have made the decision to proceed with dialysis straightforward for the majority of pediatric patients. For certain groups, however, such as children with multiple comorbid conditions, children and families with few social and economic resources, and neonates and infants, the decision of whether to proceed with dialysis remains much more controversial. In this review, we will examine the best available data regarding the outcomes of dialysis in these populations and analyze the important ethical considerations that should guide decisions regarding dialysis for these patients. We conclude that providers must continue to follow a nuanced and individualized approach in decision making for each child and to recognize that, regardless of the decision reached about dialysis, there is a continued duty to care for patients and families to maximize the remaining quality of their lives.
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Affiliation(s)
- Aaron G Wightman
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital, Seattle, Washington; and
| | - Michael A Freeman
- Department of Pediatrics, Penn State College of Medicine, Hershey, Pennsylvania
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20
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Ayestaran FW, Schneider MF, Kaskel FJ, Srivaths PR, Seo-Mayer PW, Moxey-Mims M, Furth SL, Warady BA, Greenbaum LA. Perceived appetite and clinical outcomes in children with chronic kidney disease. Pediatr Nephrol 2016; 31:1121-7. [PMID: 26857711 PMCID: PMC5627603 DOI: 10.1007/s00467-016-3321-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Revised: 01/11/2016] [Accepted: 01/11/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND Children with chronic kidney disease (CKD) may have impaired caloric intake through a variety of mechanisms, with decreased appetite as a putative contributor. In adult CKD, decreased appetite has been associated with poor clinical outcomes. There is limited information about this relationship in pediatric CKD. METHODS A total of 879 participants of the Chronic Kidney Disease in Children (CKiD) study were studied. Self-reported appetite was assessed annually and categorized as very good, good, fair, or poor/very poor. The relationship between appetite and iohexol or estimated glomerular filtration rate (ieGFR), annual changes in anthropometrics z-scores, hospitalizations, emergency room visits, and quality of life were assessed. RESULTS An ieGFR < 30 ml/min per 1.73 m(2) was associated with a 4.46 greater odds (95 % confidence interval: 2.80, 7.09) of having a worse appetite than those with ieGFR >90. Appetite did not predict changes in height, weight, or BMI z-scores. Patients not reporting a very good appetite had more hospitalizations over the next year than those with a very good appetite. Worse appetite was significantly associated with lower parental and patient reported quality of life. CONCLUSIONS Self-reported appetite in children with CKD worsens with lower ieGFR and is correlated with clinical outcomes, including hospitalizations and quality of life.
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Affiliation(s)
| | | | | | | | | | - Marva Moxey-Mims
- National Institute of Diabetes and Digestive Kidney Disease, National Institutes of Health, Bethesda, MD
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21
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Paglialonga F, Consolo S, Pecoraro C, Vidal E, Gianoglio B, Puteo F, Picca S, Saravo MT, Edefonti A, Verrina E. Chronic haemodialysis in small children: a retrospective study of the Italian Pediatric Dialysis Registry. Pediatr Nephrol 2016; 31:833-41. [PMID: 26692024 DOI: 10.1007/s00467-015-3272-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2015] [Revised: 10/23/2015] [Accepted: 11/02/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND Chronic haemodialysis (HD) in small children has not been adequately investigated. METHODS This was a retrospective investigation of the use of chronic HD in 21 children aged <2 years (n = 12 aged <1 year) who were registered in the Italian Pediatric Dialysis Registry. Data collected over a period of >10 years were analysed. RESULTS The median age of the 21 children at start of HD was 11.4 [interquartile range (IQR) 6.2-14.6] months, and HD consisted mainly of haemodiafiltration for 3-4 h in ≥4 sessions/week. A total of 51 central venous catheters were placed, and the median survival of tunnelled and temporary lines was 349 and 31 days, respectively (p < 0.001). Eight children (38 %) showed evidence of central vein thrombosis. Although 19 % of patients received growth hormone and 63.6 % received enteral feeding, the weight and height of these patients remained suboptimal. During the HD period the haemoglobin level increased in all patients, but not to normal levels (from 8.5 to 9.6 g/dl) despite erythropoietin administration (503-600 U/kg/week). The hospitalisation rate was 1.94/patient-year. Seventeen patients underwent renal transplantation at a median age of 3.0 years. Four patients, all affected by severe comorbidities, died during follow-up (in 2 cases due to absence of a vascular access). The 5- and 10-year cumulative survival was 82.4 and 68.7 %, respectively. CONCLUSIONS Extracorporeal dialysis is feasible in children aged <2 years, but comorbidities, vascular access, growth and anaemia remain major concerns.
