Search

Background: Dialysis is lifesaving for acute kidney injury (AKI), but access is poor in less resourced settings. A "peritoneal dialysis (PD) first" policy for paediatric AKI is more feasible than haemodialysis in low-resource settings. Methods: Retrospective review of modalities and outcomes of children dialysed acutely at Red Cross War Memorial Children's Hospital between 1998 and 2020. Results: Of the 593 children with AKI who received dialysis, 463 (78.1%) received PD first. Median age was 9.0 (range 0.03–219.3; IQR 13.0–69.6) months; 57.6% were < 1 year old. Weights ranged from 0.9 to 2.0 kg (median 7.0 kg, IQR 3.0–16.0 kg); 38.6% were < 5 kg. PD was used more in younger children compared to extracorporeal dialysis (ECD), with median ages 6.4 (IQR 0.9–30.4) vs. 73.9 (IQR 17.5–113.9) months, respectively (p = 0.001). PD was performed with Seldinger soft catheters (n = 480/578, 83%), predominantly inserted by paediatricians at the bedside (n = 412/490, 84.1%). Complications occurred in 127/560 (22.7%) children receiving PD. Overall, 314/542 (57.8%) children survived. Survival was significantly lower in neonates (< 1 month old, 47.5%) and infants (1–12 months old, 49.2%) compared with older children (> 1 year old, 70.4%, p < 0.0001). Survival was superior in the ECD (75.4%) than in the PD group (55.6%, p = 0.002). Conclusions: "PD First for Paediatric AKI" is a valuable therapeutic approach for children with AKI. It is feasible in low-resourced settings where bedside PD catheter insertion can be safely taught and is an acceptable dialysis modality, especially in settings where children with AKI would otherwise not survive. [ABSTRACT FROM AUTHOR]

Background: Acute post-streptococcal glomerulonephritis (APSGN) is the most common cause of acute nephritis in children globally and, in some cases, may be associated with progressive kidney injury and failure, cumulating in the need for long-term dialysis and/or kidney transplantation. Methods: Our retrospective study describes the occurrence of APSGN among children (< 14 years) admitted to a tertiary children's hospital in Cape Town, South Africa, from January 2015 to December 2020. Results: Of 161 children who presented with acute nephritis (haematuria, oedema, oliguria, and hypertension), 100 met the inclusion criteria. Demographic, clinical features, laboratory findings, management, and outcome data were collected. APSGN was defined by the clinical presentation of at least two clinical signs of acute nephritis, and low serum complement 3 (C3) level or evidence of a recent streptococcal infection. Most cases of APSGN were associated with streptococcal skin infections: 55/100 (55%); 10/100 (10%) children presented with hypertensive seizures; C3 levels were low in 86/92 (93.5%) children; 94/94 (100%) children had elevated anti-deoxyribonuclease-B (anti-DNase-B) levels; and 80/94 (85%) also had elevated anti-streptolysin O titre (ASOT) at presentation. Eleven (11%) children had a percutaneous kidney biopsy; 4/11 (36%) showed histological features of post-infectious nephritis, and 7/11(64%) also had crescentic glomerulonephritis with immune complex deposits. Sixty-two (62%) children confirmed recovered, and five (5%) progressed to kidney failure, but 29 presumed recovered as they did not return for follow-up to our institution. Conclusions: Childhood APSGN remains an important health problem in South Africa (SA) with favourable outcomes in most, apart from those with crescentic glomerulonephritis who progressed to kidney failure. [ABSTRACT FROM AUTHOR]

