Hemodialysis in children: how, when and why

End-stage renal diseases requiring chronic dialysis are rare in childhood and adolescence, but they are associated with high mortality and impaired quality of life (1, 2). The most common disease that causes chronic kidney disease (CKD) is primary glomerular disease (GD), followed by congenital abnormalities of the kidney and urinary tract, cystic, hereditary or congenital disorders and, more rarely, secondary GD. However, patients with secondary GD, urologic disorders, and metabolic diseases have greater mortality risk than patients with primary GD (3). Here, we focused on the different options of treatment available, and specifically we compared peritoneal dialysis and hemodialysis, showing pros and cons between them.

Pediatric urolithiasis

Urolithiasis is a well-known condition that can affect any part of the urinary tract. With a rate of 3-5% the incidence of upper urinary tract for long has been higher in adults (1-3), but recently it has increased among children reaching 3,3% . Indeed, more than 1% of all urinary stones are seen in patients aged less than 18 years (4). Pediatric urolithiasis is endemic in Turkey and Far East and it is probably due to malnutrition and racial factors (5). The spontaneous stone passage is more likely in children than in adults, indeed ureteral calculi spontaneously pass into 41-63% of children (1). Rate of stone passage depends on size and stone location in the urinary system. Stones sized less than 5 mm have a passage rate ranging from 40% to 98%, whilst stones > 5 mm have between 55% and 50% (6). In the last decade, the use of alpha blockers has proven well efficacious in helping spontaneous passage of distal ureteric stones in adults (7-9). The latest EAU guidelines support their use in adults while remain vague about their use in children because of unclear safety and efficacy (4). In search of evidence supporting or not the use of medical expulsive therapy in children we reviewed the literature dealing with the management of urolithiasis in pediatric patients. The primary aim of the present study was to evaluate the efficacy of medical expulsive therapy (MET), defined as stone expulsion rate, with a-blockers compared to a control group. The secondary aim was to assess the safety, defined as side effects rate, of MET compared to a control group.

Chyloperitoneum associated with idiopathic pancreatitis: case report and review of the literature

Acute chylous peritonitis is defined as the onset of acute abdomen findings due to abrupt chylous fluid accumulation in the peritoneal space. A correct diagnosis of this condition is seldom made preoperatively. The optimal management of true chylous pancreatitis depends upon the underlying etiology. Thorough lavage of the abdomen and adequate drainage has proven to be an excellent treatment modality for acute chylous peritonitis, since resolution of chylous ascites usually occurs within the next few days. However, conservative treatment may be appropriate in selected cases. We present a case report and a brief review of the literature.

[Recurrent giant retroperitoneal leiomyosarcoma. Report of a clinical case]

The Authors report the case of a male patient, 52 year old, suffering from retroperitoneal leiomyosarcoma, submitted to multiple operations in the space of about seven years, for the presence of liver metastases and local relapses; the good general health state, the moderate grade of the neoplasm and the disease's fair interval free, have justified the therapeutic attitude adopted; the patient at present enjoys good health.

[Renal transplant from living donor. Experience of the Parma Center]

BACKGROUND AND AIMS

The scarce availability of organs and the excellent results obtained using living donors, due to the improved degree of compatibility between donor and recipient, the short period of organ storage and the possibility of choosing the ideal surgical "timing", in the authors' opinion justify the use of living donors from a clinical and ethical-moral point of view.

METHODS

Between April 1986 and December 1996 a 406 renal transplants were performed; of these, 10 patients received grafts from living donors. Preliminary screening consisted in a careful clinical and immunological evaluation to evaluate the operating risk, good compatibility with the recipient and the perfect bilateral function of the kidney.

RESULTS

The 10 donors had no postoperative mortality or morbidity, no alterations of renal function, and no onset of hypertension and/or proteinuria in the immediate post-operative period or at a distance. The organ and patient survival rate (including a follow-up of between 2 and 54 months, mean 25 months) was 100%.

CONCLUSIONS

The authors suggest that living donors represent a valid alternative in uremic patients. This therapeutic act must be carried out in complete respect for ethical, moral and legislative principles and must be based on a careful clinical selection to minimise the risks of donation and to guarantee the maximum benefit for the recipient. It is to be hoped that further improvements are made in immunodepressive treatment, and above all an appropriate increase in transplants from cadaveric donors, making the use of living donors superfluous since this practice maims a perfectly healthy individual.

