Peritonitis rates and common microorganisms in continuous ambulatory peritoneal dialysis and automated peritoneal dialysis

Background:  The aim of the present study was to perform a multicenter investigation in Turkish children on chronic peritoneal dialysis by examining the rates of peritonitis as well as causative organisms according to year.
Methods:  Twelve pediatric renal units participated in this study and data were obtained by review of the medical records.
Results:  One hundred and thirty-two patients were on continuous ambulatory peritoneal dialysis (CAPD), 21 were on automated peritoneal dialysis (APD) and 59 were on CAPD and APD at different times. Mean durations of CAPD and APD were 24.2 ± 21.1 months and 22.9 ± 12.8 months, respectively. Seventy-one (33%) out of 212 patients had no peritonitis episode. Overall peritonitis rate was one episode per 15.5 patient-months. The peritonitis rate was one episode per 15.4 patient-months for APD and one episode per 15.6 patient-months for CAPD. Coagulase-negative staphylococcus was the most common cause of peritonitis among patients with positive culture (20.6%). While the incidence of Gram-negative infection remained unchanged according to year in patients on CAPD ( P  = 0.68), the rate of Gram-negative peritonitis in children on APD was significantly higher ( P  = 0.03).
Conclusions:  Peritonitis rate was similar in CAPD and APD, but the risk of Gram-negative peritonitis in APD was higher than that of CAPD.     

Pretransplant peritoneal dialysis and graft thrombosis following pediatric kidney transplantation: a NAPRTCS report

Graft thrombosis is a common cause of graft failure in pediatric renal transplantation. Several previous studies, including a North American Pediatric Renal Transplant Cooperative Study (NAPRTCS) review of pretransplant dialysis status and graft outcomes, have described a potential correlation of peritoneal dialysis (PD) and graft thrombosis. This issue is of particular concern for pediatric transplant programs as more than 65% of children with end stage renal disease are treated with PD. We reviewed 7247 pediatric renal transplants performed between 1987 and 2001. Thrombosis was the cause of graft loss in 2.7% (199) of all the transplants performed. Among failed transplants, thrombosis was the third most common cause of graft loss in both index (11.6%) and subsequent transplants (14.5%). Thrombosis becomes the most common cause of graft failure (21%, 61/294) if one looks at transplants in the later cohort, from 1996 to 2001. This change is primarily because of a decrease in the incidence of acute rejection. In the PD group, 3.4% of all grafts were lost as a result of thrombosis. This compares with 1.9% in the hemodialysis group, 2.4% in the pre-emptive transplant group, and 4.1% among patients who received both dialysis modalities. There was a statistically significant difference in thrombosis failure risk in the different dialysis groups (p = 0.005) with those who received only peritoneal dialysis having the highest risk. Additional significant risk factors for graft thrombosis included; cadaver donor source (p < 0.001), cold ischemia time >24 h (p < 0.001), history of prior transplant (p < 0.001), donor age <6 yr (p < 0.001), and >5 pretransplant blood transfusions (p = 0.02). Using stepwise proportional hazards modeling, only pretransplant peritoneal dialysis, >24 h cold ischemia time, prior transplant, and donor age <6 yr were simultaneously associated with an increased risk of thrombosis. We conclude that pretransplant PD is associated with an increased risk of graft thrombosis. Special precautions should be undertaken in pediatric renal transplant patients who have received PD, especially infants and young children.     