Background: Kidney transplantation remains the treatment of choice for children with kidney failure (KF). In South Africa, kidney replacement therapy (KRT) is restricted to children eligible for transplantation. This study reports on the implementation of the Paediatric Feasibility Assessment for Transplantation (pFAT) tool, a psychosocial risk score developed in South Africa to support transparent transplant eligibility assessment in a low‐resource setting. Methods: Single‐center retrospective descriptive analysis of children assessed for KRT using pFAT tool from 2015 to 2021. Results: Using the pFAT form, 88 children (median [range] age 12.0 [1.1 to 19.0] years) were assessed for KRT. Thirty (34.1%) children were not listed for KRT, scoring poorly in all domains, and were referred for supportive palliative care. Fourteen of these 30 children (46.7%) died, with a median survival of 6 months without dialysis. Nine children were reassessed and two were subsequently listed. Residing >300 km from the hospital (p =.009) and having adherence concerns (p =.003) were independently associated with nonlisting. Of the 58 (65.9%) children listed for KRT, 40 (69.0%) were transplanted. One‐year patient and graft survival were 97.2% and 88.6%, respectively. Only one of the four grafts lost at 1‐year posttransplant was attributed to psychosocial issues. Conclusions: Short‐term outcomes among children listed using the pFAT form are good. Among those nonlisted, the pFAT highlights specific psychosocial/socioeconomic barriers, over which most children themselves have no power to change, which should be systemically addressed to permit eligibility of more children and save lives. [ABSTRACT FROM AUTHOR]

Background: Access to care for children with kidney disease is limited in less well-resourced regions of the world and paediatric nephrology (PN) workforce development with good practical skills is critical. Methods: Retrospective review of a PN training program and trainee feedback from 1999 to 2021, based at Red Cross War Memorial Children's Hospital (RCWMCH), University of Cape Town. Results: A regionally appropriate 1–2-year training program enrolled 38 fellows with an initial 100% return rate to their country of origin. Program funding included fellowships from the International Pediatric Nephrology Association (IPNA), International Society of Nephrology (ISN), International Society of Peritoneal Dialysis (ISPD), and the African Paediatric Fellowship Program (APFP). Fellows were trained on both in- and out-patient management of infants and children with kidney disorders. "Hands-on skills" training included examination, diagnosis and management skills, practical insertion of peritoneal dialysis catheters for management of acute kidney injury and kidney biopsies. Of 16 trainees who completed > 1 year of training, 14 (88%) successfully completed subspecialty exams and 9 (56%) completed a master's degree with a research component. PN fellows reported that their training was appropriate and enabled them to make a difference in their respective communities. Conclusions: This training program has successfully equipped African physicians with the requisite knowledge and skills to provide PN services in resource-constrained areas for children with kidney disease. The provision of funding from multiple organizations committed to paediatric kidney disease has contributed to the success of the program, along with the fellows' commitment to build PN healthcare capacity in Africa. [ABSTRACT FROM AUTHOR]

Children treated in a pediatric intensive care unit (PICU) are at risk of distress and pain. This study investigated if aromatherapy massage can reduce children's distress and improve comfort. This observational before‐after study was performed in a 22‐bed PICU in Cape Town, South Africa. The aromatherapy massage consisted of soft massaging using the "M‐technique" and a 1% blend of essential oils of Lavender (Lavandula angustifolia), German Chamomile (Matricatia recutita) and Neroli (Citrus aurantium) mixed with a grapeseed carrier oil. All present children were eligible, except those who had recently returned, were asleep or deemed unstable. The primary outcome was distress measured with the COMFORT‐Behavior scale (COMFORT‐B). Secondary outcomes were heart rate, oxygen saturation (SatO2), the Numeric Rating Scale (NRS)‐Anxiety and pain assessed by the NRS‐Pain scale. Outcomes variables were evaluated with Wilcoxon signed‐rank test and multiple regression analysis. The intervention was applied to 111 children, fifty‐one of whom (45.9%) were younger than three years old. The group median COMFORT‐B score before intervention was 15 (IQR 12–19), versus 10 (IQR 6–14) after intervention. Heart rate and NRS‐Anxiety were significantly lower after the intervention (P < 0.001). Multiple regression analysis showed that interrupted massages were less effective than the uninterrupted massages. Parental presence did not influence the outcome variables. We did not find a significant change on the NRS‐Pain scale or for SatO2. Aromatherapy massage appears beneficial in reducing distress, as measured by the COMFORT‐B scale, heart rate and the NRS‐Anxiety scale, in critically ill children. Thus, the potential of aromatherapy in clinical practice deserves further consideration. [ABSTRACT FROM AUTHOR]