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Affiliation(s)
- Fabio Paglialonga
- Pediatric Nephrology and Dialysis Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Commenda 9, 20122, Milan, Italy.
| | - Silvia Consolo
- Pediatric Nephrology and Dialysis Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Commenda 9, 20122, Milan, Italy
| | - Carmine Pecoraro
- Nephrology and Dialysis Unit, Santobono Children's Hospital, Naples, Italy
| | - Enrico Vidal
- Pediatric Nephrology, Dialysis and Transplant Unit, Department of Women's and Children's Health, University Hospital Padua, Padua, Italy
| | - Bruno Gianoglio
- Nephrology Dialysis and Transplantation Unit, Regina Margherita University Hospital, Turin, Italy
| | - Flora Puteo
- Nephrology Division, Giovanni XXIII Children's Hospital, Bari, Italy
| | - Stefano Picca
- Nephrology and Dialysis Unit, Department of Nephrology-Urology, IRCCS "Bambino Gesù" Children's Hospital, Rome, Italy
| | | | - Alberto Edefonti
- Pediatric Nephrology and Dialysis Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Commenda 9, 20122, Milan, Italy
| | - Enrico Verrina
- Dialysis Unit, Paediatric Nephrology and Dialysis Department, IRCCS Giannina Gaslini Institute, Genoa, Italy
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The Lure of Technology: Considerations in Newborns with Technology-Dependence. ETHICAL DILEMMAS FOR CRITICALLY ILL BABIES 2016. [DOI: 10.1007/978-94-017-7360-7_10] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Sustaining life or prolonging dying? Appropriate choice of conservative care for children in end-stage renal disease: an ethical framework. Pediatr Nephrol 2015; 30:1761-9. [PMID: 25330877 DOI: 10.1007/s00467-014-2977-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Revised: 09/22/2014] [Accepted: 09/29/2014] [Indexed: 10/24/2022]
Abstract
Due to technological advances, an increasing number of infants and children are surviving with multi-organ system dysfunction, and some are reaching end-stage renal disease (ESRD). Many have quite limited life expectancies and may not be eligible for kidney transplantation but families request dialysis as alternative. In developed countries where resources are available there is often uncertainty by the medical team as to what should be done. After encountering several of these scenarios, we developed an ethical decision-making framework for the appropriate choice of conservative care or renal replacement therapy in infants and children with ESRD. The framework is a practical tool to help determine if the burdens of dialysis would outweigh the benefits for a particular patient and family. It is based on the four topics approach of medical considerations, quality-of-life determinants, patient and family preferences and contextual features tailored to pediatric ESRD. In this article we discuss the basis of the criteria, provide a practical framework to guide these difficult conversations, and illustrate use of the framework with a case example. While further research is needed, through this approach we hope to reduce the moral distress of care providers and staff as well as potential conflict with the family in these complex decision-making situations.
