Low protein Z levels in children with nephrotic syndrome

Acquired deficiency of anticoagulant proteins, due to loss in the urine, has been proposed as one of the major thrombogenic alterations in nephrotic syndrome (NS). Protein Z (PZ) is a single-chain vitamin K-dependent glycoprotein. Low PZ levels are reported to be a risk factor for thrombosis. The aim of this study was to investigate protein Z and other natural anticoagulant levels in children with NS. Thirty children aged between 1.5 and 12 years with NS (Groups I and II) and 19 age-and-sex-matched healthy controls (Group III) were enrolled into the study. Patients were divided into two groups: Group I (proteinuria >40 mg/m²/hr) and Group II (patients in remission). Plasma PZ levels in Group I were significantly lower than Group II (p=0.009) and group III (p=0.018). Plasma levels of AT III for Group I were significantly lower than for Groups II and III (p=0.009, p=0.005, respectively). Protein C levels in Group I were higher than in Group II and Group III (p=0.002, p=0.000, respectively). Protein Z levels positively correlated with serum total protein and albumin levels (p=0.003, p=0.003, respectively) and negatively with the degree of proteinuria (p=0.000). Protein Z levels were positively correlated with AT III (r=0.037, p=0.04). Along with the other coagulation abnormalities, decreased protein Z may contribute to increased risk of thromboembolic complications in children with NS. The negative correlation between proteinuria and PZ level suggests the possibility of renal PZ loss. Further studies are needed to investigate the mechanism and role of decreased PZ in NS.     

Serum uric acid is associated with high blood pressure in pediatric hemodialysis patients

Serum uric acid (UA) is positively associated with hypertension (HTN). HTN is common in pediatric patients receiving hemodialysis (HD) and peritoneal dialysis (PD). We assessed the relationship between UA and BP in 63 pediatric dialysis patients by measuring pre-treatment UA levels and BP in HD patients and in-center UA levels and blood pressure (BP) in PD patients. UA levels were similar in both groups [6.8 ± 0.2 (HD) vs. 6.5 ± 0.3 (PD), p = 0.6]. Pre-treatment systolic BP percentile was associated with a high UA level [91.9 ± 2.3 (>6.0 mg/dL) vs. 79.3 ± 5.8 mm Hg (≤6.0 mg/dL), p = 0.01] in HD patients only. There was a negative relationship between UA and dialysis vintage (r = −0.31, p = 0.01). In both groups, there was no relationship between UA and Kt/V. In HD patients, fluid overload was unrelated to UA level [4.2 ± 0.6% (≤6.0 mg/dL) vs. 4.3 ± 0.3% (>6.0 mg/dL), p = 0.9]. Moreover, pre-HD treatment systolic BP percentile correlated with UA (beta 0.36, p = 0.02) independent of volume. UA levels were higher in patients receiving anti-hypertensive medications [6.3 ± 0.2 (No Meds] vs 7.0 ± 0.2 (BP Meds) mg/dL,  p= 0.01]. Finally, there was no relationship between serum UA and normalized protein catabolic rate (r = 0.14; p = 0.4). In summary, serum UA impacts BP in pediatric HD patients, independent of volume, nutritional and weight status.     

Sleep Disorders in Hemodialysis Patients

A high prevalence of sleep disorders has been reported in patients with renal failure and is linked to cardiovascular complications in those patients. The exact etiology and pathogenesis of sleep disorders are not exactly known. Knowledge of the underlying factors helps to define better management for these complications. The study involved 30 patients with ESRD on regular hemodialysis (HD; group 1) and 20 normal control subjects (group 2). For both groups complete history taking and clinical examination, assessment of sleep disorders using the Pittsburgh Sleep Quality Index (PSQI), biochemical tests, efficiency of dialysis using KT/V in the patient group and plasma interleukin-6 level using ELISA technique were done. Poor sleep (PSQI > 5) was found in 70% of the patient group vs. 15% of the control group with significant differences between group 1 and 2 regarding mean PSQI (p < 0.001; 9.53 ± 5.46, 3.7 ± 2.53, respectively). The greatest sleep disorder in the patient group was sleep efficiency. The PSQI score is independently determined by KT/V (p = 0.03), LDL (p = 0.005), age (p = 0.04), coffee consumption (p = 0.03), Hb (p = 0.024), and IL-6 levels (p = 0.004). Independent predictors for poor sleep are age (p = 0.001), serum albumin (p < 0.001), KT/V (p = 0.001), and IL-6 levels (p < 0.001). Sleep disorders are very common in HD patients. Independent predictors for poor sleep are age, serum albumin, KT/V, and IL-6 levels. Sleep disorders are significantly associated with the efficiency of dialysis and IL-6 levels, which are related to inflammation. Sleep disorders may be a possible cause of the oxidative stress and inflammation in hemodialysis patients contributing to the development of complications.     