Background: Surgery for reno-vascular hypertension (RVH) is complex, and the techniques utilized vary with anatomical presentations of the disease. The long-term outcome of revascularization on RVH in children with Takayasu's arteritis (TA)-induced renal artery stenosis (RAS) at our centre was reviewed. Methods: This study was a 21-year retrospective review of pre- and post-intervention RVH in children with angiographically confirmed RAS. The outcome of hypertension was defined as follows: (1) cured (normotensive off anti-hypertensives), (2) improved (normotensive on same or reduced number of medications), or (3) failure (no cure or improvement in number of medications). Results: The medical histories of 59 children (median age 9.98 years) were reviewed, of whom 20 (44 %) had revascularization procedures. All were hypertensive, with a mean systolic and diastolic blood pressure of 161.5 ± 36 and 106.5 ± 31 mmHg, respectively. RAS was present in 45 (76.3 %) children. Twenty-four revascularization procedures were performed in 20 children (44 %), of whom five had contralateral nephrectomies. Outcome was available for 17 patients at the 3- and 6-months follow-up, with cure, improvement and failure rates at 3 months of 2/17 (11.8 %), 7/17 (41.2 %) and 8/19 (47 %), respectively, and similar rates at 6 months. Associations between outcome and age ( p = 0.51), sex ( p = 0.32), number of pre-surgery anti-hypertensives ( p = 0.18) and stenosis sites ( p = 0.22) were not statistically significant. Conclusions: Revascularization was beneficial to the management of blood pressure control in about half of our RVH patients. [ABSTRACT FROM AUTHOR]

Summary: Before the era of highly active antiretroviral therapy, more than 40% of human immunodeficiency virus (HIV)-infected children experienced renal complications. In sub-Saharan Africa, approximately 2.1 million children are infected with HIV-1. In the absence of antiretroviral therapy, young African children frequently died of AIDS-related complications before renal diseases could be manifested or diagnosed. As antiretroviral therapy has become more available, and their survival has increased, our experience in treating kidney disease in HIV-infected children has improved. This article discusses relevant clinical and pathologic findings related to kidney disease in HIV-infected children. [Copyright &y& Elsevier]

Over the past two decades, chronic peritoneal dialysis (PD) has emerged as the first choice pediatric dialysis modality. A recent study visually identified the cause of malfunction of PD catheters at the Red Cross Children's Hospital in Cape Town. The reasons that could be found, lead to changed Tenckhoff insertion-techniques from open to laparoscopic. This included suturing of the tip, omentectomy and ovarian-pexy by laparoscopy. In the present paper we prospectively analyzed, if changed insertion technique lead to an improved outcome. Patients and Methods: 26 Patients required 36 laparoscopic Tenckhoff insertions during the period August of 2003 and July of 2006. Overall a total number of 222.5 catheter-months have been observed. Laparoscopic insertion technique required 3 port placements. The tip of the catheter was sutured to pelvic peritoneum, omentectomy performed through a port site and ovariopexy done when required. Results: The mean lifespan of all Tenckhoff's was 6.4 6.3 months. The tip of the catheter was sutured 20 times, omentectomy done in 9 cases and 6 patients underwent ovarian pexy. In the group where the tip was sutured to the pelvic peritoneum catheter life was 8.4 months compared to the non-sutured group which was only 4.1. Omentectomy lead to an overall catheter survival of 8.0 months compared to the no omentectomy group, which had a survival of 5.8 months. The complication-rate concerning early problems and malfunctions in the sutured and omentectomy groups was also lower. Patients who underwent both, suturing of the tip and omentectomy had no malfunctions at all. Conclusion: Omentectomy and suturing the tip can lower the complication-rate and prolong catheter survival. Using these procedures could decrease costs and morbidity and prevent patients from having further operations. [ABSTRACT FROM AUTHOR]

