Psychosocial adjustment and adherence to dialysis treatment regimes

Sixty children and adolescents in end-stage renal failure who were undergoing either haemodialysis or continuous ambulatory peritoneal dialysis at one of five United Kingdom dialysis centres were assessed on psychosocial adjustment and adherence to their fluid intake, diet and medication regimes. Parental adjustment was also measured and data on sociodemographic and treatment history variables collected. A structured family interview and standardised questionnaire measures of anxiety, depression and behavioural disturbance were used. Multiple measures of treatment adherence were obtained, utilising children's and parents' self-reports, weight gain between dialysis, blood pressure, serum potassium level, blood urea level, dietitians' surveys and consultants' ratings. Correlational analyses showed that low treatment adherence was associated with poor adjustment to diagnosis and dialysis by children and parents (P<0.01), self-ratings of anxiety and depression in children and parents (P<0.001), age (adolescents tended to show poorer adherence than younger children,P<0.001), duration of dialysis (P<0.05), low family socioeconomic status (P<0.05) and family structure (P<0.01). These findings demonstrate the importance of psychosocial care in the treatment of this group of children. Future research should develop and evaluate psychosocial interventions aimed at improving treatment adherence.     

High serum D-lactate in patients on continuous ambulatory peritoneal dialysis

Background. As abnormally high serum D-lactate levels may cause nephrological impairment, we determined whether patients undergoing continuous ambulatory peritoneal dialysis (CAPD) with lactate-containing fluids have increased serum D-lactate concentrations. Methods. D- and L-lactate concentrations were determined in peritoneal dialysis fluids and in serum from control subjects (n = 10), haemodialysis patients (n = 10), and CAPD patients (n = 30) before and after 1 h of dialysis. Results. We found the median D-lactate concentration in Dianeal CAPD fluid to be 26 mM (range 19-27), whereas it was less than 0.5 mM in DPCA2 fluid. Control, haemodialysis, and CAPD (DPCA2) patient median serum D-lactate concentrations were below 0.07 mM. However, CAPD (Dianeal)_patient serum D-lactate concentrations were 4-fold higher than controls (P <0.0001), at 0.28 mM, an hour after instillation of D-lactate-containing fluid. Three patients, whose serum D-lactate averaged 0.59 mM, were found to have D-lactate concentrations at 0.22 mM after overnight cessation of dialysis. Conclusion. We conclude that CAPD with D-lactate-containing fluids raises serum D-lactate to abnormal levels.     

Comparison of the rehabilitation status of continuous ambulatory peritoneal dialysis and in-centre haemodialysis in Chinese patients

Summary: In Hong Kong, dialysis treatment has become more accessible in recent years. Due to a shortage of kidney donors patients are required to stay on dialysis for longer periods. the rehabilitation status of 181 end-stage renal failure (ESRF) patients on dialysis, 34 on in-centre haemodialysis (ICHD) and 147 on continuous ambulatory peritoneal dialysis (CAPD), at the Prince of Wales Hospital was studied. There was no statistically significant difference in physical functioning due to treatment type; however, CAPD patients were shown to be more socially active and had a better family life than ICHD patients (P < 0.01). There were no statistically significant correlations between physical functioning, social life or family life and the duration of dialysis in both ICHD and CAPD patients. In both groups of patients 52.9% of ICHD and 52.4% of CAPD patients had decreased employment status. All the patients were assessed by doctors-in-charge on their physical fitness for employment, 85.7% (n= 6) of the unemployed ICHD patients and 71% (n= 44) of the unemployed CAPD patients were considered to be physically fit to work. Due to the ageing of the general population and greater availability of dialysis treatment and higher survival rate of the chronically ill have led to an increase in the number of elderly patients on dialysis (aged 60 years and over). the proportion of elderly dialysis patients in our renal centre increased from 7–23% in the past 5 years. Continuous ambulatory peritoneal dialysis patients aged less than 60 years were found to be significantly more physically active and socially active than CAPD patients aged over 60 years (P < 0.01). In the aspect of a better family life for these patients, no statistically significant difference was found between the two groups. Rehabilitation of ESRF patients can be achieved by renal replacement therapy. It is concluded that CAPD patients have better adaptation in social life and family life than ICHD patients.     