Protein C, protein S, and antithrombin III levels in patients on continuous ambulatory peritoneal dialysis and hemodialysis

Patients undergoing dialysis are subject to risk of thrombotic complications. We studied the plasma levels of natural coagulation inhibitors including protein C (PC), protein S (PS), and antithrombin III (AT III) in 20 patients on hemodialysis and 20 patients on continuous ambulatory peritoneal dialysis (CAPD). Total PS antigen, free PS antigen, immunological and functional activities of PC and AT III were measured. Hemodialysis patients had a higher total PS level but a lower free PS level compared with healthy controls. Both the immunological and functional activities of AT III in hemodialysis patients were significantly lower than those of controls. With the exception of total PS level, CAPD patients had comparable or even higher plasma level of natural coagulation inhibitors compared with healthy controls. Furthermore, the plasma levels of PC, PS, and AT III were significantly lower in hemodialysis patients compared with CAPD patients despite greater daily losses of PC, PS, and AT III through urinary and peritoneal routes in patients on CAPD treatment. Most of the AT III in the peritoneal dialysate was still functionally active but most of the PC was inactive. Our observations suggest an effective turnover and production of these natural coagulation inhibitors in patients on CAPD therapy but a similar compensatory mechanism does not operate efficiently in patients receiving hemodialysis.     

Effect of carnitine supplementation on lipid profile and anemia in children on chronic dialysis

We prospectively evaluated the effects of L-carnitine supplementation on plasma free carnitine (FC) levels, serum lipid profile, and erythropoietin (rhEPO) requirement in 24 children treated with peritoneal dialysis (PD; n = 16) or hemodialysis (HD; n = 8). The study was divided into a 3-month observation period, and a 3-month treatment period during which patients received 20 mg/kg per day of L-carnitine given orally. Clinical, biochemical, and hematological data were collected every 3 months. FC levels were measured in plasma and peritoneal dialysate by tandem mass spectrometry. There were no statistically significant changes in lipid levels, hemoglobin, or rhEPO requirements during the course of the study. Fifteen patients (13 PD, 2 HD) had plasma FC levels measured before and after treatment; FC levels increased from 32.1 ± 14.1 μmol/l to 80.9 ± 38.7 μmol/l (P < 0.001). In PD patients, dialysate FC losses increased from 106 ± 78 μmol/day at baseline to 178 ± 119 μmol/day after supplementation. Positive correlations between FC plasma levels and dialysate levels (R = 0.507) or daily excretion (R = 0.603) were found after treatment. In our case series, an oral dose of 20 mg/kg per day of L-carnitine restored FC levels and produced a positive carnitine balance with no significant effects on hematological parameters or lipid profile over a 3-month period. Prolonged treatment duration may be required to obtain significant results.     