暴发性肝衰竭型肝豆状核变性2 例报告并文献复习

目的探讨儿童暴发性肝衰竭型肝豆状核变性的临床特点,早期诊断及治疗。方法回顾2例暴发性肝衰竭型肝豆状核变性患儿的临床资料,并复习相关文献。结果 2例患儿均为女性,分别为5岁和8岁,临床表现为急性黄疸、血红蛋白尿、肝衰竭、肝性脑病、肾衰竭、心肌损伤、脏器出血,肝大,裂隙灯下K-F环阳性,符合肝豆状核变性诊断。应用DNA序列分析检测ATP7B基因外显子区域,2例患儿分别为p.P992L和p.A1063V复合杂合突变、2764del9缺失突变。结论儿童急性肝损伤应警惕暴发性肝衰竭型肝豆状核变性。     

Indigenous automatic peritoneal dialysis unit

Automatic peritoneal dialysis unit has been developed and fabricated indigenously from multiple electronic and electro-magnetic components available in India. Flow of fluid in and out of the peritoneal cavity is controlled automatically. Dialysis fluid of each cycle is weighed mechanically. If flow of fluid is inadequate the unit gives both audio and visual alarm for immediate attention. Number of cycles and total return of the fluid can be observed at any time. Risk of infection has been minimised as there is no need to change the dialysis fluid at each cycle. There is no need to autoclave the unit as the dialysis fluid does not come in direct contact with the unit. Running cost of the unit is only the cost of dialysis fluid. With easy availability of this unit the peritoneal dialysis facilities can be made avialable in each hospital and even at home in children with chronic ronal failure. This will improve the health care of children with renal failure. The approximate cost of the unit will be Rs. 10,000 only.     

Successful resumption of peritoneal dialysis following living donor liver transplantation in children with end‐stage renal disease

Children with ESRD in need of RRT are commonly managed by PD due to difficulty with vascular access for HD and the relatively large extracorporeal blood volume required. Major abdominal surgery may result in injury to the peritoneum and consequent adhesion, thereby resulting in a reduction in the anatomical capacity and transport capability across the peritoneal membrane. Here, we report successful resumption of PD after LDLT in two pediatric patients. The causes of ESRD were PH1 and juvenile nephronophthisis, respectively. Both patients were managed by PD prior to LDLT. PD was converted to HD starting three days before LDLT and was continued postoperatively until resumption of PD on days 13 and 28, respectively. The PD weekly Kt/V urea was maintained before and after LDLT. The patients continued to do well on PD without complications. Meticulous intra‐operative techniques during LDLT allow postoperative PD resumption by preservation of peritoneal integrity with effective transport capability and without added risk of peritonitis.     

Bilateral laparoscopic nephrectomy with simultaneous peritoneal dialysis catheter implantation

Bilateral nephrectomy prior to transplantation is indicated in some patients with end-stage renal disease. The indications for bilateral nephrectomy include persistent heavy proteinuria, refractory hypertension, and urinary tract infections. We report an eight-month-old baby with male pseudohermaphroditism and renal failure secondary to diffuse mesangial sclerosis. While awaiting renal transplantation, dialysis became necessary and the child presented standard drug therapy-resistant hypertension. A bilateral nephrectomy was performed simultaneously to peritoneal dialysis catheter implantation by using laparoscopy. At the present time, the patient is doing well with ambulatory dialysis and all antihypertensive medication has been discontinued. We recommend this technique in children who require bilateral nephrectomy and peritoneal dialyisis. Not only is it somewhat less aggressive than traditional open surgery, but it also reduces post-operative pain, allows earlier initiation of peritoneal dialysis, and improves cosmetic appearance.     

Subcutaneous recombinant human erythropoietin in children with renal anemia on continuous ambulatory peritoneal dialysis

Subcutaneous recombinant human erythropoietin (rHuEpo) treatment of renal anemia was performed in four boys and eight girls on CAPD, aged 0.8–12.5 (mean 7.4) years. In contrast to previous studies, our therapeutic goal was not set with a hematocrit of 30% but with full correction of anemia. Following a maximum weekly rHuEpo dosage of median 120 (range 100–240) IU/kg body weight, hcmatocrit increased in 10 children from 24 (14–29)%) within 12 (4–17) weeks to 40.1 (33.5–48.4)%. The weekly increase in hematocrit was 1.27 (0.5–3.1)%. The corrected reticulocyte count increased from I.3 (0.7–1.8)% to 2.3 (1.4–3.9)% within 4 (2–6) weeks. Eight childrcn fulfilled the protocol; six with an uncomplicated course were able to maintain a hematocrit of 37.1 (35.1–42.7)% with only one sc medication per week of approximately two-thirds of their highest weekly rHuEpo dosage. No serious adverse effect of rHuEpo therapy was observed.     