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.     

Peritoneal morphology in children treated by continuous ambulatory peritoneal dialysis

Fifty peritoneal biopsies (PB) from 35 patients with end-stage renal disease, treated by continuous ambulatory peritoneal dialysis (CAPD) and aged 2 months to 18 years, were examined by light microscopy (n=50) and/or scanning electron microscopy. PB were performed during surgical procedures immediately before the start of, during, or after the cessation of CAPD treatment. PB from 15 children without renal disease undergoing laparatomy were examined similarly. Before the start of CAPD, a scarcity and shortening of the mesothelial microvilli was observed by scanning electron microscopy. During and after CAPD, variable alterations of mesothelium, interstitium and capillaries were found. The mesothelial layer was absent in all 5 PB obtained during episodes of active peritonitis. In patients treated by CAPD for longer than 6 months, mesothelial denudation was observed more frequently (6/11) than in children treated for shorter periods (1/7) (P<0.08). Fibrosis of the peritoneal membrane was present in about 50% of patients during or after the cessation of CAPD without impairment of peritoneal function. No correlation was found between the presence of fibrosis and the frequency of peritonitis or the duration of CAPD treatment.     

Comparison of high-efficiency and standard haemodialysis providing equal urea clearances by partial and total dialysate quantification

Background. Short-duration high-efficiency haemodialysis has been utilized increasingly in recent years to deliver adequate blood urea clearances per dialysis session. However, high-efficiency and standard-duration haemodialysis schedules, which achieve equal patient urea clearances, may not represent equivalent dialytic therapy due to solute differences in intercompartmental dysequilibrium during dialysis and differences in dialysis mechanics. Methods. To circumvent the effects of intercompartmental dysequilibrium and postdialysis rebound solute clearances were measured by direct dialysis quantification (total and partial dialysate collections) rather than blood clearances. High-efficiency haemodialysis (dialyser blood flow rate=400 ml/min; dialysis time=170.67 min) was compared with standard haemodialysis (dialyser blood flow rate=200 ml/min; dialysis time=240 min) performed in random order in six anuric patients using Fresenius F8 dialysers and the same haemodialysis machine. Such haemodialysis schedules were prescribed to provide equivalent urea clearances. Results. Patient plasma water urea clearances measured by direct quantification were equivalent, whereas high efficiency haemodialysis achieved significantly lower phosphate clearances (P=0.01), less net bicarbonate absorption (P=0.01), and {beta}2microglobulin removal (P<0.001) than standard haemodialysis. Estimated total dialysate effluent volumes with partial dialysate collection and total dialysate collection correlated closely (r=0.95) and there were no differences between patient urea, creatinine and phosphate clearances measured by partial and total dialysate quantification. Conclusions. The data indicate that even if high-efficiency and standard haemodialysis provide equal whole-body urea clearances, delivered dialysis therapy is not equivalent. The partial dialysate collection method is as accurate as the cumbersome total dialysate collection approach and may be applied to assess delivered dose by minor modification of current haemodialysis machines.     

Efficacy and toxicity of sunitinib in patients with metastatic renal cell carcinoma with severe renal impairment or on haemodialysis

Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? Sunitinib is approved for the first‐ and second‐line treatment of advanced renal cell carcinoma (RCC). Chronic kidney disease is commonly seen in patients with RCC, but knowledge regarding the effect of sunitinib in patients with severe renal impairment or on haemodialysis is limited. In this study we define the toxicity profile and clinical outcomes of a patient cohort with RCC with severe renal impairment, or on haemodialysis who were treated with sunitinib. This retrospective study suggests that these patients can be safely treated with sunitinib at the standard dose, and the observed efficacy of therapy is similar to that reported in patients with normal renal function.

OBJECTIVE

To further investigate the effect of sunitinib, which is currently a standard of care for the treatment of metastatic renal cell carcinoma (mRCC), in patients with severe renal impairment or those undergoing dialysis.

PATIENTS AND METHODS

Clinical databases were used to identify all patients with mRCC treated with sunitinib in seven institutions internationally. Databases were searched to identify only those patients with an estimated glomerular filtration rate of <30 mL/min/1.73 m² or those who had end‐stage renal disease requiring dialysis. Baseline characteristics, adverse event data, response and progression‐free survival were recorded.

