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Background Our previously demonstrated continuous flow peritoneal dialysis (CFPD) technique in children with acute kidney injury (AKI), although effective, was manpower heavy and expensive due to the high-volume pumps required. The aim of this study was to develop and test a novel gravity-driven CFPD technique in children using readily available, inexpensive equipment and to compare this technique to conventional PD. Methods After development and initial in vitro testing, a randomised crossover clinical trial was conducted in 15 children with AKI requiring dialysis. Patients received both conventional PD and CFPD sequentially, in random order. Primary outcomes were measures of feasibility, clearance and ultrafiltration (UF). Secondary outcomes were complications and mass transfer coefficients (MTC). Paired t-tests were used to compare PD and CFPD outcomes. Results Median (range) age and weight of participants were 6.0 (0.2-14) months and 5.8 (2.3-14.0) kg, respectively. The CFPD system was easily and rapidly assembled. There were no serious adverse events attributed to CFPD. Mean ± SD UF was significantly higher on CFPD compared to conventional PD (4.3 ± 3.15 ml/kg/h vs. 1.04 ± 1.72 ml/kg/h; p < 0.001). Clearances for urea, creatinine and phosphate for children on CFPD were 9.9 ± 3.10 ml/min/1.73 m.sup.2, 7.9 ± 3.3 ml/min/1.73 m.sup.2 and 5.5 ± 1.5 ml/min/1.73 m.sup.2 compared to conventional PD with values of 4.3 ± 1.68 ml/min/1.73 m.sup.2, 3.57 ± 1.3 ml/min/1.73 m.sup.2 and 2.53 ± 0.85 ml/min/1.73 m.sup.2, respectively (all p < 0.001). Conclusion Gravity-assisted CFPD appears to be a feasible and effective way to augment ultrafiltration and clearances in children with AKI. It can be assembled from readily available non-expensive equipment. Graphical abstract, Author(s): Peter Nourse [sup.1] , Mignon McCulloch [sup.1] , Ashton Coetzee [sup.1] , Tim Bunchman [sup.2] , Stefano Picca [sup.3] , Jody Rusch [sup.4] , Andre Brooks [sup.5] , Hilton [...]

Acute kidney injury (AKI) is an increasingly frequent complication among hospitalized children. It is associated with high morbidity and mortality, especially in neonates and children requiring dialysis. The different renal replacement therapy (RRT) options for AKI have expanded from peritoneal dialysis (PD) and intermittent hemodialysis (HD) to continuous RRT (CRRT) and hybrid modalities. Recent advances in the provision of RRT in children allow a higher standard of care for increasingly ill and young patients. In the absence of evidence indicating better survival with any dialysis method, the most appropriate dialysis choice for children with AKI is based on the patient's characteristics, on dialytic modality performance, and on the institutional resources and local practice. In this review, the available dialysis modalities for pediatric AKI will be discussed, focusing on indications, advantages, and limitations of each of them., Author(s): Lara de Galasso [sup.1] , Stefano Picca [sup.1] , Isabella Guzzo [sup.1] Author Affiliations: (1) grid.414125.7, 0000 0001 0727 6809, Division of Nephrology and Dialysis, Department of Pediatrics, Bambino [...]

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 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 [greater than or equal to]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, Author(s): Fabio Paglialonga[sup.1] , Silvia Consolo[sup.1] , Carmine Pecoraro[sup.2] , Enrico Vidal[sup.3] , Bruno Gianoglio[sup.4] , Flora Puteo[sup.5] , Stefano Picca[sup.6] , Maria Teresa Saravo[sup.2] , Alberto Edefonti[sup.1] , Enrico [...]

Background Mortality among critically ill children requiring continuous renal replacement therapy (CRRT) is high. Several factors have been identified as outcome predictors. Many studies have specifically reported a positive association between the fluid overload at CRRT initiation and the mortality of critically ill pediatric patients. Methods This study is a retrospective single-center analysis including all patients admitted to the pediatric intensive care unit (PICU) of our hospital who received CRRT between 2000 and 2012. One hundred thirty-one patients were identified and subsequently classified according to primary disease. Survival rates, severity of illness and fluid balance differed among subgroups. The primary outcome was patient survival to PICU discharge. Results Overall survival to PICU discharge was 45.8 %. Based on multiple regression analysis, mortality was independently associated with onco-hematological disease [odds ratio (OR) 11.7, 95 % confidence interval (CI) 1.3-104.7; p = 0.028], severe multiple organ dysfunction syndrome (MODS) (OR 5.1, 95 % CI 1.7-15; p = 0.003) and hypotension (OR 11.6, 95 % CI 1.4-93.2; p = 0.021). In the subgroup analysis, a fluid overload (FO) of more than 10 % (FO>10 %) at the beginning of CRRT seems to be a negative predictor of mortality (OR 10.9, 95 % CI 0.78-152.62; p = 0.07) only in children with milder disease (renal patients). Due to lack of statistical power, the independent effect of fluid overload on mortality could not be analyzed in all subgroups of patients. Conclusions In children treated with CRRT the underlying diagnosis and severity of illness are independent risk factors for mortality. The degree of FO is a negative predictor only in patients with milder disease., Author(s): Lara de Galasso[sup.1] , Francesco Emma[sup.2] , Stefano Picca[sup.2] , Matteo Di Nardo[sup.3] , Emanuele Rossetti[sup.3] , Isabella Guzzo[sup.2] Author Affiliations: (1) Nephrology and Dialysis A Unit, 'Sapienza' University [...]