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Carey WA, Martz KL, Warady BA. Outcome of Patients Initiating Chronic Peritoneal Dialysis During the First Year of Life. Pediatrics 2015; 136:e615-22. [PMID: 26304827 DOI: 10.1542/peds.2015-0980] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Among children with end-stage renal disease (ESRD), those who abstract initiated chronic dialysis during the first year of life historically were less likely to survive or receive a kidney transplant compared with those who initiated dialysis later in childhood.We hypothesized that recently treated infants have experienced improved outcomes. METHODS We queried the North American Pediatric Renal Trials and Collaborative Studies database, obtaining information on 628 children who initiated maintenance peritoneal dialysis for treatment of ESRD at ,1 year of age. We further subcategorized these children by age(neonates, #31 days and infants, 32–365 days) and date of dialysis initiation (past,1992–1999, and recent, 2000–2012). RESULTS Survival while on dialysis and overall survival were significantly better among neonates and infants in the recent cohort. Overall survival at 3 years after dialysis initiation was 78.6%and 84.6% among the recently treated neonates and infants, respectively. Neonates and infants in the recent cohort also were more likely to terminate dialysis for transplantation, and graft survival was improved among recently transplanted infants (3-year graft survival 92.1%). CONCLUSIONS Among children who initiate chronic peritoneal dialysis for treatment of ESRD in the first year of life, survival has improved in recent years. Graft survival also has improved for the subset of these patients who received a kidney transplant.
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Affiliation(s)
- William A. Carey
- Division of Neonatal Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Bradley A. Warady
- Division of Pediatric Nephrology, Children’s Mercy Hospital, Kansas City, Missouri
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25
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Infectious outcomes following gastrostomy in children receiving peritoneal dialysis. Pediatr Nephrol 2015; 30:849-54. [PMID: 25472828 DOI: 10.1007/s00467-014-2951-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Revised: 07/22/2014] [Accepted: 08/26/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Early institution of enteral feeding in paediatric end-stage kidney disease (ESKD) is recommended. For patients on peritoneal dialysis (PD) there is concern that gastrostomy tube (GT) insertion may be complicated by increased peritonitis, in particular fungal. Our unit favours early planned GT insertion, and for those with late presentation, there is prompt consideration of GT insertion following dialysis initiation. This study evaluates our rates of peritonitis with GT insertion following or concurrent with PD initiation. METHODS This was a retrospective, single-centre, cross-sectional study of of 17 New Zealand children with ESKD who received PD in the period 2000-2011. Inclusion criteria were GT placement while on PD or initiation of PD within 72 h of GT insertion. RESULTS There were no cases of fungal peritonitis among the 17 children; however, two cases of early peritonitis with organisms derived from the gastrointestinal tract were identified. No statistically significant difference was found between incident rates of bacterial peritonitis before GT placement (0.6 episodes per patient-year; 95% confidence interval (CI) 0.26-1.18) and post-GT placement (1.21 episodes per patient-year; 95% CI 0.69-1.97). CONCLUSION Fungal peritonitis has never been encountered by out unit during its many years of experience in GT placement in patients without advanced malnutrition. When children on PD have insufficient dietary intake to maintain appropriate growth velocity, enteral feeding should be initiated promptly. A GT is considered to be safe for long-term use in selected patients.
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Evaluation of quality of life by young adult survivors of severe chronic kidney disease in infancy. Pediatr Nephrol 2014; 29:1387-93. [PMID: 24609826 DOI: 10.1007/s00467-014-2785-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2013] [Revised: 01/27/2014] [Accepted: 02/05/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND The health related quality of life (HRQoL) of young adults treated for chronic kidney disease (CKD) stage 4/5 from infancy is unknown. METHODS A HRQoL questionnaire was sent to all 41 patients aged >16 years from a previously characterised cohort of infants with CKD stage 4/5 born between 1986 and 1997. Patient scores were compared with a previously reported cohort of patients who needed renal replacement therapy (RRT) in mid childhood and in the normal population. RESULTS All patients (11 women) completed the questionnaire at a median (range) age of 19.2 (16.3-23.4) years. At the time of the survey, 5 (12.5 %) were on dialysis, 35 (85.5 %) had a functioning kidney transplant, one (2 %) was still conservatively treated and 22 (54 %) had comorbidities; 68 % were either studying or in paid employment, with 17 % actively seeking employment. Although patients described a lower HRQoL than a healthy, age-matched UK group, in some aspects, scores were comparable with patients needing RRT in later childhood. Lower scores were associated with comorbidities, dialysis at last follow-up, more than one treatment modality change and short stature. CONCLUSIONS Our survey demonstrates very encouraging results for long-term HRQoL of infants with severe CKD and highlights the negative impact of comorbidities. These data will help clinicians to counsel and inform families.