终末期肾病慢性腹膜透析患儿贫血影响因素病例对照研究

目的 了解终末期肾病慢性腹膜透析(腹透)患儿贫血的影响因素。方法 回顾性分析2006年1月至2012年4月在复旦大学附属儿科医院（我院）肾脏风湿科登记并行长期规律腹透治疗患儿,腹透后建立随访档案,要求每3个月来我院随访1次,至少随访12个月,并行随访指标的检查。腹透开始前的基线随访指标以例数表现,腹透后随访指标中的计量计数指标（体检项目、实验室检查项目和感染情况）以例次表现,选取每3个月随访时间±3 d时Hb值判断贫血,如符合贫血诊断标准则该阶段随访指标纳入贫血组统计,反之纳入非贫血组统计。 单因素分析采用独立样本t检验,计数资料采用χ2检验,多因素分析采用Logistic回归分析。结果（1）符合本文纳入排除标准的32例患儿进入分析,开始腹透年龄(8.4±3.7)岁,开始腹透前30例（93.8%）存在贫血;开始腹透后共随访120例次,8例次失访,贫血组57例次（47.5%）,非贫血组63例次,贫血组Hb、红细胞压积均明显低于非贫血组。（2）单因素分析显示：①基本情况：贫血组与非贫血组相比,腹透时年龄、性别差异无统计学意义（P＞0.05）;②体检项目： BMI、收缩压、舒张压两组差异无统计学意义（P＞0.05）;③实验室检查项目：随访12个月,贫血组血清全段甲状旁腺激素（iPTH）水平高于非贫血组［(605±582) vs （386±434） pg·mL-1, P＜0.05］,血清iPTH在500~1 000 pg·mL-1患儿贫血的发生率显著高于iPTH＜500 pg·mL-1者（P＜0.05）;贫血组残肾Kt/V值低于非贫血组［（0.35±0.42）vs (0.62±0.63),P＜0.05］,左心肥厚的发生率高于非贫血组（62.5% vs 35.1%,χ2=5.758, P=0.016）;贫血组血清白蛋白、总Kt/V、总CrCL、残肾CrCL均低于非贫血组（P＞0.05）,血尿素氮、肌酐均高于非贫血组(P＞0.05);④ACEI使用率贫血组与非贫血组间差异无统计学意义（P＞0.05）;⑤贫血组元素铁剂量、促红细胞生成素（EPO）剂量均低于非贫血组［元素铁剂量：(3.5±1.9) vs (4.2±1.2) mg·kg-1·d-1; EPO:每周（134±66） vs (170±62) U·kg-1, P＜0.05］;⑥感染发生率贫血组高于非贫血组（35.1% vs 19.0%,P＜0.05）;（3）多元回归分析显示,血清iPTH水平、残肾Kt/V、感染与慢性腹透患儿的贫血具有相关性（P＜0.05）。结论 ①慢性腹透患儿血清iPTH水平、有无感染和残肾Kt/V与贫血具有相关性;②强调EPO、铁剂的个体化治疗,在高血清iPTH水平、感染等情况下,可能需要更大剂量的EPO、铁剂改善贫血;③应加强对慢性肾脏病患儿管理,重视肾性贫血的早期治疗。     