RESULTS

Nineteen patients met the inclusion criteria, 10 of whom were undergoing haemodialysis. Of the nine non‐dialysis‐dependent patients at drug initiation, the median estimated glomerular filtration rate was 27 mL/min/1.73 m² (range 23–29). Baseline characteristics included a median age of 61 years (range 44–77); 17 patients had a Karnofsky performance status of >80; eight patients had more than two metastatic sites and 17 had undergone prior nephrectomy. The estimated median progression‐free survival of this cohort was 43 weeks (range 7 to 158+) and progression has not yet been reached in six patients. Partial response or stable disease was observed as best response in 15 patients. The most common treatment‐related adverse events included fatigue, diarrhoea, hand–foot skin reaction (HFSR), nausea and vomiting and rash. Grade three treatment‐related adverse events including fatigue (seven patients), HFSR (two patients), diarrhoea (one patient), rash (one patient) and stomatitis (one patient) occurred in a total of 12 patients. Only one patient experienced a grade four adverse event (HFSR). Only diarrhoea (P = 0.0002), HFSR (P < 0.0001) and neutropenia (P = 0.001) were more common in patients undergoing haemodialysis compared with non‐dialysis‐dependent patients. Four of the non‐dialysis dependent patients started at a dose of 50 mg compared with three of the patients undergoing haemodialysis. However five and two of the patients undergoing haemodialysis started at doses of 37.5 mg and 25 mg daily, respectively, compared with four and one of the non‐dialysis‐dependent patients. All patients took sunitinib for 4 out of every 6 weeks. Dose reductions during treatment were performed in eight patients but only one patient required discontinuation of treatment.

CONCLUSION

These data suggest that patients with severe renal impairment or end‐stage renal disease on haemodialysis can be safely treated with sunitinib at doses of 25–50 mg daily for 4 weeks followed by a 2‐week break. The observed efficacy of therapy is similar to that reported in patients with normal renal function. These preliminary results warrant confirmation in a larger cohort of patients.     

Plasma hypercoagulability in haemodialysis patient: impact of dialysis and anticoagulation

Background: Thrombotic complications are common in patients with endstage renal disease and contribute substantially to the morbidity and mortality in this population. The aim of the present study was to: I) determine the prevalence and the extent of hypercoagulability in patients undergoing dialysis treatment by measuring parameters that directly reflect thrombin concentrations, ii) assess changes in coagulation status during haemodialysis (HD); iii) quantify the relative impact of heparin, dialysis and their combined effects on coagulation status and iv) detect factors that modify coagulation haemostasis in dialysis patients. Method: A total of 39 patients (HD: n=29, CAPD: n=10) was analysed for procoagulatory and fibrinolytic activity determined by measurements of partial thromboplastin time, prothrombin fragments F1+2, thrombin-antithrombin complexes and D-dimer concentrations. HD patients were investigated prior to and during dialysis. A subgroup of patients was infused heparin alone without dialysis or was dialysed without heparin administration. Furthermore, subgroup and correlation analyses were performed for the type of dialysis (HD vs CAPD), dialyzer and shunt, Kt/V, underlying disease and treatment with recombinant erythropoietin (rhEPO). Results: Baseline levels of all parameters-procoagulatory and fibrinolytic- were substantially elevated in all patients, but to a higher degree among those on CAPD. Moreover, haemodialysis treatment increased procoagulatory markers even further, suggesting stimulated coagulation and/or insufficient anticoagulation during dialysis. However, after 3 h of dialysis thrombin concentrations, determined by quantification of prothrombin fragments, were inversely correlated with Kt/V. Selective heparin infusion diminished procoagulatory activity only slightly and incompletely, whereas HD without heparin resulted in excess thrombin accumulation. Finally, subgroup analyses revealed more pronounced thrombin formation among patients treated with polysulfon dialyzers, whereas erythropoietin dosage was positively related with lower procoagulatory activity. Conclusion: A majority of patients on dialysis are in a hypercoagulable state, which is further aggravated by the haemodialysis procedure itself and may not be sufficiently controlled with current anticoagulation regimens. Intensified heparin treatment and the use of rhEPO are likely to improve coagulation haemostasis, whereas the type of dialyzer should be considered as a relevant procoagulatory factor.     

