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Objective: To quantify the environmental impact of standard direct laryngoscopy surgery and model the environmental benefit of three feasible alternative scenarios that meet safe decontamination reprocessing requirements. Study Design: This is a life cycle assessment (LCA) modeling study. Setting: Yale‐New Haven Hospital (YNHH), a 1541‐bed tertiary medical center in New Haven, Connecticut, USA. Methods: We performed cradle‐to‐grave LCA of DLS at Yale New Haven Hospital in 2022, including global warming potential (GWP), water consumption, and fine particulate matter formation. Three alternative scenarios were modeled: disinfecting surgical tools using high‐level disinfection rather than steam sterilization, substituting non‐sterile for sterile gloves and gowns; and reducing surgical towel and drape sizes by 30%. Results: Changes in disinfection practices would decrease procedure GWP by 11% in each environmental impact category. Substituting non‐sterile gowns and gloves reduced GWP by 15%, with nominal changes to water consumption. Linen size reduction resulted in 28% less procedure‐related water consumption. Together, a nearly 30% reduction across all environmental impact categories could be achieved. Conclusions: Not exceeding minimum Center for Disease Control (CDC) decontamination standards for reusable devices and optimizing non‐sterile consumable materials could dramatically reduce healthcare‐associated emissions without compromising safety, thereby minimizing the negative consequences of hospital operations to environmental and human health. Findings extend to other non‐sterile surgical procedures. Level of Evidence: NA Laryngoscope, 134:3206–3214, 2024 [ABSTRACT FROM AUTHOR]

Intravenous 0.9% saline has saved countless lives since it was introduced over a century ago. It remains the most widespread crystalloid in both adult and pediatric practice. However, in recent years, evidence of deleterious effects is accruing. These include increased mortality, acute kidney injury (AKI), metabolic acidosis, and coagulopathy. The predominant cause for these sequelae appears to be the excess chloride concentration of 0.9% saline relative to plasma. This has led to development of balanced isotonic solutions such as PlasmaLyte. This review summarizes current evidence for adverse effects of chloride-rich intravenous fluid and considers whether 0.9% saline should still be used in 2018 or abandoned as a historical treatment in favor of balanced crystalloid solutions., Author(s): Wesley Hayes [sup.1] [sup.2] Author Affiliations: (Aff1) grid.420468.c, Great Ormond Street Hospital, , London, UK (Aff2) 0000000121901201, grid.83440.3b, University College London Institute of Child Health, , London, UK Introduction [...]

Anemia is a common complication of chronic kidney disease (CKD) in children, and dysregulation of iron homeostasis plays a central role in its pathogenesis. Optimizing iron status is a prerequisite for effective treatment of anemia. Insufficient iron can lead to inappropriate escalation of the erythropoiesis-stimulating agent (ESA) dose, which is associated with adverse outcomes. Excess iron supplementation also has negative sequelae including free radical tissue damage and increased risk of systemic infection. Notwithstanding the importance of optimizing bioavailable iron for erythropoiesis for children with advanced CKD, achieving this remains challenging for pediatric nephrologists due to the historical lack of practical and robust measures of iron status. In recent years, novel techniques have come to the fore to facilitate accurate and practical assessment of iron balance. These measures are the focus of this review, with emphasis on their relevance to the pediatric CKD population., Author(s): Wesley Hayes [sup.1] [sup.2] Author Affiliations: (Aff1) grid.420468.c, Great Ormond Street Hospital, , London, UK (Aff2) 0000000121901201, grid.83440.3b, University College London Institute of Child Health, , London, UK Introduction [...]

Dysregulation of intravascular fluid leads to chronic volume overload in children with end-stage kidney disease (ESKD). Sequelae include left ventricular hypertrophy and remodeling and impaired cardiac function. As a result, cardiovascular complications are the commonest cause of mortality in the pediatric dialysis population. The clinical need to optimize intravascular volume in children with ESKD is clear; however, its assessment and management is the most challenging aspect of the pediatric dialysis prescription. Minimizing chronic fluid overload is a key priority; however, excessive ultrafiltration is toxic to the myocardium and can precipitate intradialytic symptoms. This review outlines emerging objective techniques to enhance the assessment of fluid overload in children on dialysis and outlines evidence for current management strategies to address this clinical problem., Author(s): Wesley Hayes [sup.1] [sup.2] , Fabio Paglialonga [sup.3] Author Affiliations: (Aff1) grid.420468.c, Great Ormond Street Hospital, , London, UK (Aff2) 0000000121901201, grid.83440.3b, University College London Institute of Child Health, [...]

