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Background This study is aimed at comparing ultrasound dilution (UD) and thermodilution (TD) with color Doppler ultrasound (CDU) for arteriovenous fistula (AVF) assessment in children on hemodialysis (HD). Material and methods All patients were dialysed with the Fresenius 5008 HD machine. UD was performed using the Transonic device. The two methods were compared with CDU performed on a non-HD day. AVF flow rate was expressed as ml/min/1.73 m.sup.2. Results Sixteen measurements of AVF flow rate and recirculation with UD and TD were compared with CDU in 16 patients with a median weight of 39 kg. Both UD and TD overestimated AVF flow rate when compared with CDU (+437 (95% CI + 200, + 674) and + 476 (95% CI + 80, + 871) ml/min/1.73 m.sup.2 for UD and TD, respectively). CDU flow rate was significantly correlated to UD flow rate (r.sup.2 = 0.761, p < 0.001), but not to TD flow rate (r.sup.2 = 0.164, p = 0.120). Although recirculation in all AVF was estimated to be 0% and < 15% with UD and TD, respectively, 7 significant stenoses were diagnosed by CDU. AVF with stenosis had lower flow rates when measured by CDU, UD or TD, but only CDU measurements reached statistical significance (p = 0.008, p = 0.142 and p = 0.174, respectively). Conclusion UD and TD overestimate AVF flow rate when compared with CDU, which is the most reliable non-invasive method for screening vascular access for stenosis. UD seems more accurate than TD for AVF flow rate assessment. Recirculation via UD or TD should not be used for early screening of AVF stenosis in children on HD., Author(s): Vasiliki Karava [sup.1] , Theresa Kwon [sup.1] , Gilbert Franco [sup.2] , Deschenes Georges [sup.1] , Marie-Alice Macher [sup.1] , Julien Hogan [sup.1] Author Affiliations: (Aff1) grid.50550.35, 0000 0001 [...]

Objectives We aimed to examine longitudinal changes in left ventricular (LV) structure and function and evaluate factors associated with LV remodelling in children on chronic haemodialysis. Methods Retrospective longitudinal study including all children from the start of chronic haemodialysis with two or more m-mode 2D echocardiograms and tissue Doppler studies. Left ventricular mass (LVM) in g/m.sup.2.7, geometry and LV function were compared at baseline (dialysis start) with follow-up studies at least 6 months following commencement. Left ventricular hypertrophy (LVH) was defined if greater than 95th percentile as per age-specific centiles. We also defined LVH as indexed LV mass index (LVMI) > 51 g/m.sup.2.7 and using LV mass-for-height z-scores greater than the 95th percentile. Biochemical data, interdialytic weight change and blood pressure level were assessed for their association with change in indexed LVM. Results Twenty-three of the 32 children < 18 years were included (n = 5, < 5 years) with last follow-up study performed following dialysis after a median (IQR) of 21 (10-34) months. The prevalence of LVH reduced significantly (69.6%, (n = 16/23) vs. 39.1% (n = 9/23), P = 0.002); LV geometry improved (13% concentric and 56.5% eccentric vs. 8.7% and 17.4% respectively) with mean ± SD reduction in indexed LVM (50.8 ± 23.1 g/m.sup.2.7 vs. 38.6 ± 14.7 g/m.sup.2.7, P = 0.002) and LV mass-for-height z-scores (0.67 ± 1.66 vs. - 0.46 ± 1.88, P = 0.002) from baseline to last follow-up respectively. There was no change in systolic function (LV fractional shortening, 37% vs. 38%, P = 0.39) and diastolic function (mean E/E' 10.8 vs. 9.0, P = 0.09). Multiple regression analysis identified improved systolic BP control ([beta] = 0.41, P = 0.04) as an independent predictor for change in indexed LVM. Conclusions LV structure and function can improve in children despite long-term chronic intermittent haemodialysis. Cardiovascular health in this population does not always deteriorate but can be stabilised and indeed improved with optimal blood pressure management., Author(s): Nabil Melhem [sup.1] , Alex Savis [sup.2] , Arran Wheatley [sup.1] , Helen Copeman [sup.1] , Kay Willmott [sup.1] , Christopher J. D. Reid [sup.1] , John Simpson [sup.2] [...]

