Management of End-Stage Renal Disease in Children with Acquired Immune Deficiency Syndrome Nephropathy

Predictors and outcome of catheter-related bacteremia in children on chronic hemodialysis

Tunneled central venous catheters are often used in children on chronic hemodialysis. This study was done to evaluate the spectrum of catheter-related bacteremia (CRB) and to determine predictors of recurrent CRB in children on hemodialysis. Chart review was performed in 59 children from a pediatric dialysis unit with chronic, tunneled, cuffed hemodialysis catheters between January 1999 and December 2003. CRB was diagnosed in 48 of 59 (81%) patients. The incidence of CRB was 4.8/1,000 catheter days. Overall catheter survival (290+/-216 days) was significantly longer than infection-free catheter survival (210+/-167 days, p<0.05). Organisms isolated were gram-positive in 67%, gram-negative in 14%, and polymicrobial in 19%. Systemic antibiotics cleared CRB in 34% and an additional 23% cleared with the inclusion of antibiotic-heparin locks; 43% required catheter exchange. There was a significant likelihood of early catheter exchange with polymicrobial CRB (p<0.01). Catheter loss occurred from infection in 63%. Risk factors for CRB included young age (<10 years) and presence of human immunodeficiency virus (HIV) infection. Patients with >2 initial positive blood cultures (p<0.0001) had a significantly higher rate of recurrence after 6 weeks of initial treatment. In conclusion, CRB remains a major determinant of catheter loss. However, overall catheter survival is longer than infection-free catheter survival, suggesting that systemic antibiotics with antibiotic-heparin locks should be the initial step in the management of CRB and this approach may salvage some catheters.

HIV nephropathy in children

The evaluation and management of children with HIV nephropathy provide a great challenge to the pediatric nephrologist caring for patients with this tragic illness, of which the nephropathy is only part of their problem and extends beyond the patient to the family and all of the supportive team involved. Care decisions should be based on a multi-disciplinary approach in which the infectious disease component is included. There are many areas that require a better understanding, particularly the pathogenesis of HIV nephropathy and the approach to treatment of the nephropathy with specific drugs. Early identification of children affected with this condition and an aggressive approach to management seem essential to the improvement of the outcome of these patients.