Search

BACKGROUND: The proportion of gram-negative causative organisms in peritoneal dialysis-associated peritonitis is increasing. Little published information for this complication exists in children. The objective of this study is to evaluate the clinical presentation, early and late response to treatment, and identification of factors influencing the outcome of gram-negative peritonitis (GNP) in children. STUDY DESIGN: Case series. SETTING AND PARTICIPANTS: 104 children (aged 7.9 +/- 5.9 years) with 121 GNP episodes reported to the International Pediatric Peritonitis Registry from October 2001 through December 2004. PREDICTORS: Patient, clinical, bacteriological, and treatment features. OUTCOMES: Initial response to empirical treatment was assessed after approximately 72 hours of therapy. Final outcome was judged according to the occurrence of death, technique failure, relapse, need for catheter exchange, and a composite end point defining full functional recovery. RESULTS: 44% of episodes of GNP occurred in children younger than 5 years. Causative organisms included Pseudomonas species, 21%; Klebsiella species, 18%; Escherichia coli, 17%; and Acinetobacter species, 12%. Thirty-two percent of organisms classified as gram-negative were not identified further. Clinical manifestations were severe and uniform for all causative gram-negative agents. A substantial proportion (20%) of organisms were resistant to ceftazidime, with resulting suboptimal response to empirical therapy. By day 3 of initial empiric treatment, 85% of children with GNP had improved clinically (39%, complete resolution; 46%, improvement in symptoms), 10% showed poor response, and 5% had worsening of symptoms. Multivariate analysis identified severe abdominal pain, use of a single-cuff catheter, and intermittent (versus continuous) intraperitoneal ceftazidime administration as independent predictors of worse initial response to treatment. Full functional recovery was achieved in 86% of episodes. Nineteen patients (16%) required catheter removal, 11 (9%) experienced a relapse, 7 (6%) discontinued peritoneal dialysis therapy permanently, and 3 died. Lack of clinical improvement after 72 hours of therapy (odds ratio, 5.39; P < 0.01) and the presence of an exit-site infection (odds ratio, 7.69; P = 0.01) independently increased the risk of an incomplete functional recovery. LIMITATIONS: The study was not designed to assess absolute incidence figures or risk factors for the development of GNP in children. CONCLUSIONS: GNP is a significant complication of long-term peritoneal dialysis therapy in children, and a substantial proportion of affected children are at risk of permanent sequelae. Because results of empiric treatment with ceftazidime are suboptimal in the setting of this infection, alternative antimicrobial agents should be reconsidered. Copyright © 2008 National Kidney Foundation, Inc. [ABSTRACT FROM AUTHOR]

Renal osteodystrophy starts very early in chronic renal failure. Although vitamin D levels are normal in patients with 70-80% function, the levels are not appropriate to the prevailing biochemical milieu. Renal osteodystrophy may contribute to renal growth failure but a correlation between the degree of renal osteodystrophy and growth failure is not observed. Catch-up growth cannot be obtained over a longer period of time with vitamin D. The main reason for osteomalacia is Al intoxication. Aluminium osteopathy is more common in pediatric renal patients than anticipated. The mechanism whereby Al produces its effect on bone is uncertain. Guidelines for the diagnosis and therapy of renal osteopathy are presented. Prophylaxis of renal osteopathy can be attempted by phosphate restriction and/or vitamin D and by avoiding Al-containing drugs. All vitamin D compounds can be used for treatment and all have their advantages and disadvantages. [ABSTRACT FROM AUTHOR]

Peritoneal clearances and dialysate protein losses occurring in paediatric patients undergoing different continuous cycling peritoneal dialysis (CCPD) regimens have not been well defined. We, therefore, evaluated 10 children aged 15.8±2.5 (SD) years who were maintained on home peritoneal dialysis for 20.5±10 months. All patients had at least 3 months of CCPD. The patients were admitted to the Clinical Research Center for 48 hours and allocated to five different dialysis protocols. In protocol I, the frequency of exchanges was 10 per 10 hours; in Protocol II it was 5 per 10 hours; and in Protocol III it was 3 per 10 hours. Protocol II D and III D had, in addition, a daytime dwell of one-half the night-time vol ume. A 1.5% glucose dialysate solution was used for night-time dialysis, and 4.25% glucose dialysate solution for the daytime dwell. The mean inflow dialysate volume per exchange was 36.7±5.6 ml/kg body weight and was constant in each patient for each study protocol. BUN and creatinine clearances for each protocol were calculated and dialysate protein losses were measured. The data indicate that hourly night-time dialysis (Protocol I) provides best solute clearance. A daytime dwell further enhances the total solute clearance and should be used preferably in anuric patients. Residual urine output contributes significantly to the total solute clearance. Protein losses are maximum with low-frequency exchanges and a daytime dwell. No significant differences in the serum albumin concentrations were found during the different protocols; however, the long-term effect of the protein loss on the nutritional status of the patients requires further evaluation. [ABSTRACT FROM PUBLISHER]

Studies aluminium toxicity in patients on dialysis due to aluminium absorption from sucralfate. Promotion of peptic ulcer healing by sucraflate; Indication of aluminium absorption from increments in urinary aluminium; Increase in plasma aluminium level in patients on dialysis after three weeks of sucraflate therapy.

