Tuberculosis in children undergoing continuous ambulatory peritoneal dialysis

The incidence of tuberculosis (TB) is increasing worldwide. Due to an impairment of cellular immunity, patients with chronic renal failure are susceptible to reactivation of TB. Seventy patients were treated by continuous ambulatory peritoneal dialysis (CAPD) in our pediatric nephrology department during the years 1989–1997. TB was diagnosed in 4 patients, representing 5.7% of all CAPD patients in our department. One patient had extrapulmonary (TB osteomyelitis) and the others had pulmonary TB. All patients were treated with antituberculous drugs.Two patients with pulmonary TB were cured. Symptoms improved in the other 2 patients but they died at home for unknown reasons. We recommend that all children in regions of high prevalence of TB should be investigated for TB, especially if they have a cough or fever of unknown etiology. Received: 13 January 1998 / Revised: 7 December 1998 / Accepted: 11 December 1998     

Intraperitoneal pressure and hernias in children on peritoneal dialysis

Abdominal wall hernias have been increasingly recognized in patients on continuous ambulatory peritoneal dialysis (CAPD). They are also more frequent in children than in adults. The aim of this study was to determine the influence of intraperitoneal pressure (IPP) on the development of hernias in children on CAPD, and if there was a difference between IPP in children and adults. We studied 14 children aged 11.2±3.2 years, body weight 31.1±9.4 kg, who had undergone CAPD for 16.2±14.4 months. Also, 10 adults were studied, aged 48±18 years, body weight 62.4±13.9 kg, on the CAPD program for 35±27 months. The IPP was measured via a column of dialysate in the peritoneal dialysis line, immediately before the drainage of the peritoneal cavity. The pressure was measured with the patients in the supine position, at the level of the umbilical cicatrix with the zero point located on the mean axillary line. IPP was measured at inspiration and at expiration, and the mean of these two measurements was calculated. The children were divided in two groups : group 1 (n=7) without hernias and group 2 (n=7) with hernias (5 umbilical and 2 inguinal). The IPP of all children was 9.5±2.9 cm H₂O. The IPP was 8.1±2.6 and 10.9±2.6 cm H₂O in groups 1 and 2, respectively (P=0.003). The instilled volume for test was similar in both groups. The IPP of the adults was 13.8±2.8 cm H₂O, which was significantly greater than that of the children (P=0.001). In conclusion, hernia is a common complication in children on CAPD and its prevalence is affected by IPP. Other associated factors may be the presence of anatomically weak sites in the abdominal wall of the children, since IPP is lower in children than in adults. Received: 20 July 1998 / Revised: 26 January 1999 / Accepted: 26 January 1999     

Humoral immunity and frequency of peritonitis in chronic peritoneal dialysis patients

This study was designed to investigate the humoral immune status and immunological abnormalities in relation to the pathogenesis of peritonitis in patients undergoing continuous ambulatory peritoneal dialysis (CAPD). The levels of serum and dialysate total protein, immunoglobulins (IgG, IgA, IgM, and IgG subgroups), and C3 were measured at baseline and at the end of the study in 12 children and 10 adult patients on CAPD. The relationship between the levels of immunoglobulin and C3 and the frequency of peritonitis was investigated. Peritonitis occurred at a frequency of one episode every 3.9 and 6.3 patient-months in children at the beginning and at the end of the study, respectively; however, the respective rates for adult patients were one episode every 5.6 and 9.8 patient-months. The levels of serum immunoglobulin and C3 were normal in adults at the beginning and at the end of the study. However, the levels of serum IgG were low in 4 of 12 pediatric patients. Of the 4 patients with low total IgG, IgA was low in 1 and IgM was low in 2 patients. Of 4 patients with low total IgG, 2 also had low IgG1 and IgG2. However, 3 of the patients with normal IgG had low IgG2 levels at the end of the study. The levels of C3 were low in 6 of 12 and in 3 of 10 pediatric patients at the beginning and at the end of the study, respectively. The protein levels of dialysate were increased at 1-year follow-up in both groups, but the difference was only statistically significant in adult patients (P<0.05). No correlation was found between the levels of serum and dialysate immunoglobulin and the frequency of peritonitis in either group. In this study, hypogammaglobulinemia and hypocomplementemia were determined in pediatric patients undergoing CAPD. Although these immunological deficits are not major factors in the occurrence of CAPD-related peritonitis, they may contribute to the frequency of peritonitis. Received: 19 September 2000 / Revised: 7 February 2001 / Accepted: 24 August 2001     