Blood pressure control in pediatric hemodialysis: the Midwest Pediatric Nephrology Consortium Study

Hypertension is frequent in pediatric patients receiving dialysis, with an especially high rate reported in children on hemodialysis (HD). We performed the present study to assess blood pressure (BP) status and identify risk factors for poor BP control in children on maintenance HD. One month’s dialysis records were collected from 71 subjects receiving HD in ten dialysis units participating in the Midwest Pediatric Nephrology Consortium (MWPNC). For each HD session, data on pre- and posttreatment weights and BPs were recorded. Hypertension, defined as mean BP ≥ 95th percentile, was found in 42 (59%) subjects. Eleven subjects (15.5%) had prehypertension, defined as mean BP between the 90th and 95th percentiles, while 18 subjects (25.3%) had normal BP (<90th percentile). BP significantly decreased at the end of a dialysis session; however, only 15 of 42 hypertensive subjects (35%) normalized their BP. Hypertensive subjects were younger (p = 0.03), had higher serum phosphorus (p = 0.01), and had more elevated posttreatment weight above estimated dry weight (p = 0.02). Logistic regression showed that younger age (p = 0.02) and higher serum phosphorus (p = 0.02) independently predicted hypertensive status. In conclusion, this study emphasizes the difficulty of BP control in pediatric HD patients. Especially poor BP control was found in younger children; those patients who do not reach their posttreatment weight goals, perhaps reflecting their hypervolemic state; and those who have higher serum phosphorus levels.     

Chronic kidney disease in the VACTERL association: clinical course and outcome

Approximately 60% of VACTERL (vertebral defects, anal atresia, cardiac defects, tracheoesophageal fistula with atresia, renal defects/radial limb dysplasia) patients have renal anomalies that can be associated with chronic kidney disease (CKD). With improved medical care, a large proportion of these patients survive into adulthood. Longitudinal follow-up data regarding the management of kidney disease in these children is lacking. Twelve VACTERL patients with CKD stage 2–5 and 12 age-matched controls with similar urologic anomalies and CKD [mean follow-up period 15.0 ± 1.4 (SE) and 11.9 ± 2.1 years, respectively] were identified in a single center. Eight VACTERL patients progressed to end-stage renal disease (ESRD) compared to four controls (66.7 vs. 33.3%, respectively). Six VACTERL patients were dialyzed pre-transplant. Of the four patients on peritoneal dialysis (PD), three had to be switched to hemodialysis due to complications, whereas two of the three controls on PD did not experience significant problems. Seven VACTERL patients underwent renal transplantation compared to four controls. Mean creatinine clearance 2 years post-transplant was 65.8 ± 6.3 in VACTERL patients vs. 87.8 ± 7.1 ml/min per 1.73 m² in controls (p = 0.03). VACTERL patients had a significantly lower mean height standard deviation score than the controls (−2.34 ± 0.41 vs. −1.27 ± 0.24, respectively; p < 0.05). Based on these results, VACTERL patients with CKD develop ESRD more frequently, experience more complications with dialysis, may have a poorer transplant outcome, and have more severe growth failure than controls.     

Relation Between Thyroid Hormones and Insulin Resistance in Hemodialysis Patients

Insulin resistance (IR) is a common problem in patients with ESRD on regular HD, and it is related to many complications, including cardiovascular complications, the major killer in these patients. Disorders of thyroid function are common in patients with ESRD. Many factors have been claimed to contribute to IR in HD patients. Our aim is to study the relations between thyroid hormones and IR in HD patients for better understanding and management of IR. The study involved 35 patients with ESRD under regular HD (group 1) and 20 normal control subjects (group 2). All of them underwent complete history taking and clinical examination: biochemical and hematological, thyroid hormones TSH, free T3 (FT3) and free T4 (FT4), and insulin resistance using the homeostasis model assessment (HOMA-IR). Patients with DM and those with known thyroid disorders were excluded from the study. Comparing HD patients and normal control subjects shows significant differences as regards FT3 (p = 0.04) 33.58 ± 12.14 vs. 40.63 ± 11.27 pg/l, respectively; TSH (p = 0.03) 3.29 ± 3.83 vs. 1.80 ± 0.88 mu/l, respectively; fasting insulin level (p < 0.001) 30.1 ± 6.05 vs. 10.68 ± 2.77 mu/ml, respectively; HOMA (p < 0.001) 6.72 ± 1.41 vs. 2.4 ± 0.67, respectively. There is no significant difference as regards FT4 (p = 0.36) 15.17 ± 6.72 vs. 16.35 ± 2.66 pmol/l, respectively. Bivariate correlation in HD patients shows HOMA IR correlates with FT3 (p < 0.001), FT4 (p < 0.001), TSH (p < 0.001), HDL (p < 0.001), and hematocrit (p < 0.001). No correlations were found with BMI, age, total cholesterol, LDL, or triglycerides. Linear regression analysis showed HOMA-IR was independently determined by HDL (p = 0.04), hematocrit (p = 0.02), and TSH (p = 0.008). IR is very common in HD patients. There is a close correlation between IR and thyroid hormones. TSH, HDL, and hematocrit levels independently determine IR. Regular follow-up of these factors is necessary for proper management of IR.     