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27
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Survival and clinical outcomes of children starting renal replacement therapy in the neonatal period. Kidney Int 2014; 86:168-74. [DOI: 10.1038/ki.2013.561] [Citation(s) in RCA: 128] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2012] [Revised: 11/20/2013] [Accepted: 11/21/2013] [Indexed: 01/06/2023]
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Lantos JD, Warady BA. The evolving ethics of infant dialysis. Pediatr Nephrol 2013; 28:1943-7. [PMID: 23131864 PMCID: PMC3626731 DOI: 10.1007/s00467-012-2351-1] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2012] [Revised: 10/02/2012] [Accepted: 10/03/2012] [Indexed: 11/28/2022]
Abstract
In this paper, we review ethical issues that arise when families and doctors face clinical decisions about renal replacement therapy for an infant with end-stage renal disease (ESRD). Over the last 20 years, many centers have begun to routinely offer renal replacement therapy. However, doctors and nurses both continue to view such therapy as optional, rather than mandatory. We speculate that the burdens of therapy on the family, and the uncertainties about satisfactory outcomes have led to a situation in which renal replacement therapy remains desirable, but non-obligatory. We discuss the reasons why this is likely to remain so, and the ways in which renal replacement therapy for infants with ESRD is similar to, or different from, other clinical situations in pediatrics. Finally, we propose a research agenda to answer questions that are crucial to making good ethical decisions about infant dialysis.
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Affiliation(s)
- John D Lantos
- Children's Mercy Hospital, University of Missouri, 2401 Gillham Road, Kansas City, MO 64108, USA.
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Johnson RJ, Warady BA. Long-term neurocognitive outcomes of patients with end-stage renal disease during infancy. Pediatr Nephrol 2013; 28:1283-91. [PMID: 23553044 DOI: 10.1007/s00467-013-2458-z] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2012] [Revised: 02/27/2013] [Accepted: 03/01/2013] [Indexed: 10/27/2022]
Abstract
BACKGROUND End-stage renal disease (ESRD) during infancy has been associated with poor short-term neurocognitive outcomes. Limited information exists regarding long-term outcomes. METHODS Neurocognitive outcomes for 12 patients diagnosed with ESRD during the first 16 months of life were assessed. Nine patients (mean age: 11 years) were compared to their healthy siblings (mean age: 10 years) on measures of intellectual and executive functioning, memory, and academic achievement using paired-samples t tests. RESULTS Patients' Full Scale IQ (FSIQ) scores (M = 78, SD = 16.1) were significantly lower than sibling controls (M = 94, SD = 18.9; p < 0.03). For patients, FSIQ negatively correlated with total months on dialysis (r = -0.6, p < 0.04), as did WISC-IV Processing Speed (r = -0.6, p < 0.05). Patients' scores on the Metacognition Index of the BRIEF (M = 61.4, SD = 16.3) were significantly higher (indicating greater risk for dysfunction) than siblings (M = 46.7, SD = 6.4; p < 0.04). Patients' scores (M = 84, SD = 19) on the WIAT-II-A Total Achievement were significantly lower than siblings (M = 103, SD = 20, p < 0.01). Younger age at transplant was associated with higher scores on measures of Processing Speed (r = -0.7, p < 0.05), as well as higher scores on measures of executive functioning, memory, and academic achievement. CONCLUSIONS In summary, patients diagnosed with ESRD as infants had intellectual and metacognitive functioning significantly lower than sibling controls. Fewer months on dialysis and younger age at transplant were associated with better outcomes.