Background Hypoalbuminemia is a strong predictor of hospitalization and mortality among adult dialysis patients. However, data are scant on the association between serum albumin and hospitalization among children new to dialysis. Methods In a retrospective cohort study of children 1-17 years old with end-stage renal disease receiving dialysis therapy in a large US dialysis organization 2007-2011, we examined the association of serum albumin with hospitalization frequency and total hospitalization days using a negative binomial regression model. Results Among 416 eligible patients, median (interquartile range) age was 14 (10-16) years and mean ± SD baseline serum albumin level was 3.7 ± 0.8 g/dL. Two hundred sixty-six patients (64%) were hospitalized during follow-up with an incidence rate of 2.2 (95%CI, 1.9-2.4) admissions per patient-year. There was a U-shaped association between serum albumin and hospitalization frequency; hospitalization rates (95%CI) were 2.7 (2.2-3.2), 1.9 (1.5-2.4), 1.6 (1.3-1.9), and 2.7 (1.7-3.6) per patient-year among patients with serum albumin levels < 3.5, 3.5- < 4.0, 4.0- < 4.5, and [greater than or equal to] 4.5 g/dL, respectively. Case mix-adjusted hospitalization incidence rate ratios (IRRs) (95%CI) were 1.63 (1.24-2.13), 1.32 (1.10-1.58), and 1.25 (1.06-1.49) at serum albumin levels 3.0, 3.5, and 4.5 g/dL, respectively (reference: 4.0 g/dL). Similar trends were observed in hospitalization days. These associations remained robust against further adjustment for laboratory variables associated with malnutrition and inflammation. Conclusions Both high and low serum albumin were associated with higher hospitalization in children starting dialysis. Because the observed association is novel and not fully explainable especially for high serum albumin levels, interpreting the results requires caution and further studies are needed to confirm and elucidate this association before clinical recommendations are made., Author(s): Yusuke Okuda [sup.1] , Yoshitsugu Obi [sup.1] , Elani Streja [sup.1] , Marciana Laster [sup.2] , Connie Rhee [sup.1] , Craig B. Langman [sup.3] , Stephanie M. Jernigan [sup.4] [...]

Background Bioimpedance spectroscopy (BIS) with a whole-body model to distinguish excess fluid from major body tissue hydration can provide objective assessment of fluid status. BIS is integrated into the Body Composition Monitor (BCM) and is validated in adults, but not children. This study aimed to (1) assess agreement between BCM-measured total body water (TBW) and a gold standard technique in healthy children, (2) compare TBW_BCM with TBW from Urea Kinetic Modelling (UKM) in haemodialysis children and (3) investigate systematic deviation from zero in measured excess fluid in healthy children across paediatric age range. Methods TBW_BCM and excess fluid was determined from standard wrist-to-ankle BCM measurement. TBW_D2O was determined from deuterium concentration decline in serial urine samples over 5 days in healthy children. UKM was used to measure body water in children receiving haemodialysis. Agreement between methods was analysed using paired t test and Bland-Altman method comparison. Results In 61 healthy children (6-14 years, 32 male), mean TBW_BCM and TBW_D2O were 21.1 ± 5.6 and 20.5 ± 5.8 L respectively. There was good agreement between TBW_BCM and TBW_D2O (R.sup.2 = 0.97). In six haemodialysis children (4-13 years, 4 male), 45 concomitant measurements over 8 months showed good TBW_BCM and TBW_UKM agreement (mean difference - 0.4 L, 2SD = ± 3.0 L). In 634 healthy children (2-17 years, 300 male), BCM-measured overhydration was - 0.1 ± 0.7 L (10-90th percentile - 0.8 to + 0.6 L). There was no correlation between age and OH (p = 0.28). Conclusions These results suggest BCM can be used in children as young as 2 years to measure normally hydrated weight and assess fluid status., Author(s): Indranil Dasgupta [sup.1] , David Keane [sup.2] , Elizabeth Lindley [sup.2] , Ihab Shaheen [sup.3] , Kay Tyerman [sup.3] , Franz Schaefer [sup.4] , Elke Wühl [sup.4] , Manfred [...]