[Neoplasms and kidney transplantation. Case contribution]

BACKGROUND

The incidence of malignancies after transplantation is higher when compared with expected cancer in control patients, particularly skin and female genital cancer, non-Hodgkin's disease and Kaposi's sarcoma. The aim of this study is to evaluate the frequency and the efficacy of the treatment of cancer following renal transplantation.

METHODS

A retrospective analysis of 404 recipients was performed and it showed the onset of 15 cancers (8 skin cancers, 3 Kaposi's sarcomas, 2 renal carcinomas, 1 urotelioma and 1 colon cancer) in 11 patients (3.7%). At the time of diagnosis, the mean period of immunosuppressive therapy (7 cases of double therapy, 4 cases of triple therapy) was 44.8 months. Skin cancer (53.3%) and Kaposi's sarcoma (20%) were the most frequent in personal experience as reported in literature. Neither lymphomas, nor female genital cancers were detected.

RESULTS

All the cases were surgically treated, except patients with Kaposi's sarcoma, whose immunosuppressive therapy was reduced without alteration of renal function. Death-rate was 0.25% (1 case), the remaining patients show no signs of local recurrence or metastasis with preserved renal function except for the patient with renal carcinoma of the transplanted kidney, who underwent nephrectomy and returned in replacement therapy.

CONCLUSIONS

The conclusion is drawn that the research of relationship between type of immunosuppressive therapy and cancer incidence and careful clinical and instrumental examination of transplant patients may contribute to reduce the onset of neoplastic degenerations and lead to an early diagnosis.

[The large hiatal stomach hernia and its surgical correction: the authors' personal experience]

The authors report their experience with hiatus hernia surgery (9 cases of large hernia with severe gastroesophageal reflux). The fundamental role of instrumental diagnostics in establishing both a clear indication for surgical correction and the quality of the results obtained is emphasized. Technical details of the surgical treatment are report as well. On the basis of their experience and in accordance with other authors the Nissen fundoplication is considered a valid antireflux procedure. Furthermore, the abdominal approach used for this procedure allows to treat other abdominal pathologies often associated with hiatal hernia.

Role of transesophageal pacing in recurrent atrial fibrillation. Experience with propafenone

To assess the role of transesophageal pacing (TP) at very high rates in the follow-up of patients with recurrent and sustained paroxysmal atrial fibrillation (AF) on therapy, the authors studied 15 patients (10 women, 5 men; aged forty-four to seventy-seven years old). Of them only 1 had a mild mitral regurgitation; none had hyperthyroidism or acute ischemic heart disease. They tested propafenone (P) at a dose of 1.4-2 mg/kg over ten minutes as an intravenous bolus and 0.5 mg/minute as intravenous maintenance for two hours and then 300 mg twice daily orally and chronically. Serial TPs at very rapid rates (up to 600 bpm) were performed to test the long-term efficacy of P to prevent paroxysmal AF. The mean follow-up was fifteen months (nine to twenty-four months).

RESULTS

Intravenous P converted AF in five to ninety minutes (mean twenty-one minutes) in 9/15 patients (conversion rate of 60%); in an additional 4 patients oral P converted AF in two to fifteen hours. In the other 2 patients P failed to convert AF. Three patients experienced recurrence of AF in the early follow-up. Of the 10 patients who completed the entire protocol, only 1, who had mild mitral prolapse regurgitation and AF induction by TP, experienced new episodes of AF during follow-up. No significant side effects were noted during P therapy.

CONCLUSIONS

Propafenone appears safe and effective for controlling and preventing recurrent and sustained AF. Transesophageal pacing is a valid tool for predicting the efficacy of long-term therapy in the follow-up of patients with paroxysmal atrial fibrillation.