Residual renal function and nutrition in young patients on chronic hemodialysis

Residual renal function (RRF) has been associated with a better nutritional status in adult patients on chronic dialysis, but there is as yet no data available for young patients on chronic hemodialysis (HD). We have retrospectively analyzed 3-day dietary reports and simultaneous urea kinetic monitoring data (n = 179) of 30 children, adolescents and young adults on chronic HD. The protein catabolic rate (PCR) was calculated and normalized by body weight (nPCR). The HD dialysis dose (Kt/VHD), RRF (calculated by urea clearance, Ku, and expressed as residual Kt/V) and total Kt/V (Kt/Vtot) were evaluated. In all patients, nPCR was correlated with dietary protein intake (nDPI) (p < 0.0001) and Kt/Vtot (p < 0.0001) but not with Kt/VHD (p = 0.11). In patients with RRF, Ku was associated with nPCR (p < 0.0001), while Kt/VHD was not (p = 0.10), and nPCR was higher than in patients without RRF (1.46 ± 0.41 vs. 1.03 ± 0.33 g/kg/day; p < 0.0001). Patients on recombinant growth hormone (rhGH) treatment showed higher nPCR values than those without rhGH (1.34 ± 0.41 vs. 1.01 ± 0.39 g/kg/day; p < 0.0001). In a multiple regression model including age, rhGH treatment, RRF, Kt/Vtot and Kt/VHD, and nPCR showed the best correlation with RRF (β = 0.128; p < 0.0001). In conclusion, in children, adolescents and young adults on chronic HD treatment, RRF positively affects nutrition independently of HD efficiency and rhGH treatment.     

Alterations in appetite-regulating hormones influence protein–energy wasting in pediatric patients with chronic kidney disease

Protein–energy wasting is a common problem in pediatric patients with chronic kidney disease (CKD). Disturbances in appetite-regulating hormones have been suggested as causative factors. Acyl ghrelin is a potent orexigenic hormone, whereas desacyl ghrelin and obestatin have the opposite effect. The regulation of acyl ghrelin and its anorexigenic opponents and its role in the development of CKD-associated protein–energy wasting is poorly understood. We measured total and acylated ghrelin, obestatin, leptin, and adiponectin in children with CKD (n = 29), children undergoing hemodialysis (HD) or peritoneal dialysis (PD; n = 29), renal transplant recipients (RTx; n = 91), and healthy controls (n = 27), and analyzed the data in relation to body mass index (BMI) and height. Patients with renal insufficiency showed lower BMI standard deviation score (SDS) values and height SDS compared with controls and RTx patients. Total ghrelin was elevated in CKD and dialyzed patients compared with controls or transplant recipients (P < 0.001). Acyl ghrelin did not differ between groups, and the acyl ghrelin/total ghrelin ratio was reduced in uremic patients (P < 0.05). Obestatin plasma levels were increased in patients with renal insufficiency compared with controls and RTx patients (P < 0.01). Uremia leads to an accumulation of the anorexigenic hormones desacyl ghrelin and obestatin. Orexigens like acyl ghrelin are not elevated. A disturbed balance between anorexigenic and orexigenic hormones may influence development of CKD-associated protein–energy wasting in pediatric patients.     

Effect of hemodialysis on protein C, protein S, and antithrombin III levels.