Effects of haemodialysis and continuous ambulatory peritoneal dialysis on the plasma clearance of an albumin-bound furan dicarboxylic acid

Organic acids that are strongly bound to albumin are not removedby dialysis and the plasma concentrations of one such substance,a furan dicarboxylic acid (3-carboxy-4-methyl-5-propyl-2-furan-propanoicacid; 5-propyl FPA) have been measured by HPLC in healthy subjects(n=21), patients on regular haemodialysis (n=30), and patientstreated by continuous ambulatory peritoneal dialysis (n=21).The mean (±SD) concentrations of 5-propyl FPA were significantlyhigher in haemodialysis (95±44 µM) compared toCAPD patients (28±19 µM)) and both were higherthan in healthy individuals (14±7 µM). Haemoglobinconcentrations in CAPD patients were significantly higher thanin those on haemodialysis while these patients had significantlyhigher albumin concentrations than CAPD patients. The concentrationof 5-propyl FPA was positively correlated with the durationof dialysis for haemodialysis patients but not for CAPD patients.The lower concentrations of 5-propyl FPA in CAPD patients mayat least partly explain the higher haemoglobin levels foundin these patients.     

Bone mineral density and bone turnover markers in children with chronic renal failure

Bone mineral density (BMD) at lumbar spine (L₂-L₄) was measured by dual-energy X-ray absorptiometry (DEXA) in 21 children with predialysis chronic renal failure (CRF) and 44 children with end-stage renal failure (ESRF) on regular hemodialysis. BMD results were expressed as Z-scores. Osteopenia was documented in 13 predialysis patients (61.9%) and 26 patients (59.1%) with ESRF. No significant correlation was observed between Z-scores and the duration of CRF or estimated creatinine clearance. In osteopenic children there was a negative correlation between Z-scores and serum phosphorus (r=–0.61, P=0.004), intact parathyroid hormone (iPTH) (r=–0.47, P=0.03), and bone-specific alkaline phosphatase (r=–0.52, P=0.02) and a positive correlation with total calcium (r=0.41, P=0.07) and 25-hydroxycholecalciferol (r=0.53, P=0.02). Osteopenic children who had iPTH values 200 pg/ml were more osteopenic than those who had lower iPTH levels (P=0.006). In conclusion, osteopenia, assessed by DEXA, is frequent in children with CRF. It occurs early irrespective of the duration or the severity of CRF. In children with ESRF the degree of osteopenia is correlated with laboratory markers of renal osteodystrophy and patients with biochemical findings of secondary hyperparathyroidism are more osteopenic than the others.     

Endothelin-1 in children with chronic renal failure

Endothelin-1 (ET-1) was meansured after extraction from plasma of normal adults (5.9±1.9 pg/ml,n=22), normal children (7.1±1.86 pg/ml,n=29), nonhaemodialysed children with chronic renal failure (CRF) (11.1±1.8 pg/ml),n=10), renal graft recipients (9.5±3.4 pg/ml,n=37), haemodialysed children 24 h after a haemodialysis session (20.02±10.9 pg/ml,n=26) and haemodialysed children before and after a haemodialysis session (15.31±10.6 and 13.8±8.5 respectively,n=14). A sensitive and specific radioimmunoassay was used. ET-1 was significantly higher in non-haemodialysed CRF children and in renal graft recipients than in normal children (P<0.001 andP<0.01, respectively) and significantly higher in haemodialysed children when compared with normal children, non-haemodialysed CRF children and renal graft recipients (P<0.001). ET-1 concentrations were similar in normal children and normal adults. ET-1 was inversely correlated with glomerular filtration rate in non-haemodialysed CRF children (r=–0.39,P<0.01) and positively correlated with extracellular volume in haemodialysed children (r=0.435,P<0.03). After haemodialysis, ET-1 increased in 6 and decreased in 8 of the 14 children studied before and after a haemodialysis session.     