Background Erythropoietin-stimulating agent hyporesponsiveness (ESAH) is associated with increased cardiovascular mortality in patients with end-stage renal disease (ESRD) on hemodialysis. Dynamic treatment regimes (DTR), a clinical decision support (CDS) tool that guides the prescription of specific therapies in response to variations in patient states, have been used to guide treatment for chronic illnesses that require frequent monitoring and therapy changes. Our objective is to explore the role of utilizing a DTR to reduce ESAH in pediatric hemodialysis patients. Methods Retrospective analysis of ESRD patients on hemodialysis who received ESAs. Dosing was adjusted using a locally developed protocol designed to target a hemoglobin between 10 and 12 g/dl. Analyzing this protocol as a DTR, we assessed adherence to the protocol over time measuring how the hyporesponse index (ESA dose/hemoglobin value) changed due to varying levels of adherence. Results Eighteen patients met study criteria. Median hemoglobin was 11.4 g/dl (range 6.1-15.4), and median weekly ESA dose (darbepoetin-equivalent) was 0.4 mcg/kg/dose (range 0-2.1). Full adherence to the DTR was identified in 266 (71%) of the 4-week periods, with a median average adherence score of 0.80 (range 0.63-0.91). As adherence to the DTR improved, ESAH decreased. During the last 12 weeks, 13 out of 18 patients had lower average ESA/hemoglobin ratio than the first 12 weeks. Conclusions A DTR appears to be well-suited to the treatment of anemia in ESRD and reduces ESAH. Our work shows the potential of DTRs to drive the development and evaluation of clinical practice guidelines., Author(s): Ari H Pollack [sup.1] [sup.2] , Assaf P. Oron [sup.3] , Joseph T. Flynn [sup.1] [sup.2] , Raj Munshi [sup.1] [sup.2] Author Affiliations: (Aff1) 0000 0000 9026 4165, grid.240741.4, [...]

Background Impairment in orexigenic/anorexigenic hormone balance may be key in the pathogenesis of protein energy wasting in children with chronic kidney disease (CKD). Measurement of ghrelin and obestatin concentrations in children with CKD would help assess the potential contribution of these hormones to uremic protein energy wasting. Methods This was a cross-sectional case-control study. Acylated and unacylated ghrelin and obestatin were measured in 42 children on conservative treatment (CT), 20 children on hemodialysis, 48 pediatric renal transplant (RTx) recipients and 43 controls (CTR) (mean age 11.9, range 5-20 years). Weight, height and bicipital, tricipital, subscapular and suprailiac folds were measured, and the body mass index-standard deviation score (BMI-SDS), percentage of fat mass and fat-free mass were calculated. Urea and creatinine were measured and the glomerular filtration rate (GFR) calculated. Results Unacylated ghrelin level was higher in patients than controls (p = 0.0001), with the highest levels found in hemodialysis patients (p = 0.001 vs. CKD-CT, p = 0.0001 vs. RTx, p < 0.0001 vs. CTR). Obestatin level was significantly higher in patients on hemodialysis than those on conservative treatment, RTx recipients and controls (p < 0.0001 in each case). Unacylated ghrelin negatively correlated with weight-SDS (p < 0.0001), BMI-SDS (p = 0.0005) and percentage fat mass (p = 0.004) and positively correlated with percentage fat-free mass (p = 0.004). Obestatin concentration negatively correlated with weight-SDS (p = 0.007). Unacylated ghrelin and obestatin concentrations positively correlated with creatinine and urea and inversely with eGFR, even after adjustments for gender, age, puberty and BMI-SDS (p < 0.0001 for each model). Conclusions Unacylated ghrelin and obestatin, negatively related to renal function, seem to be promising inverse indicators of nutritional status in children with CKD. Potential therapeutic implications in terms of optimization of their removal in patients on hemodialysis could be hypothesized., Author(s): Alice Monzani [sup.1] , Michela Perrone [sup.2] , Flavia Prodam [sup.1] , Stefania Moia [sup.1] , Giulia Genoni [sup.1] , Sara Testa [sup.2] , Fabio Paglialonga [sup.2] , Anna [...]