Background In severe neonatal hyperammonemia, extracorporeal dialysis (ECD) provides higher ammonium clearance than peritoneal dialysis (PD). However, there are limited outcome data in relation to dialysis modality. Methods Data from infants with hyperammonemia secondary to inborn errors of metabolism (IEM) treated with dialysis were collected in six Italian centers and retrospectively analyzed. Results Forty-five neonates born between 1990 and 2011 were enrolled in the study. Of these, 23 were treated with PD and 22 with ECD (14 with continuous venovenous hemodialysis [CVVHD], 5 with continuous arteriovenous hemodialysis [CAVHD], 3 with hemodialysis [HD]). Patients treated with PD experienced a shorter duration of predialysis coma, while those treated with HD had a shorter ammonium decay time compared with all the other patients (p < 0.05). No difference in ammonium reduction rate was observed between patients treated with PD, CAVHD or CVVHD. Carbamoyl phosphate synthetase deficiency (CPS) was significantly associated with increased risk of death (OR: 9.37 [1.52-57.6], p = 0.016). Predialysis ammonium levels were significantly associated with a composite end-point of death or neurological sequelae (adjusted OR: 1.13 [1.02-1.27] per 100 [mu]mol/l, p = 0.026). No association was found between outcome and dialysis modality. Conclusions In this study, a delayed ECD treatment was not superior to PD in improving the short-term outcome of neonates with hyperammonemia secondary to IEM. Electronic supplementary material The online version of this article (doi:10.1007/s00467-014-2945-x) contains supplementary material, which is available to authorized users, Author(s): Stefano Picca[sup.1] , Carlo Dionisi-Vici[sup.2] , Andrea Bartuli[sup.3] , Tommaso De Palo[sup.4] , Francesco Papadia[sup.5] , Giovanni Montini[sup.6] , Marco Materassi[sup.7] , Maria Alice Donati[sup.8] , Enrico Verrina[sup.9] , [...]

Secondary hyperparathyroidism is a common complication of chronic renal failure. Kidney transplantation corrects renal insufficiency and most metabolic abnormalities but hyperparathyroidism persists in 50% of children after transplantation. The aim of this study was to investigate parathyroid hormone (PTH) course and potential risk factors for hyperparathyroidism in children after renal transplant. We collected data from 145 transplanted children (mean follow-up 4.7 years). Intact PTH level (iPTH) rapidly decreased in the first 6 months post-transplant and continued to decline in the following years. iPTH was above the normal range in 69.1% of the patients at the time of transplant and in 47% 1 year later, this improvement continuing thereafter. Hypercalcemia was present in 20.3% of the patients before transplant and in 6.3 and 4.1% of patients 6 months and 1 year after transplant, respectively. Hypophosphatemia was present in 5.5% of the patients at 6 months, and 45.5% of the patients needed phosphorus supplements during the first 6 months after transplant. Multivariate analysis indicated pre-transplant hyperparathyroidism, dialysis duration, creatinine clearance and hypophosphatemia as predictors of persistent hyperparathyroidism. In kidney transplanted children, serum iPTH normalized in the long term in the majority of cases. Thus, parathyroidectomy should be reserved for selected patients., Author(s): Isabella Guzzo [sup.1] , Giacomo Di Zazzo [sup.1] , Chiara Laurenzi [sup.1] , Lucilla Ravà [sup.1] , Germana Giannone [sup.1] , Stefano Picca [sup.1] , Luca Dello Strologo [sup.1] [...]

Abstract We have previously described severe hyperparathyroidism during the pubertal growth spurt in three uremic adolescents treated with recombinant human growth hormone (rhGH). Here we investigate the possible role of [...]

Background Autologous arteriovenous fistulas (AVFs) are the current gold standard for vascular access in hemodialysis (HD). However, in pediatric patients, specific clinical settings may contraindicate the procedure, thus mandating the use of a prosthetic graft (PG). Case-Diagnosis/Treatment We report a case of successful polycarbonate urethane graft implantation and subsequent resumption of HD 12 h after the procedure in a young girl with end-stage renal disease (ESRD), challenging vascular anatomy and the absence of vascular access. Conclusions The use of polycarbonate urethane PGs in children with ESRD and difficult vascular accesses may represent a valid alternative for early resumption of HD., Introduction In children, prosthetic grafts (PGs) are rarely used to create arteriovenous fistulas (AVFs) for hemodialysis (HD). When implanted, a "maturation" of at least 14 days before cannulation is recommended. [...]

The number of children with acute kidney injury (AKI) requiring dialysis is increasing. To date, systematic analysis has been largely limited to critically ill children treated with continuous renal replacement therapy (CRRT). We conducted a survey among 35 European Pediatric Nephrology Centers to investigate dialysis practices in European children with AKI. Altogether, the centers perform dialysis in more than 900 pediatric patients with AKI per year. PD and CRRT are the most frequently used dialysis modalities, accounting for 39.4% and 38.2% of treatments, followed by intermittent HD (22.4%). In units treating more than 25 cases per year and in those with cardiothoracic surgery programs, PD is the most commonly chosen dialysis modality. Also, nearly one quarter of centers, in countries with a gross domestic product below $35,000/year, do not utilize CRRT at all. Dialysis nurses are exclusively in charge of CRRT management in 45% of the cases and pediatric intensive care nurses in 25%, while shared management is practiced in 30%. In conclusion, this survey indicates that the choice of treatment modalities for dialysis in children with AKI in Europe is affected by the underlying ethiology of the disease, organization/set-up of centers and socioeconomic conditions. PD is utilized as often as CRRT, and also intermittent HD is a commonly applied treatment option. A prospective European AKI registry is planned to provide further insights on the epidemiology, management and outcomes of dialysis in pediatric AKI.