We studied the effect of hemodialysis on natural coagulation inhibitors including protein C (PC), protein S (PS), and antithrombin III (AT III), as well as the correlations between the antigen level (immunological activity) and functional activity of individual coagulation inhibitor. Plasma AT III, PS, and PC were measured in 20 uremic patients on maintenance hemodialysis immediately before, during, and after dialysis treatment. These values were compared with those obtained from 20 matched healthy controls. Plasma PC and total PS antigen levels were measured by enzyme immunoassay. The plasma AT III antigen level was determined by Laurell rocket immunoelectrophoresis. Functional activities of PC and AT III were determined by the amidolytic method. Free PS antigen level was quantitated by measuring the free PS-related antigen after the sample was treated with polyethylene glycol to remove the C4b-binding protein. Uremic patients on maintenance hemodialysis had a higher total PS antigen level, but a lower free PS antigen level compared with the controls. Both the antigen level and functional activity of AT III in uremic patients were significantly lower than those of controls. Their predialysis plasma PC antigen level and functional activity were not different from those of normal controls. A significant correlation between the antigen level and functional activity of PC, PS, and AT III was demonstrated in healthy controls, but not in hemodialysis patients. No significant change in the level of AT III or PS was observed with hemodialysis, but a progressive increase of functional activity of PC was documented with hemodialysis. Furthermore, the coefficient of correlation between the antigen level and functional activity of PC improved significantly with dialysis treatment.(ABSTRACT TRUNCATED AT 250 WORDS)     

Elevated FGF 23 and phosphorus are associated with coronary calcification in hemodialysis patients

Increased mortality of adult chronic hemodialysis (HD) patients is associated with coronary calcifications (CC), increased serum phosphorus (P), use of calcium (Ca)-containing P-binders, and vitamin D deficiency. Serum concentration of fibroblast growth factor 23 (FGF 23) is markedly elevated in adults receiving dialysis and is independently associated with increased mortality. Although coronary calcifications have been described in pediatric and adult HD patients, no significant association between serum FGF 23 and CC has been reported. In our study, 5/16 patients had CC. Patients with CC were older, had longer dialysis vintage and higher serum P. Serum Ca, total PTH, elemental Ca intake, and calcitriol doses were not different for CC patients. Serum FGF 23 levels were markedly elevated in all patients (mean 4,024, range 874–8,253), but significantly higher in patients with CC (4,247 ± 10,35 vs 2,427 ± 11,92, p = 0.01) and positively correlated with Agatston calcification score (r = 0.69, p = 0.003) and serum P (r = 0.49, p = 0.05). Using multivariate analysis, serum FGF 23 and serum P remained the most significant factors associated with Agatston score. This study confirms the occurrence of CC in pediatric HD patients and is the first to show a significant association between CC and elevated serum FGF 23 in children.     

Health-related quality of life in pediatric patients with ESRD

As part of creating a pediatric ESRD-specific Health-Related Quality of Life (HRQOL) assessment instrument, we established pilot data with the PedsQL 4.0 Generic Core Scales in 96 pediatric patients with ESRD receiving hemodialysis (HD), peritoneal dialysis (PD) or with a renal transplant (TX). Patient age ranges were: 2–4 (8; PD n=3, TX n=5), 5–7 (12; HD n=9, TX n=3), 8–12 (25; HD n=5, PD n=6, TX n=14), 13–18 (51; HD n=18, PD n=10, TX n=23). PedsQL ESRD data were compared to healthy children (n=131 child report; n=145 parent report) and across HD/PD/TX. For all domains, ESRD patient HRQOL scores were significantly lower than healthy controls. Transplant patients reported better physical and psychosocial health than dialysis patients. No difference was noted between HD and PD patients for any PedsQL domain. Our data demonstrate that the PedsQL 4.0 Generic Core Scales is a useful measurement instrument to screen for HRQOL impairment in pediatric patients with ESRD. We suggest that the ESRD-specific HRQOL instrument in development is needed to help define condition-specific HRQOL differences between modalities.     