Background: Intermittent oral or intravenous doses of calcitriol given two or three times per week are commonly used to treat secondary hyperparathyroidism (secondary HPT). This study was undertaken to compare the biochemical and skeletal responses to thrice weekly intraperitoneal (i.p.) versus oral doses of calcitriol in children with secondary HPT undergoing peritoneal dialysis (CCPD).Methods: Forty-six patients aged 12.5+/-4.8 years on CCPD for 22+/-25 months were randomly assigned to treatment with oral (p.o.) or i.p. calcitriol for 12 months; 17 subjects given p.o. calcitriol and 16 subjects given i.p. calcitriol completed the study. Bone biopsies were performed at the beginning and at the end of the study, while determinations of serum and total ionized calcium, phosphorus, alkaline phosphatase, parathyroid hormone (PTH) and calcitriol levels were done monthly.Results: Serum total and ionized calcium levels were higher in subjects treated with i.p. calcitriol, P < 0.0001, whereas serum phosphorus levels were higher in those given p.o. calcitriol, P < 0.0001. For the i.p. group, serum PTH levels decreased from pre-treatment values of 648+/-125 pg/ml to a nadir of 169+/-57 pg/ml after nine months. In contrast, serum PTH levels did not change from baseline values of 670+/-97 pg/ml in subjects given p.o. calcitriol, P < 0.0001 by multiple regression analysis. Serum alkaline phosphatase levels were also lower in patients treated with i.p. calcitriol, P < 0.0001, but there was no difference between groups in the average dose of calcitriol given thrice weekly. The skeletal lesions of secondary HPT improved in both groups, 33% of patients developed adynamic bone lesion.Conclusion: Differences in the bioavailability of calcitriol and/or in phosphorus metabolism may account for the divergent biochemical response to p.o. and i.p. calcitriol. [ABSTRACT FROM AUTHOR]

Little is known about the extent and severity of bone disease in children undergoing successful renal transplantation. To address this issue, 47 patients with stable renal function 3.2 +/- 1.7 years after transplantation (Tx) underwent iliac crest bone biopsy. The mean age of patients was 12 +/- 2.0 years; 36 had received cadaveric renal grafts, whereas 11 had undergone living-related Tx. Immunosuppressive drugs included cyclosporine 0.17 +/- 0.4 mg/kg/day, prednisone 7.5 +/- 2.1 mg/kg/day, and either azathioprine 1.6 +/- 0.9 mg/kg/day or mycophenolate mofetil 30 +/- 3 mg/kg/day. In addition to quantitative bone histomorphometry, the bone mineral content (BMC) of the lumbar spine was measured by dual energy X-ray absorptiometry (DXA) in 24/47 patients. Thirty-one transplant recipients had normal bone formation (N-Bfr), 11 had mild hyperparathyroidism (HPT) and 5 had adynamic skeletal lesions (AD). The interval since Tx, duration of dialysis before Tx and cumulative prednisone dose did not differ among groups. Trabecular bone area was highest in subjects with HPT. Unexpectedly, eroded bone perimeter exceeded normal reference values both in patients with AD and in those with N-Bfr; the osteoid area and osteoid perimeter were also elevated in these two groups. Hyperparathyroidism improved or resolved after Tx in all 14 subjects with this skeletal lesion prior to Tx, but one patient developed AD after Tx. Bone histology did not change after Tx in those with N-Bfr during regular dialysis, but bone formation increased after Tx in two of three patients with AD during regular dialysis. Z-scores for height in pre-pubertal patients after Tx were below age-appropriate values in each histologic subgroup, but values did not differ among groups. Z-scores for bone mineral content at the lumbar spine were also less than age-predicted values, -0.67 +/- 1.2. After adjusting for the degree of growth retardation, height-adjusted z-scores for lumbar spine BMC after Tx were above normal in all three histologic groups (0.68 +/- 1.0). The results suggest that reductions in bone mass and post-transplant osteoporosis are not prominent findings in pediatric renal transplant recipients when the influence of growth retardation on bone mass measurements by DXA is carefully considered. [ABSTRACT FROM AUTHOR]