Introduction: In South Africa, only children considered eligible for transplantation are offered dialysis as bridge to kidney transplantation. Maintenance peritoneal dialysis (PD) is preferred and has several advantages over hemodialysis (HD). While awaiting transplantation, PD may be discontinued due to permanent transfer to HD or death while on PD, of which the occurrence and burden is not known in our setting. We investigated the rate of discontinuation of maintenance PD, and associated factors among children awaiting a kidney transplant under challenging socio-economic circumstances in a low resource setting., Methods: Single center retrospective analysis of children receiving maintenance PD. Outcomes included the proportion of children who discontinued PD before transplantation, associated factors and timing of discontinuation, and the proportion transplanted. Time to discontinuation or transplantation was displayed using a Kaplan-Meier curve., Results: Sixty-seven children who received maintenance automated PD as initial dialysis modality were identified from the kidney transplant waiting list between January 2009 and December 2018. Complete data was available for 52 of the 67 children. Four children had prior failed kidney transplants. The median age was 11 years (interquartile range 6.0, 13.1). Overall, 17/52 (32.7%) children discontinued PD, with 13 (25%) transfers to HD and 4 deaths (7.7%), whereas 29/52 (55.8%) received a kidney transplant. Three of the deaths were PD related. Six children remained on maintenance PD at the end of the study period. Over a half of our patients discontinued PD by 12 months, and 80% by 30 months. Most PD discontinuations were associated with peritonitis., Conclusions: The proportion discontinuing PD was high, highlighting the need to optimize measures to improve retention rates, especially through prevention of peritonitis., Competing Interests: Declaration of conflicting interestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objectives: To describe the prevalence of pediatric acute respiratory distress syndrome (pARDS) and the characteristics of children with pARDS in South African PICUs., Design: Observational multicenter, cross-sectional point-prevalence study., Setting: Eight PICUs in four South African provinces., Patients: All children beyond the neonatal period and under 18 years of age admitted to participating PICUs., Interventions: None., Measurements and Main Results: Clinical and demographic data were prospectively collected on a single day of each month, from February to July 2022, using a centralized database. Cases with or at risk of pARDS were identified using the 2015 Pediatric Acute Lung Injury Consensus Conference criteria. Prevalence was calculated as the number of children meeting pARDS criteria/the total number of children admitted to PICU at the same time points. Three hundred ten patients were present in the PICU on study days: 166 (53.5%) male, median (interquartile range [IQR]) age 9.8 (3.1-32.9) months, and 195 (62.9%) invasively mechanically ventilated. Seventy-one (22.9%) patients were classified as being "at risk" of pARDS and 95 patients (prevalence 30.6%; 95% CI, 24.7-37.5%) fulfilled pARDS case criteria, with severity classified as mild (58.2%), moderate (25.3%), and severe (17.6%). Median (IQR) admission Pediatric Index of Mortality 3 risk of mortality in patients with and without pARDS was 5.6 (3.4-12.1) % versus 3.9 (1.0-8.2) % ( p = 0.002). Diagnostic categories differed between pARDS and non-pARDS groups ( p = 0.002), with no difference in age, sex, or presence of comorbidities. On multivariable logistic regression, increasing admission risk of mortality (adjusted odds ratio [aOR] 1.02; 95% CI, 1.00-1.04; p = 0.04) and being admitted with a respiratory condition (aOR 2.64; 95% CI, 1.27-5.48; p = 0.01) were independently associated with an increased likelihood of having pARDS., Conclusions: The 30.6% prevalence of pARDS in South Africa is substantially higher than reports from other sociogeographical regions, highlighting the need for further research in this setting., Competing Interests: Dr. Morrow’s institution received funding from the Society of Critical Care Medicine, the National Research Foundation of South Africa, and the Critical Care Society of Southern Africa; she received funding from the European Cystic Fibrosis Society and Brazilian Physiotherapy Association. Drs. Solomon and Khan received funding from the Critical Care Society of Southern Africa. Dr. Solomon received funding from ANN LAKE Publications. Dr. Naidoo received funding from Mbuso Medical, Fresenius Kabi, and Nutricia. Dr. Argent received funding for travel, accommodation, and registration to attend a number of conferences as an invited guest speaker and for providing expert witness evidence to a number of medicolegal cases. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2023 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.)