Laparoscopic placement of peritoneal dialysis catheters: 7 years experience

Background: Since 1994 we have placed all peritoneal dialysis (Tenckhoff) catheters at our hospital laparoscopically using a technique that incorporates suture fixation into the pelvis. The purpose of this study was to determine the long‐term outcome of this approach. Method: Perioperative and follow‐up data for all patients undergoing placement of a peritoneal dialysis catheter at the Royal Adelaide Hospital were collected prospectively and managed on unit specific and hospital wide computerized databases. A total of 148 procedures were carried out in 123 patients from March 1994 to November 2001. Follow‐up ranged from 3 to 68 months (median, 42 months). All procedures were undertaken or supervised by one surgeon, and catheters were routinely sutured into the pelvis at laparoscopy. Results: There was no perioperative mortality in this series, and only one catheter could not be placed laparoscopically. This was in a patient with extensive intra‐abdominal adhesions. Mean operative time was 27 min (range, 10?100 min), and mean postoperative stay was 2.8 days (range, 1?12 days). Seven (5%) patients experienced peri/postoperative haemorrhage, and four of these underwent surgical re‐exploration. Twenty‐five (17%) catheters are still used for dialysis. Thirty‐four (23%) catheters were removed when the recipient received a subsequent renal transplant, and 42 (28%) patients died during follow‐up. Forty‐six (31%) patients required catheter revision or removal because of technical problems; 26 (18%) recurrent peritonitis or exit site infection; and 20 (14%) catheter blockage. Twenty‐eight reinsertion procedures were carried out in 25 patients. Ten (7%) patients developed port site hernias at late follow‐up, and required hernioplasty. Catheter migration leading to malfunction (poor drainage) occurred in eight (5%) patients only. Conclusions: Laparoscopic placement of peritoneal dialysis catheters is a safe and effective procedure. The majority of patients will dialyse successfully using this technique. Suturing the catheter tip into the pelvis is associated with a low rate of catheter migration.     

One year's experience with recombinant erythropoietin in children undergoing continuous ambulatory or cycling peritoneal dialysis

Fourteen patients (aged 5.9–22.1 years) undergoing continuous ambulatory or cycling peritoneal dialysis were treated with recombinant human erythropoietin (rhEPO), which was given intravenously once a week at a dosage of 300 units/kg. The mean haematocrit level increased from 18.5% to 27.5% and the reticulocyte count from 19 to 62 within 1 month. After an average time of 3.1 months rhEPO dosage could be adjusted to 100 units/kg per week to keep the haematocrit level at 30%. Only 1 patient had an exacerbation of hypertension, which required a dosage reduction; other side-effects were not noted.     

Continuous peritoneal dialysis in children: a single-centre experience in a developing country

Continuous peritoneal dialysis (CPD) is the most commonly used modality of dialysis in children. Continuous ambulatory peritoneal dialysis (CAPD) has been an established form of therapy in adult patients with end-stage renal failure in India for more than a decade. There is a paucity of published experience of CPD in children from developing countries. We retrospectively studied children with end-stage renal failure (ESRD) that had been on CAPD over the past 10 years. Thirty patients with ESRD, mean age 13±8 years (range 5–21 years), male 18, were started on CAPD from 1994 to October 2004. The mean break-in period was 12±3 days. Of these 30 patients, 15 had a total of 21 episodes of peritonitis. The peritonitis rate was 0.58 episodes per patient year. E. coli was the commonest organism causing peritonitis. On outcome analysis, 7/30 (23.3%) patients received a renal transplant, while 11/30 (36.6%) continued on CAPD, awaiting a kidney transplant. Of the rest, eight (26.6%) patients died, two (6.7%) suffered technique failure and were changed to haemodialysis, and two (6.7%) were lost to follow-up after 2 months. The mean cumulative survival time of patient on CPD was 42 months. We conclude that CPD is a viable option for dialysis in ESRD children in a developing country and is a successful bridge between ESRD and renal transplantation     

Sustained low-efficiency dialysis versus continuous veno-venous hemofiltration for postsurgical acute renal failure

Background

In postsurgical acute renal failure patients with moderate unstable hemodynamics or fluid overload, the choice of dialysis modality is difficult. This study was performed to compare the outcomes between the sustained low-efficiency dialysis (SLED) and continuous veno-venous hemofiltration (CVVH) in these patients.

