Comparison of darbepoetin alpha and recombinant human erythropoietin for treatment of anemia in pediatric chronic kidney disease: a non-inferiority trial from India

To determine whether or not Darbepoetin alpha (DA) was non-inferior to recombinant human erythropoietin (rHuEPO) in the treatment of anemia in children with chronic kidney disease (CKD) stage 3-5 (on or not on dialysis). This was a randomized, open-label, two-arm, parallel group, active-controlled, non-inferiority trial conducted at a tertiary care center in New Delhi, India. Fifty patients of either gender (aged 1-18 years) with CKD stage 3-5 (on or not on dialysis) who had baseline hemoglobin (Hb) between 9 and 12 g/dL and were on stable erythropoietin therapy for at least 8 weeks were randomized (1:1) to either continue rHuEPO or switch to DA therapy for a period of 28 weeks. Doses were titrated in the initial 23 weeks to maintain the Hb between 11 and 12 g/dL, and efficacy was assessed between weeks 24 and 28. The primary efficacy outcome was the mean change in Hb between baseline and the evaluation period. In the intention-to-treat population (n = 50), the adjusted between-group difference in mean Hb change between the baseline and the evaluation period was 0.131 g/dL (95% CI: - 0.439 to 0.719, p = 0.629). The lower limit of the two-sided 95% CI for the difference in the mean change in Hb between the two treatment groups was well above the pre-specified non-inferiority margin of - 1.0 g/dL. Similar pattern of non-inferiority was seen for per protocol population. The safety profile of DA and rHuEPO was also comparable (injection site pain:rHuEPO-3, DA-7; p-0.296).   Conclusion: DA is non-inferior to rHuEPO for the treatment of anemia of CKD (stage 3-5) in pediatric population with a comparable safety profile.   Trial registration: ClinicalTrials.gov Identifier: NCT04959578 (retrospectively registered), Date: July 13, 2021. What is Known: • Limited studies showing darbepoetin alpha is effective in children as an erythropoiesis stimulating agent. • No RCT from Indian subcontinent addressing this topic. What is New: • Darbepoetin alpha is non inferior to recombinant human erythropoietin for treatment of anemia in children with CKD stage 3-5 (on or not on dialysis) with safety comparable to recombinant human erythropoietin. • A cost reduction of approximately 8.6% per patient by shifting to darbepoetin alpha.

Therapeutic Plasma Exchange in Children - Experience From a Tertiary Care Center

OBJECTIVE

To assess the safety, efficacy and outcomes of therapeutic plasma exchange (TPE) in children.

METHODS

Data were retrieved from hospital records for all children £18 years who underwent TPE between August, 2011 and July, 2018.

RESULTS

46 children [median (range) age 96 (8-204) months] underwent 293 sessions of TPE by membrane plasma separation technique. Renal disease was the commonest indication (24, 52.2%) followed by neurological illnesses (17; 36.9%). 36 (78.2%) patients belonged to American Society for Apheresis category I. Overall, the most common indication was atypical hemolytic uremic syndrome (aHUS) (16; 34.8%). Fresh frozen plasma plus albumin was used as replacement fluid in aHUS, while albumin was used in others. 40 (86.9%) patients had complete/partial recovery while six did not show any sign of recovery. Complications were seen in 21 (7.1%) sessions; majority of which were minor in the form of blood pressure fluctuations.

CONCLUSION

TPE can be performed safely and effectively for renal and non-renal indications, even in small children.

Continuous renal replacement therapy in children with severe sepsis and multiorgan dysfunction - A pilot study on timing of initiation

Objective:

Scanty literature is available regarding continuous renal replacement therapy (CRRT) utility in severe sepsis with multiorgan dysfunction syndrome (MODS) from developing countries. Author unit's experience in pediatric CRRT is described and outcome of early initiation of CRRT with sepsis and MODS is assessed.

Materials and Methods:

Children aged <16 years with sepsis and MODS who required CRRT from September 2010 to February 2015 were analyzed on demographic factors, timing of initiation of CRRT, mode of CRRT, effect of CRRT onhemodynamics, oxygenation parameters, and outcome.

Results:

Twenty-seven children required CRRT (male - 16). The median age was 11 years (range 1.1–16). Twenty-one had severe sepsis with MODS. Eighteen patients were given CRRT within 48 h of admission to Intensive Care Unit (ICU). Statistically significant improvement in the P/F ratio, decrement in plateau pressure and vasoactive-inotropic score were noted in survivor group compared to nonsurvivor group (P = 0.022, 0.00, and 0.03, respectively). There was no statistically significant difference in duration of ICU stay, fluid overload, CRRT duration, PRISM score at 12 and 24 h, percentage of decrease in inotrope score, plateau pressure, and percentage of increase in P/F ratio in relation to timing of CRRT initiation. However, the survival rate was 61.1% (11/18) who received CRRT within 48 h of ICU admission compared to 33.3% (3/9) who received after 48 h (P = 0.0001).

Conclusion:

Our study emphasizes the CRRT role in improving the oxygenation status and hemodynamics. Survival benefit may be expected in those children who receive CRRT early in the course of sepsis. However, multicenter RCTs are required to prove mortality benefit.

CT diagnosis of strangulated diaphragmatic hernia

Strangulated diaphragmatic hernia is a surgical emergency which on occasions can be a diagnostic dilemma. We report of a 2-year-old-male child with strangulated diaphragmatic hernia in whom a correct preoperative diagnosis was made with progression of illness. CT depicted a curvilinear fat stripe in a fluid filled hemithorax.