Atrial natriuretic peptide and cyclic 3′5′-guanosine monophosphate as indicators of fluid volume overload in children with chronic renal failure

Plasma atrial natriuretic peptide (ANP) and cyclic 35-guanosine monophosphate (cGMP) were investigated as indicators of fluid volume overload in children and adolescents with chronic renal failure. Plasma ANP and cGMP were measured in both paediatric patients with chronic renal failure (n=17, mean serum creatinine 371±242 mol/l) and those with end-stage renal disease on haemodialysis (n=18). cGMP was higher in children with chronic renal failure than in 45 healthy controls (1.0±0.4 vs 2.1±0.8 nmol/l,P<0.01), whereas plasma ANP was similar (26.9±9.7 vs 34.0±12.3 pmol/l). Both ANP and cGMP were markedly elevated in children with end-stage renal disease before haemodialysis and fell significantly during dialysis. During dialysis body weight decreased by 1.6±0.7 kg, corresponding to 4.5±2.1% of body weight. Plasma ANP correlated positively with plasma cGMP in haemodialysed patients (r=0.43,P<0.05). Reduction in body weight and in mean arterial pressure correlated more closely with plasma ANP than with cGMP. Therefore, elevation of plasma ANP appears to indicate volume overload in children undergoing haemodialysis, but whether it can be used also in children with chronic renal failure requires further investigation     

Oxalate Metabolism in End-Stage Renal Disease: the Effect of Ascorbic Acid and Pyridoxine

Oxalate metabolism was studied in ten patients with end-stagerenal disease. No patient with primary hyperoxaluria was includedin this study. Five patients were on regular haemodialysis andfive patients were on chronic ambulatory peritoneal dialysis(CAPD). Oxalate metabolism was assessed by measurement of plasmaoxa late concentration (P_ox) oxalate metabolic pool size (OxMP),tissue oxalate accumulation rate (TOxA), oxa late productionrate (OxPR) and dialysis clearance of oxalate (DC_ox These observationswere made on three separate occasions in each of the ten patients:initially when the patients were taking a routine ascorbic acidsup plement of 100mg per day; then after a period of I monthwith no ascorbic acid supplement; and then finally after a furtherperiod of I month's treatment with pyridoxine 800 mg daily. The values for P_ox OxMP and TOxA were significantly increasedin all ten patients and in the range observed in some patientswith type I primary hyperoxaluria. There was no significantdifference between immediate pre haemodialysis P_ox and the P_oxin the CAPD patients. The DC was very much greater during haemodialysis(mean 85 mI/mm) than during CAPD (mean 8 mI/mm). The acute fall,in P during haemodialysis was greater than 50% of the immediatepre-haemodialysis concentration. Ascorbic acid in a dose of 100 mg/day had no signifi cant effecton the parameters of oxalate metabolism studied. Pyridoxinein a dose of 800 mg/day produced a significant fall in P_ox inboth haemodialysis and CAPD patients.     

Fas Expression on Peritoneal Macrophages during Continuous Ambulatory Peritoneal Dialysis Peritonitis

Background. Peritonitis is a common complication of end stage renal failure (ESRF) patients receiving continuous ambulatory peritoneal dialysis (CAPD). Peritoneal macrophage may participate in the activation of specific T cells and in the generation of local cell-mediated immunity to various pathogens. The purpose of this study is to investigate the possible role of macrophage in CAPD patients with peritonitis. Methods. We evaluated the expression of Fas receptor (CD95), ICAM-1 (CD54), CD25, and CD69 by two-color flow cytometry on extravasted macrophages from 16 ESRF patients on CAPD with peritonitis (peritonitis-positive) and compared them to 11 ESRF patients on CAPD without peritonitis (peritonitis-negative) and normal controls. Results. We found an increased expression of CD95, CD54, and CD25 on macrophage in peritonitis-positive group compared to controls (all p < 0.001). In the peritonitis-positive group, the CD95 expression was significantly higher than that of the peritonitis-negative group (p < 0.001). The expression of CD54, CD25, and CD69, however, was not significantly different between the peritonitis-positive and peritonitis-negative CAPD subgroups. Conclusion. We found an abnormally increased percentage of macrophage-expressing Fas receptor and ICAM-1, and the percentage of CD95+ macrophage, but not those of other markers, were increased among the subset of CAPD patients with peritonitis. The later finding suggests that this macrophage phenotype is associated with peritonitis occurring in CAPD.     