Methods

Sequential postsurgical acute renal failure patients undergoing acute dialysis with CVVH (2002-2003), or SLED (2004-2005) as a result of severe fluid overload or moderately unstable hemodynamics were analyzed. Multivariate analyses of comorbidity, disease severity before initiating dialysis, biochemical measurements, and hemodynamic parameters for 3 days after the first dialysis session were performed by fitting multiple logistic regression models to predict patient's 30-day after hospital discharge (AHD) mortality.

Results

Among the 101 recruited patients, 38 received SLED and the rest received CVVH. The 30-day AHD mortality was 62.4%. The independent risk factors of 30-day AHD mortality included older age (P = .008), lower first postdialysis mean arterial pressure (MAP) (P = .021), higher first postdialysis blood urea nitrogen level (P = .009), and absence of a history of hypertension (P = .002). A further linear regression analysis found that dialysis using SLED was associated with higher first postdialysis MAP (P = .003).

Conclusions

Among the postsurgical patients requiring acute dialysis with severe fluid overload or moderately unstable hemodynamics, the patients treated with SLED had a higher first postdialysis MAP than those treated with CVVH, which led to lower mortality. Further multicenter randomized clinical trials of larger sample size are needed to compare the effects of SLED and CVVH on the outcomes of postsurgical acute dialysis patients.     

Fabry disease in patients receiving maintenance dialysis

Background. Fabry disease is an X-linked disorder resulting from a deficiency of lysosomal α-galactosidase. Renal insufficiency is one of its most important manifestations and affects the prognosis of the disease. We clarified the incidence of Fabry disease in patients receiving maintenance dialysis. Methods. We measured plasma α-galactosidase activity in 722 patients (male 440, female 282) receiving maintenance dialysis. Clinical manifestations were assessed, and the patients were to be screened for mutations in the α-galactosidase gene. Results. Two male patients had low plasma α-galactosidase activity. One patient had a C-to-T transition at codon 357, resulting in substitution of the predictable termination for glutamine. The other patient died suddenly during hemodialysis, due to arrhythmia. We could not carry out further evaluation, but his daughter had moderate reduction of α-galactosidase activity in leukocytes. She was, likely, an asymptomatic heterozygote. Conclusions. Two male patients with Fabry disease were found among 440 male patients who were receiving maintenance dialysis. Fabry disease should be considered in the etiology of end-stage renal failure. Received: January 6, 1999 / Accepted: June 14, 1999     

Growth of children following the initiation of dialysis: a comparison of three dialysis modalities

Maintenance dialysis usually serves as an interim treatment for children with end-stage renal disease (ESRD) until transplantation can take place. Some children, however, may require dialytic support for an extended period of time. Although dialysis improves some of the problems associated with growth failure in ESRD (acidosis, uremia, calcium, and phosphorus imbalance), many children continue to grow poorly. Therefore, three different dialysis modalities, continuous ambulatory peritoneal dialysis (CAPD), cycler/intermittent peritoneal dialysis (CPD), and hemodialysis (HD), were evaluated with regard to their effects on the growth of children initiating dialysis and remaining on that modality for 6–12 months. Growth was best for children undergoing CAPD when compared with the other two modalities with regard to the following growth parameters: incremental height standard deviation score for chronological age [–0.55±2.06 vs. –1.69±1.22 for CPD (P<0.05) and –1.80±1.13 for HD (P<0.05)]; incremental height standard deviation score for bone age [–1.68±1.71 vs. –2.45±1.43 for CPD (P=NS) and –2.03±1.28 for HD (P=NS)]; change in height standard deviation score during the dialysis period [0.00±0.67 vs. –0.15±.29 for CPD (P=NS) and –0.23±.23 for HD (P=NS)]. The reasons why growth appears to be best in children receiving CAPD may be related to its metabolic benefits: lower levels of uremia, as reflected by the blood urea nitrogen [50±12 vs. 69±16 mg/dl for CPD (P<0.5) and 89±17 for HD (P<0.05)], improved metabolic acidosis, as indicated by a higher serum bicarbonate concentration [24±2 mEq/l vs. 22±2 for CPD (P<0.05) and 21±2 for HD (P<0.05)]. In addition, children undergoing CAPD receive significant supplemental calories from the glucose absorbed during dialysis. CAPD, and possibly, other types of prolonged-dwell daily peritoneal dialysis appear to be most beneficial for growth, which may be of particular importance for the smaller child undergoing dialysis while awaiting transplantation.     