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Affiliation(s)
- Rebecca J Johnson
- Developmental & Behavioral Sciences, Children's Mercy Hospitals and Clinics, 2401 Gillham Road, Kansas City, MO 64113, USA.
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Neu AM, Sander A, Borzych-Duzalka D, Watson AR, Vallés PG, Ha IS, Patel H, Askenazi D, Balasz-Chmielewska I, Lauronen J, Groothoff JW, Feber J, Schaefer F, Warady BA. Comorbidities in chronic pediatric peritoneal dialysis patients: a report of the International Pediatric Peritoneal Dialysis Network. Perit Dial Int 2013; 32:410-8. [PMID: 22859841 DOI: 10.3747/pdi.2012.00124] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
UNLABELLED BACKGROUND, OBJECTIVES, AND METHODS: Hospitalization and mortality rates in pediatric dialysis patients remain unacceptably high. Although studies have associated the presence of comorbidities with an increased risk for death in a relatively small number of pediatric dialysis patients, no large-scale study had set out to describe the comorbidities seen in pediatric dialysis patients or to evaluate the impact of those comorbidities on outcomes beyond the newborn period. In the present study, we evaluated the prevalence of comorbidities in a large international cohort of pediatric chronic peritoneal dialysis (CPD) patients from the International Pediatric Peritoneal Dialysis Network registry and began to assess potential associations between those comorbidities and hospitalization rates and mortality. RESULTS Information on comorbidities was available for 1830 patients 0 - 19 years of age at dialysis initiation. Median age at dialysis initiation was 9.1 years [interquartile range (IQR): 10.9], median follow-up for calculation of hospitalization rates was 15.2 months (range: 0.2 - 80.9 months), and total follow-up time in the registry was 2095 patient-years. At least 1 comorbidity had been reported for 602 of the patients (32.9%), with 283 (15.5%) having cognitive impairment; 230 (12.6%), motor impairment; 167 (9.1%), cardiac abnormality; 76 (4.2%), pulmonary abnormality; 212 (11.6%), ocular abnormality; and 101 (5.5%), hearing impairment. Of the 150 patients (8.2%) that had a defined syndrome, 85% had at least 1 nonrenal comorbidity, and 64% had multiple comorbidities. The presence of at least 1 comorbidity was associated with a higher hospitalization rate [hospital days per 100 observation days: 1.7 (IQR: 5.8) vs 1.2 (IQR: 3.9), p = 0.001] and decreased patient survival (4-year survival rate: 73% vs 90%, p < 0.0001). CONCLUSIONS Nearly one third of pediatric CPD patients in a large international cohort had at least 1 comorbidity, and multiple comorbidities were frequently reported among patients with a defined syndrome. Preliminary analysis suggests an association between comorbidity and poor outcome in those patients. As this powerful international registry matures, further multivariate analyses will be important to more clearly define the impact of comorbidities on hospitalization rates and mortality in pediatric CPD patients.
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Affiliation(s)
- Alicia M Neu
- Pediatric Nephrology, The Johns Hopkins University School of Medicine, 200 North Wolfe Street, Baltimore, MD 21287, USA.
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Rees L, Jones H. Nutritional management and growth in children with chronic kidney disease. Pediatr Nephrol 2013; 28:527-36. [PMID: 22825360 DOI: 10.1007/s00467-012-2258-x] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2012] [Revised: 05/18/2012] [Accepted: 06/09/2012] [Indexed: 01/06/2023]
Abstract
Despite continuing improvements in our understanding of the causes of poor growth in chronic kidney disease, many unanswered questions remain: why do some patients maintain a good appetite whereas others have profound anorexia at a similar level of renal function? Why do some, but not all, patients respond to increased nutritional intake? Is feed delivery by gastrostomy superior to oral and nasogastric routes? Do children who are no longer in the 'infancy' stage of growth benefit from enteral feeding? Do patients with protein energy wasting benefit from increased nutritional input? How do we prevent obesity, which is becoming so prevalent in the developed world? This review will address these issues.