Icodextrin Provides Long Dwell Peritoneal Dialysis and Maintenance of Intraperitoneal Volume

Icodextrin 7.5% is an isosmolar solution for once-daily use in peritoneal dialysis for patients with end-stage renal failure (ESRF). It produces substantial ultrafiltration (UF), performing best over longer dwells of 8–12 h in continuous ambulatory peritoneal dialysis (CAPD) patients, and up to 16 h in automated peritoneal dialysis (APD) patients. Subsequent use in other clinical areas (ultrafiltration failure) and normal postmarketing clinical experience has established its tolerability and safety profiles; a small number of patients, including those with diabetes, have now received icodextrin for up to 6 years. Icodextrin's ability to maintain intraperitoneal volume over many hours has led to its undergoing development as an intraperitoneal drug delivery system for targeted regional delivery of anticancer drugs and lymphatic delivery of anti-HIV treatment. Isosmolar icodextrin 7.5% solution represents the first major advance in the treatment of ESRF by peritoneal dialysis since the development of CAPD using glucose-based solutions 20 years ago.     

Long-term enteral nutrition in infants and young children with chronic renal failure

An inadequate nutritional intake is common in infants and young children with chronic and end-stage renal failure (CRF/ESRF), causing poor weight gain and growth retardation. In a programme of enteral feeding (EF), growth, nutritional intake and outcome for oral feeding were evaluated in 35 children with CRF/ESRF, mean (range) age 1.6 (0–4.9) years at start of EF for 30 (12–60) months. Twenty-nine had a glomerular filtration rate of 12.1 (6–26) ml/min per 1.73 m² and 6 were on peritoneal dialysis. Mean (SD) weight standard deviation scores (SDSs) in the 0 to 2-year age group (n=26) were –3.3 (1.0) 6 months before EF, –3.1 (1.3) at the start, –1.7 (1.4) at 1 year, (P=0.0003) and –1.4 (1.8) at 2 years, (P=0.0008). Height SDSs were –2.9 (0.7), –2.9 (1.2), –2.2 (1.2) (P=0.008) and –2.1 (1.3) (P=0.004). Weight SDSs in the 2 to 5-year age group (n=9) were –2.3 (1.2), –2.0 (1.1), –1.1 (1.3) (P=0.002) and –0.9 (1.0) (P=0.04). Height SDSs were –2.8 (0.6), –2.3 (0.7), –2.0 (0.7) and –2.0 (0.8). There was no change in energy intake as a percentage of the estimated average requirement, nor was this exceeded. Percentage energy from the EF in the 0 to 2 year age group remained unchanged despite an absolute increase in energy intake with age. Twenty-one have had renal transplants, of whom 86% eat and drink normally. Long-term EF prevents or reverses weight loss and growth retardation in children with CRF/ESRF, with the achievement of significant catch-up growth if started before age 2 years. Received: 27 July 1998 / Revised: 19 November 1998 / Accepted: 20 November 1998     

Immune status of children on continuous ambulatory peritoneal dialysis

Immunological parameters including serum IgG, IgA and IgM, lymphocyte phenotypes (CD3, CD4, CD8, HLA-DR+CD3-), natural killer cell activity and lymphocyte proliferation with phytohaemagglutinin were assessed in 10 children on continuous ambulatory peritoneal dialysis (CAPD) and 10 control subjects. Live vaccines were injected into 6 of the 10 children on CAPD (4 had a combined measles-mumps-rubella vaccine and the other 2 mumps vaccine). Serum antibody titres to these viruses were measured before and after vaccination. The serum IgG level was statistically lower in the CAPD group than in the control group (P<0.01), but there was no difference in the percentage of HLA-DR+CD3-cells and in the ratio of CD4 to CD8 between the two groups. There were no differences in the other parameters between the two groups. All of the 6 vaccinated children seroconverted, and serious side effects were not noted. Our results suggest that children on CAPD have no significant immune impairment.     