Traditional and “new” cardiovascular risk markers and factors in pediatric dialysis patients

Cardiovascular disease (CVD) is the principal cause of mortality in patients with end-stage renal disease (ESRD). The aim of this study was to analyze carotid intima-media thickness (cIMT), endothelium-dependent dilatation (EDD), and left ventricular mass index (LVMI) as the cardiovascular risk markers and to investigate the independent risk factors of these markers in pediatric dialysis patients. This study included 39 children and adolescents undergoing dialysis (15 hemodialysis and 24 peritoneal dialysis) and 15 age- and gender-matched healthy subjects. The cIMT and EDD were assessed by high-resolution ultrasound, and LVMI was calculated from standard echocardiographic measurements. Compared with control subjects, cIMT standard deviation scores (SDS), LVMI, total homocysteine (tHcy), and high-sensitivity C-reactive protein (hs-CRP) values were significantly higher in patients, but EDD values did not differ. The mean hs-CRP level was significantly higher in hemodialysis (HD) patients than in peritoneal dialysis (PD) patients. The cIMT-SDS and LVMI were associated with several variables in univariate analysis. Stepwise linear regression analysis, indexed SBP (p = 0.017), and hemoglobin (p = 0.001) turned out to be independent variables for predicting LVMI, and a significant predictor of cIMT was indexed diastolic blood pressure (DBP) (p = 0.035). The causes of atherosclerosis and left ventricular hypertrophy are multifactorial in children and adolescents with ESRD. Better management of hypertension and anemia may be priorities for preventing or improving CVD in these patients.     

Ventriculostomy-related hemorrhage in patients on antiplatelet therapy for endovascular treatment of acutely ruptured intracranial aneurysms. A meta-analysis

The risk of ventriculostomy-related hemorrhage among patients requiring antiplatelet therapy (AT) for the endovascular treatment of acutely ruptured intracranial aneurysms needed further investigation. The authors performed a systematic review and meta-analysis of the literature examining the EVD-related hemorrhage rate among patients with and without AT (controls). According to PRISMA guidelines, a comprehensive review of studies published between January 1990 and April 2018 was carried out. The authors identified series with > 5 patients reporting the EVD-associated hemorrhage rate among the AT group and the control group. Variables influencing outcomes were analyzed using a random-effects meta-analysis model. We included 13 studies evaluating 516 (with AT) and 647 (without AT) patients requiring ventriculostomy. EVD-related hemorrhage rates were higher among the AT group (125/516 = 20.9%, 95% CI = 11.9–30%, I2 = 90% vs 57/647 = 9%, 95% CI = 5.5–12.5%, I2 = 45.8%) (p < 0.0001). Major EVD-associated hemorrhage rates were low in both the AT and control group (25/480 = 4.4%, 95% CI = 1.7–7.7%, I2 = 53.9% vs 6/647 = 0.7%, 95% CI = 0.03–1.7%, I2 = 0%) (p < 0.0001). Ventriculostomy before embolization and intraprocedural AT were associated with lower rates of EVD-related bleeding (32/230 = 9.6%, 95% CI = 2.1–17.1%, I2 = 75.4% vs 6/24 = 25.1%, 95% CI = 8.8–41%, I2 = 0%) (p < 0.02). The rate of major hemorrhage was higher after dual AT (CP + ASA) compared to single AT (ASA or CP) used as an intraprocedural loading dose (13/173 = 7%, 95% CI = 3.3–10.7%, I2 = 0% vs 6/210 = 1.7%, 95% CI = 0.1–3.4%, I2 = 0%) (p < 0.009). AT during endovascular treatment of acutely ruptured intracranial aneurysms increases the risk of EVD-related hemorrhages, although most of them are small and asymptomatic. When ventriculostomy is performed before endovascular procedures requiring antiplatelet administration, the hemorrhagic risk is minimized. A single antiplatelet therapy is associated with a lower rate of major bleeding than a dual therapy.     