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Affiliation(s)
- Lesley Rees
- Department of Nephrology, Gt Ormond St Hospital for Children Foundation Trust, Gt Ormond St, London, WC1N 3JH, UK.
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Hassinger AB, Garimella S. Refractory hypotension after bilateral nephrectomies in a Denys-Drash patient with phenylketonuria. Pediatr Nephrol 2013; 28:345-8. [PMID: 22992984 DOI: 10.1007/s00467-012-2311-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2012] [Revised: 08/02/2012] [Accepted: 08/06/2012] [Indexed: 11/28/2022]
Abstract
BACKGROUND Denys-Drash (DDS) syndrome is a rare genetic syndrome resulting from a mutation in the Wilms' tumor suppressor gene 1 (WT1), which presents with early onset nephrotic syndrome progressing rapidly to end-stage kidney disease (ESKD), pseudohermaphroditism, and high rates of Wilms' tumor. CASE-DIAGNOSIS/TREATMENT We present the case of an infant born with DDS and phenylketonuria with neonatal ESKD and dependence on peritoneal dialysis (PD). This patient developed refractory hypotension after elective bilateral nephrectomies at 10 months of age. Despite outpatient management with sodium supplements and changes in PD fluid removal, the patient was hospitalized for refractory post-prandial hypotension with concurrent lactic acidosis. Blood pressure control and feeding tolerance was achieved using intermittent doses of midodrine, an oral alpha-adrenergic agonist. CONCLUSIONS We discuss this case to offer a therapeutic option for the rare occurrence of persistent post-nephrectomy hypotension.
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Affiliation(s)
- Amanda B Hassinger
- Department of Pediatrics, Division of Critical Care Medicine, Women and Children's Hospital of Buffalo, 219 Bryant Street, Buffalo, NY 14222, USA.
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Alexander RT, Foster BJ, Tonelli MA, Soo A, Nettel-Aguirre A, Hemmelgarn BR, Samuel SM. Survival and transplantation outcomes of children less than 2 years of age with end-stage renal disease. Pediatr Nephrol 2012; 27:1975-83. [PMID: 22673972 DOI: 10.1007/s00467-012-2195-8] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2011] [Revised: 04/04/2012] [Accepted: 04/05/2012] [Indexed: 10/28/2022]
Abstract
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.
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Affiliation(s)
- R Todd Alexander
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada.
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Chen A, Martz K, Rao PS. Does allograft failure impact infection risk on peritoneal dialysis: a North American Pediatric Renal Trials and Collaborative Studies Study. Clin J Am Soc Nephrol 2012; 7:153-7. [PMID: 22246284 DOI: 10.2215/cjn.03160411] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND AND OBJECTIVES Several adult studies report that patients returning to peritoneal dialysis after allograft failure have increased infection-related morbidity. The impact of allograft failure on infection risk in children is uncertain. We compared peritonitis-free survival between pediatric peritoneal dialysis patients with prior allograft failure and those who were transplant naive. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We studied patients, 2-21 years of age, who initiated peritoneal dialysis from January 1, 1992, to December 31, 2007, in the North American Pediatric Renal Trials and Collaborative Studies registry. Demographic characteristics were compared between transplant naive and allograft failure patients using a chi-squared statistic. Peritonitis-free survival was compared between the two groups using Kaplan-Meier estimates. A Cox regression analysis was performed to adjust for covariates, which impact risk of peritonitis. RESULTS Of 2829 patients on peritoneal dialysis, 445 had a prior history of allograft failure and 2384 did not (transplant naive). Demographic characteristics including age at dialysis initiation, race, primary renal disease, and era of dialysis initiation were significantly different between the two groups. Peritonitis-free survival was poorer for the allograft failure group. After covariate adjustment, allograft failure showed borderline significance as a factor predictive of peritonitis. CONCLUSIONS Children initiating peritoneal dialysis after allograft failure may experience a slightly higher infection risk.