Chronic peritoneal dialysis in paediatrics: Experience of a national registry

The results of the first 3 year' collaboration of the Italian Registry of Paediatric Chronic Peritoneal Dialysis (CPD) (1986–1988) are presented. This Registry acquired data on the majority of the paediatric patients treated with CPD in Italy, thus providing a national picture in a field where few nationwide surveys are available. Patients of less than 15 years of age at the start of dialysis were enrolled and clinical data collected until the age of 19 years. The number of nephrological paediatric centres participating in the Registry increased from 7 in 1986 to 11 in 1988. The total number of patients on CPD was 70 and the percentage of dialysed children treated with CPD ranged from 40.2% to 43.6%. Data on 89 peritoneal catheters were collected: during 1417 dialysis-months 70 catheter-related complications were observed (1:20.8 dialysis-months); actuarial catheter survival was 92.7% at 6 months, 84.8% at 1 year and 68.8% at 2 years. The incidence of peritonitis changed from 1 episode every 10.9 patient-months in 1986 to 1 every 19.8 in 1988. Abdominal hernias were the other main clinical complication observed. The survival of patients was 92.5% at 3 years, while the technique survival at the same time was 84%.     

Sclerosing encapsulating peritonitis in pediatric peritoneal dialysis patients

The aim of this study was to define the incidence and characteristics of sclerosing encapsulating peritonitis (SEP) in pediatric peritoneal dialysis (PD) patients in Japan. A questionnaire was sent to all dialysis units with at least two pediatric PD patients. Among 687 patients registered, 11 cases (1.6%) of SEP were diagnosed. The mean age of patients with SEP at the start of PD was 9.7±3.6 years and at SEP diagnosis, 19.1±3.8 years. All patients had undergone PD for more than 5 years, and the mean PD duration was 9.6±3.3 years. SEP was diagnosed in 6.6% and 12% of patients dialyzed for >5 years and >8 years, respectively. The incidence of peritonitis among patients with SEP was not different from that among the Japanese pediatric registry. All patients had virtually no residual urine volume and 9 had impaired peritoneal ultrafiltration. Peritoneal calcification was the most-frequent radiological finding. Peritoneal biopsy was performed in 7 patients and confirmed sclerotic peritonitis in all. Ten patients transferred to hemodialysis, and only 1 patient underwent surgery. Three patients died. We recommend that patients on PD for more than 5 years who have impaired peritoneal ultrafiltration or peritoneal calcification should be carefully managed as presumptive cases of SEP. Received: 25 February 1999 / Revised: 9 July 1999 / Accepted: 13 July 1999     

Capnocytophaga canimorsus peritonitis in a pediatric peritoneal dialysis patient

Capnocytophaga canimorsus, a bacterium rarely encountered by clinicians, was responsible for the development of peritonitis in an 18-year-old white male on automated peritoneal dialysis following the puncture of his dialysis tubing by a domestic cat. Although more than 100 cases of septicemia caused by C. canimorsus have been reported, this is the first report of the organism causing peritonitis in a patient receiving peritoneal dialysis. Of interest, the patient had a prior episode of peritonitis secondary to Pasteurella multocida, also following transmission from the same cat. Received: 20 November 1998 / Revised: 13 January 1999 / Accepted: 13 January 1999     

Paecilomyces variotii peritonitis in an infant on automated peritoneal dialysis

Fungal peritonitis is a serious complication of chronic peritoneal dialysis (CPD) and is frequently associated with CPD drop-out. Paecilomyces variotii, a common saprophytic fungus, rarely causes human infection. To date, only nine adult or adolescent patients with P. variotii peritonitis during continuous ambulatory peritoneal dialysis have been reported. In all patients, successful treatment required antifungal therapy and removal of the peritoneal catheter. We report the first case of P. variotii peritonitis in an infant on automated peritoneal dialysis successfully treated with combined intraperitoneal and oral fluconazole, without removal of the peritoneal catheter. Received: 10 March 1999 / Revised: 7 July 1999 / Accepted: 8 July 1999     

Neurodevelopmental outcome of children initiating peritoneal dialysis in early infancy