Comparative clinical outcomes between pediatric and young adult dialysis patients

Published data on the comparative achievement of The Kidney Disease Dialysis Outcome Quality Initative (KDOQI) recommended clinical performance targets between children and young adults on dialysis are scarce. To characterize the achievement of KDOQI targets among children (<18 years) and young adults (18–24 years) with prevalent end stage renal disease (ESRD), we performed a cross-sectional analysis of data collected by the Mid-Atlantic Renal Coalition, in conjunction with the 2007 and 2008 ESRD Clinical Performance Measures Projects. Data on all enrolled pediatric dialysis patients, categorized into three age groups (0–8, 9–12, 13–17 years), and on a random sample of 5% of patients ≥18 years in ESRD Network 5 were examined for two study periods: hemodialysis (HD) data were collected from October to December 2006 and from October to December 2007 and peritoneal dialysis (PD) data were collected from October 2006 to March 2007 and from October 2007 to March 2008. In total, 114 unique patients were enrolled the study, of whom 41.2% (47/114) were on HD and 58.8% (67/114) on PD. Compared to the pediatric patients, young adults were less likely to achieve the KDOQI recommended serum phosphorus levels and serum calcium × phosphorus product values, with less than one-quarter demonstrating values at or below each goal. Multivariate analysis revealed that both young adults and 13- to 17-year-olds were less likely to achieve target values for phosphorus [young adults: odds ratio (OR) 0.04, 95% confidence interval (95% CI) 0.01–0.19, p < 0.001; 13- to 17-year-olds: OR 0.17, 95% CI 0.04–0.77, p = 0.02] and calcium × phosphorus product (young adults: OR 0.01, 95% CI 0.002–0.09, p <  0.001; 13- to 17-year-olds: OR 0.09, 95% CI 0.02–0.56, p = 0.01) than younger children. In summary, there are significant differences in clinical indices between pediatric and young adult ESRD patients.     

Vascular Dysfunction in ESRD Patients Under Replacement Therapy

Endothelial dysfunction (ED) is an important factor in the pathogenesis of atherosclerosis, which is the major cause of mortality and morbidity in ESRD patients. Endothelium exerts a number of vasoprotective effects, such as vasodilatation, suppression of smooth muscle cell growth, and inhibition of inflammatory responses impairment of endothelial functions can leads to vascular dysfunction. This study involved 25 ESRD patients on regular hemodialysis (HD) (group 1), 15 ESRD patients on intermittent peritoneal dialysis (PD) (group 2) and 20 healthy control subjects (group 3). For all groups complete medical history and thorough examination, biochemical Laboratory tests including renal function tests, calcium, phosphorus, intact PTH and Echocardiography. Endothelial function was assessed by Flow mediated dilatation of the brachial artery (FMD) evaluated non-invasively by B-mode ultrasonography. Comparison of FMD of brachial artery shows significant difference between hemodialysis group and control (p < 0.001), peritoneal dialysis group and control group (p < 0.001), and between hemodialysis and peritoneal dialysis group (p < 0.001). Multiple regression test for brachial artery flow mediated dilatation shows significant correlations with age (p < 0001), serum LDL (p = 0.04), hematocrit value (p < 0.001), serum PTH (P = 0.01) and presence of DM (p = 0.009). No correlation is found with duration of dialysis (p = 0.57), total cholesterol (p = 0.62), serum triglyceride (p = 0.10) nor with calcium phosphorus products (p = 0.08). Endothelial function is impaired in ESRD patients. PD patients had more endothelial dysfunction when compared to HD patients. ED is independently affected by age, LDL, PTH, hematocrit and presence of diabetes mellitus. The main correctable factors affecting ED are Hematocrit, PTH, and LDL.     

Peritoneal dialysis versus hemodialysis in patients with delayed graft function

Delayed graft function (DGF) in kidney transplantation affects adverse outcomes. It remains unclear whether the post‐transplant dialysis modality alters perioperative or long‐term graft outcomes. We performed a retrospective observational quality initiative at two Canadian renal transplant centers, in which DGF occurred in the recipient, necessitating one of peritoneal dialysis (PD) or hemodialysis (HD). There was no difference in baseline factors between patients with post‐transplant PD (n = 14) or HD (n = 63). The use of PD was associated with an increased risk of wound infection/leakage (PD 5/14 vs. HD 6/63, p = 0.024), shorter length of hospitalization (13.7 vs. 18.7 d, p = 0.009) and time requiring dialysis post‐operatively (6.5 vs 11.0 d, p = 0.043). There were no differences in readmission to hospital within 6 months (4/14 vs. 23/63, p = 0.759), graft loss (0/14 vs. 2/63, p = 1.000) or acute rejection episodes (1/14 vs. 4/63, p = 1.000) at one yr, and GFR did not differ between the PD or HD groups at 30 d (35.7 vs. 33.8 mL/min/m², p = 0.731), six months (46.9 vs. 45.5 mL/min/m², p = 0.835) or one yr (46.6 vs. 44.5 mL/min/m², p = 0.746). Further research is needed to determine which transplant patients are most appropriate to undergo PD catheter removal at the time of transplantation.     