腹膜透析治疗小儿肾功能衰竭临床分析

目的 探讨腹膜透析对儿童肾功能衰竭治疗的效果.方法 对2003年6月至2008年4月应用腹膜透析治疗的11例急慢性肾功能衰竭患儿临床资料及随访结果 进行分析.结果 11例患儿无一例死亡,急性肾功能衰竭平均在院透析时间15.5 d,慢性肾功能衰竭平均在院透析时间22.8 d.治疗前后血尿素氮、肌酐分别由(34.03±8.44) mmol/L和(710.09±167.54) μmol/L降至(15.94±4.93) mmol/L和(233.87±92.71) μmol/L,差异有非常显著性(P＜0.01).血钠由(130.91±9.15) mmol/L升至(139.46±3.98) mmol/L,差异有显著性(P＜0.05).血碳酸氢根由(14.56±2.07) mmol/L升至(22.47±3.29) mmol/L,差异有非常显著性(P＜0.01).随访时间1个月至5年不等.5例急性肾功能衰竭患儿肾功能和尿常规均正常.1例慢性肾功能衰竭患儿规律透析后行肾移植,3例仍于院外透析中.结论 经济、实用、有效的腹膜透析辅以综合治疗可成为儿童急慢性肾功能衰竭较好替代治疗方法 .     

Presenting symptoms and natural history of Wilson disease

The presenting symptoms of Wilson disease and its natural history as related to age are described based on 283 cases collected in Japan. The disease presented with a variety of signs and symptoms; the most frequent were in order of frequency jaundice, dysarthria, clumsiness, tremor, drooling, gait disturbance, malaise and arthralgia. The mean age at onset of the disease was 12.0 years. Hepatic and osteoarthral symptoms developed early and neurological symptoms late. Fifty-eight cases develolped neurological symptoms only, 28 cases had hepatic symptoms only, and in 26 cases hepatic mortality rate was observed in hepatic, hepato-haematological and hepato-renal cases mainly due to acute hepatic failure resulting in death only a few weeks after onset. Cases having only neurological symptoms showed a more favourable prognosis with a longer survival.     

重组人生长激素在慢性腹膜透析儿童中的应用

目的研究重组人生长激素(rhGH)对慢性腹膜透析儿童身高增长的促进作用。方法回顾分析2例经rhGH治疗的慢性腹透患儿的相关临床资料。结果 2例女性患儿,分别于8岁8个月和9岁6个月时确诊尿毒症,并伴身材矮小。经过第1年腹透及纠正酸中毒、贫血和电解质紊乱,改善营养和治疗肾性骨病等,例1身高SDS由-1.9增至-1.4,例2身高SDS由-2.3减至-2.4。2例患儿分别在9岁9个月和12岁3个月时开始rhGH治疗,开始治疗时2例患儿青春发育均属于Tanner 1期。经过8个月的治疗,例1身高SDS由-1.3增加至-0.7,例2由-3.0增至-2.4;停止rhGH治疗8个月后,例1身高SDS继续由-0.7增至-0.4,例2由-2.4增至-2.2。例1于rhGH治疗8个月期间身高增长7.5cm,rhGH治疗停止8个月间身高增长减少为5.8 cm,例2身高增长则由9 cm降至4.5 cm。结论 rhGH可提高腹膜透析治疗尿毒症患儿的身高增长。     

Two infants with bilateral renal agenesis who were bridged by chronic peritoneal dialysis to kidney transplantation

Bilateral renal agenesis is associated with severe oligohydramnios and was considered incompatible with postnatal life due to severe pulmonary hypoplasia. The use of renal replacement therapy was limited by significant morbidity and mortality associated with dialysis in very young infants with major pulmonary pathology. In the United States, there is a tremendous controversy about whether or not the use of prenatal amniotic fluid infusions provides a benefit to fetuses with bilateral renal agenesis. One of the critical issues identified is that there are, as yet, no children reported who had achieved long‐term survival. Previous reports all indicated these children died shortly after birth or after unsuccessful peritoneal dialysis. We present two infants with a prenatal diagnosis of bilateral renal agenesis whose mothers elected to undergo prenatal amnioinfusions. One was born at 28 weeks with a birthweight of 1230 g and the other born at 34 weeks with a birthweight of 1940 g. We present the details of both cases, with initial management on chronic peritoneal dialysis, which started shortly after birth, as a bridge to living related kidney transplants.     