A retrospective review of 34 infants who started long-term peritoneal dialysis at ≤3 months of age was conducted. Six of the patients died during infancy, leaving 28 infants who survived >1 year and who underwent a formal neurodevelopmental evaluation. In addition to dialysis, treatment of the patients included the use of calcium carbonate as the sole phosphate binder in all patients and supplemental nasogastric tube feeding in 27. At 1 year of age, the 28 patients had a mean head circumference standard deviation score of –0.96±1.2. The mental developmental score of 22 (79%) patients fell in the average range, while only 1 (4%) child was significantly delayed. Of 19 children retested at ≥4 years of age, 15 (79%) performed in the average range and 1 (5%) performed in the impaired range. Of 16 patients ≥5 years of age, 15 (94%) attended school full time and in age-appropriate classrooms. Twenty-four patients received their initial kidney transplant at a mean age of 2.1±0.8 years. This experience provides evidence that the combination of aggressive nutrition, the elimination of aluminum as a phosphate binder, the provision of dialysis, and subsequent transplantation all contribute to a favorable developmental outcome in infants who develop end-stage renal disease in early infancy. Received: 3 March 1998 / Revised: 10 November 1998 / Accepted: 10 November 1998     

Oral l-carnitine does not decrease erythropoietin requirement in pediatric dialysis

The use of recombinant human erythropoietin (rhEPO) has greatly facilitated the treatment of anemia in children with chronic renal failure, but is expensive. Several reports on adult patients have shown that supplementation with l-carnitine can decrease the requirement for rhEPO. The objective of this study was to investigate the effect of oral supplementation with l-carnitine on the rhEPO requirement in children on dialysis. We investigated 16 children on dialysis (11 hemodialysis, 5 peritoneal dialysis) with a median age of 10.2 years. All children were stable on rhEPO treatment at least 3 months before study entrance. After obtaining baseline data, all children were supplemented with l-carnitine 20 mg/kg/day. Data were collected for 26 weeks. Follow-up was completed for 12 patients (8 hemodialysis, 4 peritoneal dialysis). At baseline free carnitine (32±18 μmol/l) and total carnitine levels (54±37 μmol/l) were normal. At the end of the study free carnitine levels had increased to 97±56 μmol/l (P<0.05) and total carnitine levels to 163±90 μmol/l (P<0.05). There was no significant change in rhEPO requirement. Hemoglobin level or hematocrit did not change significantly during the study. In conclusion we could not demonstrate a beneficial effect of supplementation with l-carnitine on rhEPO requirement in children on dialysis. Received: 17 September 1999 / Revised: 14 April 2000 / Accepted: 17 April 2000     

Peritonitis in continuous ambulatory peritoneal dialysis in children living in Saudi Arabia

The clinical aspects of peritonitis and catheter infections were reviewed in 64 children on continuous ambulatory peritoneal dialysis living in Saudi Arabia over a period of 6 years. Peritonitis occurred in 41 children (64%). The mean time from starting dialysis to the first episode of peritonitis was 7.2 months. The incidence of peritonitis was 1 episode in 9 treatment months. Gram-negative organisms were responsible for the majority of episodes (42%), followed by Gram-positive organisms (20%), and Candida albicans (6%); 32% were culture negative. Recurrent peritonitis was present in 20 cases. Catheter was replaced in 24 patients: 44% due to recurrent peritonitis. Peritoneal membrane loss occurred in 7 patients, 3 had Candida peritonitis and 3 had recurrent peritonitis due to Pseudomonas. The mortality rate was 4.6% but none of the deaths were related to peritonitis or dialysis. Received August 23, 1995; received in revised form October 2, 1996; accepted October 18, 1996     

透析治疗对慢性肾脏疾病患者勃起功能的影响

目的评价慢性肾脏疾病患者经透析治疗（血液透析和腹膜透析）后的勃起功能。方法对121名慢性肾脏疾病行透析治疗的患者和48名慢性肾脏疾病但肾功能正常的患者（对照组）用IIEF评价其勃起功能。结果血液透析组（HD）、腹膜透析组（PD）、慢性肾病肾功能正常组（对照组）ED发生率分别为80．3％、78．7％和46．2％。HD患者中有20％〈50岁和60％≥50岁患有重度ED，只有〈50岁患者的重度ED与对照组同一年龄段相比有统计学差异。〈50岁组中，中至重度患者的ED发生率明显高于对照组（P〈0．001）。PD患者的情况与HD患者的情况类似。结论男性透析患者的ED发生率较高，ED程度较重，今后的临床工作中要更多注意透析患者的整体健康评价。