Background The objective of this study was to evaluate the coronary circulation and calcification in children with end-stage renal disease (ESRD) on hemodialysis. Methods A total of 50 children with ESRD and 50 healthy controls were enrolled in the study. Cardiac functions and coronary blood flow were evaluated with conventional and tissue Doppler echocardiography. Coronary artery calcification (CAC) was evaluated using high-resolution multidetector computed tomography (CT). Results The hyperemic coronary flow volume (CFV) and coronary flow reserve were significantly lower in the patient group than in the controls, while there was no significant difference in the baseline CFV between the two groups. Hypertension was present in 60% and CAC was observed in 20% of the children in the patient group. CAC was present in 30% of the children in the hypertensive subgroup. The left ventricle myocardial performance index (LV MPI), CAC score, duration of hypertension and level of diastolic blood pressure were independent predictors of the coronary blood flow, and LV MPI, serum parathyroid hormone, duration of dialysis and E'/A' mitral valve were independent predictors of coronary calcification. Conclusion High diastolic blood pressure, long duration of hypertension, high LV MPI and increased CAC scores are independent risk factors for impaired coronary blood flow in children with ESRD., Author(s): Mohammed Al-Biltagi [sup.1] [sup.2] , Maher Ahmed Abd ElHafez [sup.1] , Doaa Mohamed El Amrousy [sup.1] , Mohamed El-Gamasy [sup.1] , Hesham El-Serogy [sup.3] Author Affiliations: (1) Pediatric Department, [...]

Author(s): Zhen Wang [sup.1] [sup.2] , Eduardo A. Oliveira [sup.1] [sup.3] , Robert H. Mak [sup.1] Author Affiliations: (Aff1) 0000 0001 2107 4242, grid.266100.3, Division of Pediatric Nephrology, Rady Children's [...]

Hemodiafiltration (HDF) combines both hemofiltration (HF) and hemodialysis in the same procedure. It was initially performed in adults in 1977, and later used in children in the early 1980s. The use of HDF allows a determined convective dialysis dose to be combined with the conventional urea dialysis dose. The dialysis session is better tolerated as a result of the effects of hemofiltration. On-line HDF, i.e., substitution fluid prepared from ultrafiltration of the ultrapure dialysate, can be performed safely due to recent advances in modern technology. However, despite interest and feasibility in children, the majority of pediatric dialysis units across the world still perform hemodialysis using highly permeable membranes, allowing back filtration in the filter and therefore a degree of convective flow, i.e., internal hemodiafiltration. In some countries, government restrictions prohibit the use of online hemodiafiltration, (such as the FDA recommendations in North America), and therefore it should not be used in these circumstances. Keywords Hemodiafiltration * Convective flow. Convection * Ultrapure * Children * Dialysis, Introduction Hemodiafiltration (HDF), which uses a combination of hemofiltration (HF) and hemodialysis (HD), was initially described in adults in 1977 [1, 2] and later used in children in the early [...]

The study aims to evaluate and assess the risk of chronic dialysis and mortality among those individuals that have survived acute kidney injury requiring dialysis. The results indicate that there was an increased risk of chronic dialysis in the case of such patients; however, not all-cause mortality.

The study aims to evaluate the efficacy of pretreatment of brain-dead donors with Dopamine on graft function after kidney transplant. The results indicate that such pretreatment is effective in reducing the need for dialysis after kidney transplantation.

The study aims to evaluate the efficacy of the use of statins like rosuvastatin in reducing cardiovascular events in patients undergoing hemodialysis. The results indicate that rosuvastatin did reduce the LDL cholesterol level among such patients but did not help prevent mortality from cardiovascular causes.

SELF-CARE AND self-management have been high on the healthcare agenda since the publication of The NHS Plan (Department of Health (DH) 2000). A more recent publication, Supporting People with Long [...]