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Affiliation(s)
- Ashton Chen
- Department of Pediatrics, Section of Pediatric Nephrology, Wake Forest Baptist Health, Winston-Salem, North Carolina 27157, USA.
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Rödl S, Marschitz I, Mache CJ, Nagel B, Koestenberger M, Zobel G. Hemodiafiltration in infants with complications during peritoneal dialysis. Artif Organs 2012; 36:590-3. [PMID: 22428733 DOI: 10.1111/j.1525-1594.2011.01434.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
End-stage renal disease (ESRD) in neonates still has a high mortality, particularly in the first year of life. We present the combination of peritoneal dialysis (PD) with intermittent hemodiafiltration (iHDF) in neonates with ESRD. Four infants younger than 28 days were treated with PD and iHDF. Renal diagnoses leading to ESRD were cortical necrosis, prune belly syndrome, neonatal hemolytic uremic syndrome, and autosomal recessive polycystic kidney disease. Initially, three patients were on iHDF until PD was started. At the time when complications occurred during PD, patients were switched back to iHDF. iHDF was used five times as a bridge to PD in case of abdominal surgery. Two of the four patients were switched to iHDF because of peritoneal ultrafiltration failure due to recurrent peritoneal leaks. Once, iHDF became necessary due to refractory peritonitis. All four patients survived the first year of life. Two patients were transplanted successfully at an age of 35 and 22 months, respectively. The others are on renal replacement therapy, one on PD at the age of 28 months and one on iHDF at the age of 25 months, respectively. In case of PD complications, iHDF may be an appropriate bridge to achieve long-term survival until kidney transplantation.
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Affiliation(s)
- Siegfried Rödl
- Pediatric Intensive Care Unit, Department of Pediatrics, Medical University of Graz, Graz, Austria.
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Zundel S, Szavay P, Schaefer JF, Amon O, Fuchs J. Single kidney and ureteral atresia in a newborn girl: a treatment concept. J Pediatr Urol 2011; 7:576-8. [PMID: 21398184 DOI: 10.1016/j.jpurol.2011.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2010] [Accepted: 02/02/2011] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To demonstrate a rare case of urological pathology, we report a combination of a single kidney and ureteral atresia. The treatment concept and outcome are outlined. PATIENT AND METHOD Antenatal ultrasound had revealed urinary ascites which lead to caesarean section in the 34th gestational week. Persisting anuria was confirmed postnatally and peritoneal dialysis started on the second day of life. Subsequent laparotomy revealed ureteral atresia after 3 cm of patent ureter. We created an ileum conduit after discussing various other therapeutic options. RESULT AND CONCLUSION A follow up of 12 months has shown steady function of the stoma with stable renal parameters. An ileal conduit represents a good option if high drainage is necessary in early childhood.
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Affiliation(s)
- Sabine Zundel
- Department of Pediatric Surgery, University Children's Hospital, Hoppe-Seyler-Str. 3, 72076 Tuebingen, Germany
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Chen A, Martz K, Kershaw D, Magee J, Rao PS. Mortality risk in children after renal allograft failure: a NAPRTCS study. Pediatr Nephrol 2010; 25:2517-22. [PMID: 20711788 DOI: 10.1007/s00467-010-1631-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2010] [Revised: 07/12/2010] [Accepted: 07/19/2010] [Indexed: 01/16/2023]
Abstract
Studies have shown that adult dialysis patients with a failed renal allograft face a greater risk of mortality on dialysis compared with transplant-naïve patients. The outcome of children returning to dialysis after allograft failure has not been previously studied. Using the North American Pediatric Renal Trials and Collaborative Studies (NAPRTCS) registry, we studied patients aged 2-21 years who initiated dialysis from 1 January 1992 to 31 December 2007. Of a total of 5,006 patients, 1,031 patients had a prior history of allograft failure and 3,975 did not (transplant-naïve). Demographic characteristics, including age at dialysis initiation, race, dialysis modality, primary renal disease, era of dialysis initiation, height Z score, and weight Z score were significantly different between the groups (p < 0.0001). Survival probability between the transplant-naïve and allograft failure groups was not significantly different (94.3% and 93.7% at 3 years respectively, log-rank p = 0.08). After covariate adjustment, allograft failure was not a significant factor contributing to increased mortality risk on dialysis (HR 0.98, CI 0.64-1.50, p = 0.94) based on Cox regression analysis. Children with failed allografts who return to dialysis are not at greater risk of mortality than their transplant-naïve dialysis counterparts.