Hyperlipidemia in pediatric patients undergoing peritoneal dialysis

We evaluated serial measurements of serum lipid levels in 68 patients aged 12.6±4.7 years undergoing treatment with continuous ambulatory peritoneal dialysis/continuous cycling peritoneal dialysis (CAPD/CCPD). Fasting mean levels of triglycerides (TG) and cholesterol (C) were elevated above the 95th percentile of published normal values by 102% and 19%, respectively, at the start of dialysis. Except for a shortterm decrease in TG levels at 6 and 9 months, no significant change in mean lipid levels was observed during a follow-up period of 2 years. At initiation of dialysis, elevated TG and C levels were present in 90% and 69% of the patients, respectively. The prevalence of hyperlipidemia (HL) varied between 63% and 88% (TG) and 61% and 93% (C), respectively, during the follow-up period. TG and C levels were not correlated with caloric intake (evaluated in 17 patients), serum albumin levels, treatment modality (CAPD or CCPD), a history of the nephrotic syndrome, or previous treatment with hemodialysis or transplantation. However, a significant inverse correlation was observed between age and serum lipids at the initiation of dialysis treatment and after 1 year (TG:r=–0.40; C:r=–0.44). Our data indicate a high prevalence of HL but no significant change of serum lipid levels during 2 years of treatment with CAPD/CCPD.     

Abnormal left ventricular mass and aortic distensibility in pediatric dialysis patients

There is ample evidence that the same pathophysiological processes that affect cardiovascular function in adults with end-stage renal disease (ESRD) also operate in children with ESRD. In adults undergoing hemodialysis (HD), a good correlation has been established between left ventricular mass (LVM) and aortic distensibility (AD) as markers of cardiovascular disease progression; however, this correlation has not been established in children. Therefore, in this retrospective study we investigated some aspects of cardiovascular damage (i.e., LVM, LVMI, and AD) in children with ESRD undergoing HD ( n =9) or peritoneal dialysis (PD, n =9), and analyzed the relationship between AD, LVM, LVMI, pre-dialysis, post-dialysis blood pressure (BP), and demographic factors in children and adolescents with ESRD. Both LVM and AD were significantly greater in the dialysis population than in a control population derived from our institutional files ( P =0.015, P =0.001). LVM and LVMI in children undergoing HD (92.9±83.7 g, 80.1±31.1 g/cm) were not statistically different from the values in children on PD (130.0±89.2 g, 89.6±35.9 g/cm), ( P =0.3, P =0.5). AD in children on HD (2.2±0.55 cm² * dynes^–1*10–6) was significantly lower than in children on PD (2.7±0.54 cm² * dynes^–1*10–6), ( P =0.01). The findings in this study confirm earlier studies that demonstrated that LVMI is greater in children on dialysis. This study also demonstrates that abnormal vascular stiffness, as defined by AD, is present in these children. The degree of vascular stiffness in children receiving HD is greater than in children receiving PD. However, further study is needed to address how control of BP, uremia, and other factors may affect these abnormalities in children with ESRD.     

Sonographic determination of the thickness of the peritoneum in healthy children and paediatric patients on CAPD

Background. Prolonged peritoneal dialysis and frequent episodes of peritonitis lead to structural changes and thickening of the peritoneum. Ultrasonography investigations may provide the opportunity to detect morphological changes early, but no systematic investigations have been performed yet. Methods. Normal values of peritoneal thickness were obtained by systematically examining 131 healthy children (0-15 years) by ultrasound. Parietal peritoneal thickness was best measured at the sternal-umbilical line distal from the xiphoid. Growth charts with 95% intervals were prepared. The data of 26 patients with end-stage renal failure (5-18 years) were compared to those of the normal children. Results. The variation coefficient for the consecutive measurements was only 5%, interobserver error was approximately 7%. Whereas gender did not have any influence, peritoneal thickness was significantly correlated to age, weight and most obviously to height (r=0.81; P<0.001). Children treated only by haemodialysis had normal values, while an increased thickness, loss of movement, and adhesion of the two peritoneal layers were found in children on CAPD. These changes were only noted in patients who had a history of peritonitis. Conclusion. Ultrasound examination is a simple, non-invasive and precise method to measure the peritoneal changes in children on CAPD.