[Diagnostic imaging in constipation]

Diagnostic imaging modalities play a key role in the definition of the possible causes of constipation. Barium Enema (BE), Defecography (DG), Intestinal Transit Time (ITT), Computed Axial Tomography (CT) and Magnetic Resonance (MR) are necessary diagnostic tools for the identification either of the possible organic causes of the disease or of the functional disorders. The ITT evaluation is the main investigation to look for functional colic constipation; this method is in fact able to distinguish between the hypertonic type (in which the fecal progression is slowed down to such an extent that radiopaque markers accumulate in the most proximal part of the colon) and the atonic one (characterized by a global slowing down with the markers distributed along the whole colon). DG gives very accurate dynamic documentation of the pathologic alteration of the rectum-anal conduit, as well as of the disease of the supporting and anchoring system and of the levator complex; this type of investigation allows the definition (characterisation) of the different types of the functional rectum-anal constipation. Even in this case TAC and RM can greatly contribute to the definition of the whole picture of the constipation.

[Risks from volatile anesthetics in operating rooms of Umbrian hospitals]

The present report is a research on air samples taken in the operating theatres environment in the hospitals of Umbria to control in order the concentration of anaesthetics in use and to define ambient pollution and to propose changes. The A.A. have divided operating theatres in for groups to analyze the data: 1) operating theatres where there were both systems: air change system and air intake system; 2) operating theatres where there was only the air-change system; 3) operating theatres where there was only the air intake system; 4) operating theatres where there were no systems. These data have been compared with the limit values advised by N.I.O.S.H. The lowest value of pollution have been recorded in those operating theatres with both systems. The A.A. have also compared the ethrane or other alogenated anaesthetics values in the air-change system equipped operating theatres with those (values) found in the intake-air system equipped operating theatres. The lowest values have been recorded in those operating theatres with normal air-change system. Where changes have been made to improve the operating theatres environment, the A.A. have effectuated new controls and found lower values of the anaesthetics levels. The concentration of anaesthetics appeared lower then before.

Mutagenic/carcinogenic hazards in a cold-rolling steel plant exposed to mineral oils: environmental monitoring phase

A survey was carried out in a cold-rolling steel plant exposed to mineral oils to study the mutagenic/carcinogenic hazards, following a coupled environmental/biological monitoring. The present paper deals only with the environmental phase by determining polycyclic aromatic hydrocarbons (PAH) and applying a mutagenicity test (Ames test), and includes the following steps: (a) work process and environment study; (b) sampling and analysing mineral oils before and after use (PAH determination and mutagenicity analysis); (c) sampling and analysing oil mist (TWA determination, PAH determination and mutagenicity analysis). The results showed that: (1) both unused and used (recycled) mineral oils contained only trace amounts of PAH and were not mutagenic; (2) the TWA concentrations of oil mists were lower than the TLV (less than 5 mg/m3); (3) oil mists contained only trace amounts of PAH and were not mutagenic. The authors suggest that these results could be due to the moderate temperature of the oil during the work process and that there is a relationship between low PAH content and absence of mutagenicity in the oils and air samples.

Application of the Salmonella mutagenicity assay and determination of polycyclic aromatic hydrocarbons in workplaces exposed to petroleum pitch and petroleum coke

Workplaces of an Italian carbon electrode factory, exposed to petroleum pitch and petroleum coke, were studied using a coupled chemical and biological approach to evaluate occupational mutagenic/carcinogenic hazards. Analytical procedures for the determination of polycyclic aromatic hydrocarbons (PAH) and Salmonella/microsome mutagenicity tests (with TA98 and TA100 strains) were performed on both industrial ingredients (pitch and coke) and airborne particulate matter of the working environment, after fractionating by sequential Soxhlet extractions with four organic solvents of increasing polarity (benzene, chloroform, methanol and acetone). The results showed: (a) the presence of extraordinarily high PAH (carcinogenic and non-carcinogenic) contents in the benzene extracts of petroleum pitch (3.6 wt% of total PAH) and of airborne particulate samples (up to 0.35 wt% of total PAH), in correlation with very high indirect (after metabolic activation) mutagenic responses of benzene extracts with strain TA98; (b) very high indirect mutagenic responses in the other extracts of the airborne particulate samples (especially with strain TA98); (c) the production during the processing at high temperatures of directly acting mutagens (without metabolic activation) which were absent in the starting materials and their release in the air of workplaces. The comparison of chemical analytical and mutagenicity data has proved to be an interesting approach for better defining the relative health hazards due to occupational exposure to potentially mutagenic/carcinogenic petroleum products.