Background: Despite the undeniable diagnostic benefits of urodynamic studies (UDS), their adoption into clinical practice in Africa has been slow. This study aimed to review the use of invasive UDS in children at a tertiary paediatric hospital in South Africa., Methods: A retrospective analysis of 1108 UDS was conducted. Patient demographic characteristics, primary diagnosis, indication and urodynamic outcomes were reviewed. Presence of urodynamic high-risk features were documented, and a comparison was made between the first study and follow-up study., Results: This study revealed increasing trends in the use of UDS from 2015. Referrals were from Urology (37.7%), Spinal defects clinic (34.4%), Nephrology (20.8%) and other departments (7.0%). The most common reason for referral was review of medical treatment (36.5%). Spinal dysraphism (58.3%) accounted for the majority of conditions seen. Majority (59.1%) of the patients were receiving more than one type of bladder treatment at the time of their first study, with clean intermittent catheterisation (46.5%) being the most common form of bladder management. 97.5% of studies were performed using transurethral bladder catheterization. Urodynamic diagnosis was neurogenic in 74.0%, anatomical (12.2%), functional (8.8%) and normal (5.0%). There was statistically significant improvement in bladder compliance, detrusor leak point pressure and detrusor sphincter dyssynergia between the first study and a subsequent study following therapeutic intervention., Conclusions: The unique ability of UDS to demonstrate changes in detrusor pressures, which is a common reason for therapy failure, makes UDS an invaluable tool in the diagnosis and management of children with lower urinary tract dysfunction., (© 2022. The Author(s).)

Background: TB remains a major challenge in transplantation, particularly in endemic countries. This study aimed to describe the incidence, clinical presentation and outcomes of TB in paediatric kidney transplant recipients and to assess the impact of INH prophylaxis., Methods: Single-centre retrospective descriptive analysis of children who received kidney transplants from 1995 to 2019 was carried out. The cohort was stratified according to receipt of INH prophylaxis which began in 2005., Results: A total of 212 children received a kidney transplant during the study period. Median age at transplantation was 11.2 years (IQR: 2.2-17.9), and 56% were males. TB was diagnosed in 20 (9%) children, with almost two-thirds (n = 12) occurring within the first year. Most infections were pulmonary. The main presenting symptoms included fever (n = 13/20), weight loss (n = 12/20) and cough (n = 10/20). TST was positive in four of 20 children. Coinfection with EBV, CMV or Staph was found in five children. Due to drug interactions, an up to threefold increase in calcineurin inhibitor dose was required to maintain therapeutic blood levels. INH prophylaxis was protective against development of TB (p = .04). Gender, age and type of allograft were not significant risk factors. Graft and patient survival was 100% upon completion of TB treatment., Conclusion: Kidney transplant recipients in endemic countries have a high risk of developing TB. Diagnosis remains a challenge. Frequent and meticulous monitoring of immunosuppression drug levels during treatment of TB is required to avoid loss of patient or graft. INH prophylaxis protects against development of TB in this population., (© 2021 Wiley Periodicals LLC.)