Carbamylated Hemoglobin as an Indicator of Hemodialysis Adequacy and Complications

Carbamylation is an irreversible process of non-enzymatic modification of proteins by the breakdown products of urea. The degree of carbamylation has been proposed as an indicator of the control of uremia by dialysis. Our aim is to study potential determinants of carbamylated hemoglobin (CarbHb) and the relationship between CarbHb with dialysis adequacy and common complications of CRF. The study was carried out on 35 patients with CRF on regular hemodialysis (HD) (group 1), 35 patients with CRF on conservative treatments (group 2), and 35 normal controls (group 3). For all groups complete history, clinical examination, routine laboratory investigations, ECG, efficiency of dialysis for group 1 using KT/V, nerve conduction, resting ECG, and CarbHb level were taken. In HD patients, CarbHb correlates with Kt/V (P < 0.001) and neuropathy (P = 0.004). Mean CarbHb is 129.47 ± 23.50, 88.09 ± 9.41, and 30.7950 ± 1.9395 μg CV/g Hb for groups 1, 2, and 3, respectively. ROC curve CarbHb with resting ECG shows the area under the curve (0.765, 0.718) for group 1 and 2, respectively. ROC curve study for CarbHb and nerve affection shows group area under the curve (0.766, 0.551) for group 1 and 2, respectively. CarbHb is higher in uremia and more with regular HD than in patients under conservative treatment. In HD patients CarbHb correlates with KT/V and can be used as a supportive measure for adequacy of dialysis. The presence of complications like IHD and neuropathy in dialysis patients correlates with CarbHb, which can be used as a marker for the tendency to develop these complications.     

Serum Lipid Profile and Plasma Fatty Acids Levels in Hemodialysis Pediatric Patients-Possible Deficiency of Essential Fatty Acids

Polyunsaturated fatty acids (PUFA) are reported to be associated with atherosclerotic and inflammatory diseases because they are the major components of the cytoplasmic membrane and are the precursor fatty acids for prostaglandins and leukotrienes. Aim of this study was to identify PUFA profile (PUFAp) in children with end stage renal disease (ESRD) on hemodialysis (HD). And study its relationship with known cardiovascular and arteriosclerotic risk factors. We examined 44 pediatric HD patients (mean age 11 ± 3.36 years). Plasma lipid profile, plasma fatty acid pattern, serum albumin and hemoglobin were studied in these children. Triglyceride levels were increased in the plasma of ESRD patients compared to the healthy subjects. Plasma PUFA decreased whereas behanic acid (saturated fatty acid) increased in ESRD patients. A lower level of eicosapentaenoic acid was revealed in HD patients with cardiomyopathy (HD-CAD) than those without cardiovascular disease(HD-norm) (0.20 ± 0.01 μ/mL vs. 0.88 ± 0.12 μ/mL, P = 0.01). An inverse correlation was found between the linoleic acid level and serum TG level in children on HD (r = −0.54, P = 0.03). A positive correlation was found between plasma arachidonic acid level and serum albumin (r = 0.86, P = 0.003). A significant positive correlation was revealed between plasma eicosapentaenoic acid concentration and serum hemoglobin level (r = −0.64, P = 0.04). Saturated acid was negatively correlated with serum albumin (r = −0.70, P = 0.03). Children under regular hemodialysis evidence significant abnormalities in serum fatty acid levels together with triglyceride abnormalities, a finding that might be relevant to the risk of cardiovascular disease in this setting.