Acute kidney injury (AKI) is common in children admitted to hospital. Whilst some recover normal kidney function following an acute kidney insult, a significant proportion experience long-term sequelae. The aim of this review is to summarize current understanding of the processes that can lead to sequelae following AKI. Kidney injury, repair, recovery and progression are described. Risk factors for progression are outlined, and potential strategies to stratify the risk of progression in children with AKI are discussed. Clinical management priorities to minimize sequelae are suggested. Looking ahead, novel therapeutic targets are discussed with the potential to accelerate adaptive repair and ameliorate the progression and sequelae of AKI in the future., Author(s): Wesley Hayes [sup.1] [sup.2] Author Affiliations: (1) Great Ormond Street Hospital for Children, 0000 0004 0426 7394, grid.424537.3, , London, UK (2) University College London, 0000000121901201, grid.83440.3b, , London, [...]

Background New-onset diabetes after transplantation (NODAT) is a significant co-morbidity following kidney transplantation. Lower post-transplant serum magnesium levels have been found to be an independent risk factor for NODAT in adult kidney transplant recipients. Methods We undertook a retrospective analysis of risk factors for NODAT in pediatric renal transplant recipients at our institution with the aim of determining if hypomagnesemia confers a significant risk of developing NODAT in this patient population. Results A total of 173 children with a median age at transplantation of 7.0 (range 1.3-17.5) years were included. Hypomagnesemia was found to be a significant independent risk factor for NODAT (p = 0.01). High trough tacrolimus levels were also independently associated with NODAT (p < 0.001). There was no significant association between NODAT and body mass index at the time of transplantation, monthly cumulative steroid dose or post-transplant cytomegalovirus viremia (p = 0.9, 0.6 and 0.7, respectively). Conclusions This study identifies hypomagnesemia as a significant independent risk factor for the development of NODAT in pediatric renal transplant recipients. Given the clear association between hypomagnesemia and NODAT in both adults and children following renal transplantation, further studies are merited to clarify the etiology of this association and to examine the effect of magnesium supplementation on NODAT., Author(s): Wesley Hayes [sup.1] [sup.2] , Sheila Boyle [sup.1] , Adrian Carroll [sup.1] , Detlef Bockenhauer [sup.1] [sup.2] , Stephen D. Marks [sup.1] [sup.2] Author Affiliations: (1) 0000 0004 0426 [...]

Background Lung ultrasound is a novel technique for detecting generalized fluid overload in children and adults with end-stage renal disease (ESRD). Echocardiography and bioimpedance spectroscopy are established methods, albeit variably adopted in clinical practice. We compared the practicality and accuracy of lung ultrasound with current objective techniques for detecting fluid overload in children with ESRD. Methods A prospective observational study was performed to compare lung ultrasound B-lines, echocardiographic measurement of inferior vena cava parameters and bioimpedance spectroscopy in the assessment of fluid overload in children with ESRD on dialysis. The utility of each technique in predicting fluid overload, based on short-term weight gain, was assessed. Multiple linear regression models to predict fluid overload by weight were explored. Results A total of 22 fluid assessments were performed in 13 children (8 on peritoneal dialysis, 5 on haemodialysis) with a median age of 4.0 (range 0.8-14.0) years. A significant linear correlation was observed between the number of B-lines detected by lung ultrasound and fluid overload by weight (r = 0.57, p = 0.005). A non-significant positive linear correlation was observed between fluid overload by weight and bioimpedance spectroscopy (r = 0.43, p = 0.2), systolic blood pressure (r = 0.19, p = 0.4) and physical examination measurements (r = 0.19, p = 0.4), while a non-significant negative linear relationship was found between the inferior vena cava collapsibility index and fluid overload by weight (r = -0.24, p = 0.3). In multiple linear regression models, a combination of three fluid parameters, namely lung ultrasound B-lines, clinical examination and systolic blood pressure, best predicted fluid overload (R.sup.2 = 0.46, p = 0.05). Conclusions Lung ultrasound may be superior to echocardiographic methods and bioimpedance spectroscopy in detecting volume overload in children with ESRD. Given the practicality and sensitivity of this new technique, it can be adopted alongside clinical examination and blood pressure in the routine assessment of fluid status in children with ESRD., Author(s): Marco Allinovi[sup.1] [sup.2] , Moin A Saleem[sup.1] [sup.3] , Owen Burgess[sup.4] , Catherine Armstrong[sup.4] , Wesley Hayes[sup.1] [sup.3] Author Affiliations: (1) Bristol Children's Renal Unit, Bristol Royal Hospital for [...]