Objectives: Major trauma in adults induces immune dysfunction, with diminished expression of human leukocyte antigen-DR on circulating monocytes. No pediatric data are available. This study described the kinetics of human leukocyte antigen-DR on circulating monocytes following major pediatric trauma and relationships between human leukocyte antigen-DR on circulating monocytes and outcomes., Design: Prospective observational study., Setting: PICU and trauma unit at a tertiary-care university hospital in South Africa., Patients: Children between 1 month and 13 years hospitalized for severe brain trauma or trauma with an Injury Severity Score greater than or equal to 16, from November 2016 to March 2017., Interventions: None., Measurements and Main Results: We included 36 children. Median (interquartile range) age and Injury Severity Score were 7 years (4.9-10.5 yr) and 25 years (22.7-30 yr), respectively. Blood samples (n = 83) for standardized human leukocyte antigen-DR on circulating monocytes measurement were collected at days 1-2, 3-4, and 8-9 after injury (D1, D3, and D8, respectively). On D1, median (interquartile range) human leukocyte antigen-DR on circulating monocytes was markedly reduced relative to normal values (7,031 [5,204-11,201] antibodies per cell). There was a significant increase in human leukocyte antigen-DR on circulating monocytes from D1 to D8. Although all patients with secondary infections (n = 8; 22%) had human leukocyte antigen-DR on circulating monocytes less than 15,000 antibodies per cell at D3, human leukocyte antigen-DR on circulating monocytes levels were not associated with the occurrence of secondary infections (p = 0.22). At D3, human leukocyte antigen-DR on circulating monocytes was significantly higher in patients discharged home (n = 21) by Day 30 after trauma compared with those who died or were still hospitalized (n = 14) (p = 0.02)., Conclusions: Pediatric severe trauma induced an early and dramatic decrease in human leukocyte antigen-DR on circulating monocytes expression. This alteration of innate immunity was not associated with the occurrence of secondary infection, possibly due to a lack of statistical power. However, human leukocyte antigen-DR on circulating monocytes at Day 3 is a potential indicator of those at high risk of secondary infection and worse outcomes., Competing Interests: Dr. Morrow’s institution received funding from National Research Foundation, and she received funding from University of Cape Town and Imperial College Press (royalties). Dr. Argent received funding from N. Kelly Attorneys and from various conferences as an invited speaker. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2020 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.)

Peritoneal dialysis and kidney transplantation remain the preferred choices for renal replacement therapy in young children. These options, however, are not always feasible, and hemodialysis (HD) is therefore an accepted alternative. In small children presenting with end-stage renal disease, HD presents several challenges and is often unavailable in lower- and middle-income countries. To assess these challenges and outcomes of maintenance HD in young children, we performed an audit of children below 20 kg with end-stage renal disease, receiving HD for ≥4 weeks, from 1 January 2008 to 31 July 2016 at the Red Cross War Memorial Children's Hospital. We identified 15 children weighing 6.8-18.5 kg (mean 12.9 kg ±3.5 SD) and aged 11.5-105 months (mean 52.2 months±4.2 SD) at HD initiation. Mean duration of HD was 11.8 months (range 1-61.5 months ± 16.9 SD). Seven children underwent successful transplantation, two patients died, and four currently still receive HD. Two patients, while on HD, relocated to other centers. An average of 2.6 (range 1-5) different vascular accesses was required per patient. Technical difficulties were the most common cause of central-line removal (81%), while catheter-associated bacteremia was 1.1/1000 catheter days. Frequent problems were intradialytic hypotension, growth stunting, and interdialytic hypertension. HD in lower- and middle-income countries is feasible in small children but presents with certain challenges. Advocacy with lobbying for funding and development of "child-friendly" dialysis equipment and specialized centers with highly skilled personnel are the cornerstones of successful pediatric HD programs in less-resourced centers., (© 2018 International Society for Apheresis, Japanese Society for Apheresis, and Japanese Society for Dialysis Therapy.)

Objective: Fluid resuscitation is integral to resuscitation guidelines and critical care. However, fluid overload (FO) yields increased morbidity., Methods: Prospective observational study of Red Cross War Memorial Children's Hospital pediatric intensive care unit admissions (February to March 2013). FO % = (fluid in minus fluid out) [liters]/weight [kg] × 100%., Primary Outcomes: FO ≥ 10%, 28 day mortality., Results: Median [interquartile range (IQR)] age: 9.5 (2.0-39.0) months, median (IQR) admission weight: 7.9 (3.6-13.7) kg. Median (IQR) FO with admission weight: 3.5 (2.1-4.9)%; three patients had FO ≥ 10%. The 28 day mortality was 10% (n = 10). Patients who died had higher mean (IQR) FO using admission weight [4.9 (2.9-9.3)% vs. 3.4 (1.9-4.8)%; p = 0.04]., Conclusions: Low FO ≥ 10% prevalence with 28 day mortality 10%. Higher FO% with admission weight associated with mortality (p = 0.04). We advocate further investigation of FO% as a simple bedside tool., (© The Author [2014]. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)