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Affiliation(s)
- Ashton Chen
- University of Michigan, Ann Arbor, MI 48109-5297, USA.
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Inherited renal tubular dysgenesis may not be universally fatal. Pediatr Nephrol 2010; 25:2531-4. [PMID: 20607303 DOI: 10.1007/s00467-010-1584-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2010] [Revised: 06/01/2010] [Accepted: 06/03/2010] [Indexed: 10/19/2022]
Abstract
Inherited renal tubular dysgenesis (RTD) is caused by mutations in the genes encoding components of the renin-angiotensin cascade: angiotensinogen, renin, angiotensin-converting enzyme (ACE), and angiotensin ΙΙ receptor type 1. It is characterized by oligohydramnios, prematurity, hypotension, hypocalvaria, and neonatal renal failure. The histological hallmark is the absence or poor development of renal proximal tubules. Except for a few cases, the prognosis has been thought to be universally poor, with patients dying either in utero or shortly after birth. We report a 3-year-old infant diagnosed clinically with RTD. The infant survived the neonatal period after 2 weeks of anuria subsequently subsiding. Hypotension and hyperkalemia normalized eventually with administration of fludrocortisone. A revision of renal tissue obtained from a sibling that died shortly after birth revealed normal glomeruli and distal tubules but no identifiable proximal tubules. A novel mutation in the ACE gene was found in the surviving child, who remains with stage 4 chronic kidney disease and normal neurodevelopment. As the number of surviving cases of RTD increases, it should be emphasized to the parents and the neonatal care team that it may not be universally fatal as previously reported. A trial of fludrocortisone may correct hyperkalemia and hypotension.
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Normal growth and intravascular volume status with good metabolic control during peritoneal dialysis in infancy. Pediatr Nephrol 2010; 25:1529-38. [PMID: 20446094 PMCID: PMC2887500 DOI: 10.1007/s00467-010-1535-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2009] [Revised: 04/05/2010] [Accepted: 04/07/2010] [Indexed: 01/19/2023]
Abstract
The most demanding patient population on peritoneal dialysis (PD) consists of children under 2 years of age. Their growth is inferior to that of older children and maintaining euvolemia is difficult, especially in anuric patients. In this prospective study reported here, we enrolled 21 patients <2 years of age (mean 0.59 years) at onset of PD and monitored their uremia parameters and evaluated their nutrition. Since no good instrument currently exists for estimating intravascular volume status, we used traditional blood pressure measurements, echocardiography, and N-terminal atrial natriuretic peptide measurements. Growth was compared with midparental height. Metabolic control was good. Long-term hypertension was seen in 43% of the patients, but left ventricular hypertrophy decreased during the study period. Mean weekly urea Kt/V was 3.38 +/- 0.66 and creatinine clearance was 49 +/- 20 L/week per 1.73 m(2). Catch-up growth was documented in 57% of the patients during PD. However, these children did not attain their midparental height at the end of PD at a mean age of 1.71 years. Although favorable metabolic control and good growth were achieved during PD, these children lagged in term of their midparental height. We conclude that several instruments are needed for determining the management of intravascular volume status and that the control of calcium-phosphorus status is demanding.
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