Background Paediatric renal biopsy standards introduced in the UK in 2010 were intended to reduce variation and improve practice. A concurrent national drive was aimed at building robust paediatric nephrology networks to ensure services cater for the needs of the family and minimise time away from home. We aimed to identify current national practice since these changes on behalf of the British Association for Paediatric Nephrology. Methods All UK paediatric nephrology centres were invited to complete a survey of their biopsy practice, including advance preparation. From 1 January to 30 June 2012, a national prospective audit of renal biopsies was undertaken at participating centres comparing practice with the British Association for Paediatric Nephrology (BAPN) standards and audit results from 2005. Results Survey results from 11 centres demonstrated increased use of pre-procedure information leaflets (63.6 % vs 45.5 %, P = 0.39) and play preparation (90.9 % vs 9.1 %, P = 0.0001). Audit of 331 biopsies showed a move towards day-case procedures (49.5 % vs 32.9 %, P = 0.17) and reduced major complications (4.5 % vs 10.4 %, P = 0.002). Biopsies with 18-gauge needles had significantly higher mean pass rates (3.2 vs 2.3, P = 0.0008) and major complications (15.3 % vs 3.3 %, P = 0.0015) compared with 16-gauge needles. Conclusions Percutaneous renal biopsy remains a safe procedure in children, thus improving family-centered service provision in the UK., Author(s): Asheeta Gupta[sup.1] , Joanna Campion-Smith[sup.2] , Wesley Hayes[sup.3] , Jane E. Deal[sup.4] , Rodney D. Gilbert[sup.5] , Carole Inward[sup.3] , Brian A. Judd[sup.6] , Rajesh G. Krishnan[sup.7] , Stephen [...]

Background Eculizumab is a humanized anti-C5 antibody approved for the treatment of atypical hemolytic uremic syndrome (aHUS). Its use is increasing in children following reports of its safety and efficacy. Methods We reviewed biochemical and clinical data related to possible drug-induced liver injury in 11 children treated with eculizumab for aHUS in a single center. Results Elevated aminotransferases were observed in 7 children aged 6 to 11 years following eculizumab treatment for aHUS. Internationally accepted liver enzyme thresholds for drug-induced liver injury were exceeded in 5 cases. In all cases, liver injury was classified as mixed hepatocellular and cholestatic. Infectious and other causes were excluded in each case. One patient with no pre-existing liver disease developed tender hepatomegaly and liver enzyme derangement exceeding 20 times the upper limit of normal following initiation of eculizumab. Recurrent liver injury following re-challenge with eculizumab necessitated its discontinuation and transition to plasma therapy. Conclusions Hepatotoxicity in association with eculizumab is a potentially important yet previously unreported adverse event. We recommend monitoring liver enzymes in all patients receiving eculizumab. Further research is required to clarify the impact of this adverse event, to characterize the mechanism of potential hepatotoxicity, and to identify which patients are most at risk., Author(s): Wesley Hayes [sup.1] , Sibylle Tschumi [sup.1] , Simon C. Ling [sup.2] [sup.3] , Janusz Feber [sup.4] , Michael Kirschfink [sup.5] , Christoph Licht [sup.1] [sup.3] Author Affiliations: (1) [...]

Background Many factors may impact upon choice of renal replacement therapy (RRT) for children and adolescents, including patient and family choice, patient size and distance from the renal centre as well as logistic issues such as facilities and staffing at the unit. We report a survey of factors influencing treatment choice in 14 European paediatric nephrology units. Methods A questionnaire was developed by consensus and completed by 14 members of the European Paediatric Dialysis Working Group on facilities, staffing and family assessments impacting on choice of therapy as well as choice of therapy for 97 patients commencing initial RRT in 2011. Results All units offered all modalities of RRT, but there were limitations for pre-emptive transplantation (PET) and largely adult surgical dependence for creation of arteriovenous fistulae and transplantation. The average waiting time for a deceased donor kidney was 18.5 (range 3-36) months. Full time dietetic support was available in six of the 14 units. There was no social worker, psychology, play therapy or teaching support in three, two, seven and four units, respectively. Assessment by other members of the multidisciplinary team and home visits before choice of therapy was carried out in 50 % of units, and although all patients were discussed at team meetings, the medical opinion predominated. In terms of types of RRT, 50 % of patients were commenced on chronic peritoneal dialysis (PD), 34 % on haemodialysis (HD) and 16 % underwent pre-emptive transplantation (PET). Chronic PD predominated in patients aged 10 years. Patient and family choice and age or size of patient were predominant factors in choice of therapy with a predictable decline in renal function favouring PET and social factors HD. Conclusions Chronic peritoneal dialysis predominated as primary choice of RRT, especially in younger children. The PET rates remain low. The influence of surgeons predominanted, and national transplant rules may be significant. Most units had insufficient multiprofessional support, which may impact upon initial choice of therapy as well as sustaining families through RRT. Keywords Choice of therapy * Renal replacement therapy * Dialysis * Pre-emptive transplantation * Psychosocial * Pediatric, Introduction The choice of chronic renal replacement therapy (RRT) for each individual child and family can be a complex issue. It involves consideration of the facilities and expertise available at [...]