Acute peritoneal dialysis in neonatal intensive care unit: An 8-year experience of a referral hospital

Background

The aim of present study was to evaluate the indications, complications and outcomes of acute peritoneal dialysis (APD) in neonates at a referral university hospital during the previous 8 years.

Peritoneal dialysis treatment in children and parental stress

The burden placed on the parents of a child in dialysis treatment can induce negative effects on the medical treatment and on the psychological development of the child. To identify which families are at risk, both parents of 14 out of 16 eligible patients in continuous ambulatory peritoneal dialysis (CAPD) answered an extensive questionnaire three times during one year. Large differences were found between the families with regard to the amount of stress experienced. Parents of older children (< 5 years) (and particularly parents of children with a failed transplantation) experienced significantly more stress. The nature of the stress was determined more by the psychological aspects than by the medical aspects of the treatment. Concern about the future contributed most to the stress experienced. Therefore, emotional support as well as practical help for families at risk is recommended.     

Oral zinc sulphate as primary therapeutic intervention in a child with Wilson disease

An 8-year-old boy with an hepatic form of Wilson disease was treated with oral zinc sulphate as the primary and sole therapy. After 4 months, liver function had dramatically improved, and the parameters characterizing copper metabolism had also normalized.Abbreviations d-pen d-penicillamine - IU international units - SCp serum ceruloplasmin - SD standard deviation - SGGT serum gamma-glutamyltransferase - SGOT serum glutamic-oxalic transaminase - SGPT serum glutamic-pyruvic transaminase     

P型ATP酶阻滞剂和激动剂对肝豆状核变性成纤维细胞胞浆铜的影响

探讨P型ATP酶阻滞剂、激动剂对肝豆状核变性患儿离体培养皮肤成纤维细胞胞浆铜含量的影响。方法采用高浓度铜及P型AFP酶阻滞剂（矾酸钠）、激动剂（长春新碱）孵育细胞，分析孵育6、12、24小时后，肝豆状核变性患儿、杂合子及正常儿童成纤维细胞胞浆中铜含量的变化。结果铜及长春新碱孵育后，患儿成纤维细胞胞浆钢水平在各时点均高于杂合子及正常儿童。铜及矾酸钠孵育后，患儿、杂合子及正常儿童胞浆铜含量在各时点均明显少于其他条件孵育后。结论患儿钢转运P型ATP酶对P型ATP酶阻滞剂的敏感性与杂合子及正常儿童相同，对激动剂的敏感性异常。P型ATP酶能减少患儿成纤维细胞对铜的摄取，在肝豆状核变性的治疗方面有一定的提示意义。     

Ascitic fluid drainage using a peritoneal dialysis catheter to prevent and treat multi‐organ dysfunction in veno‐occlusive disease in children undergoing hematopoietic stem cell transplantation

Veno‐occlusive disease (VOD), or sinusoidal obstruction syndrome, is a well‐recognised, serious complication associated with the chemotherapy conditioning therapy used in hematopoietic stem cell transplantation (HSCT). Fluid management is typically challenging in children with this condition. We describe effective early use of peritoneal dialysis catheters to drain extravascular, intra‐abdominal fluid in children with VOD, allowing intravascular fluid administration to preserve renal perfusion and function, preventing multi‐organ dysfunction. All but one of the children are long‐term survivors, both of their significant VOD and their HSCT. The child that did not survive died from their underlying metabolic illness, not VOD.     

Chronic peritoneal dialysis in children: catheter related complications. A single centre experience

Despite advancements in catheter design and dialysis technique, catheter related complications still remain a common clinical problem in paediatric patients on chronic peritoneal dialysis (PD); in particular, infections are a common cause of patient’s morbidity and technique failure. In the present paper, data on 89 catheters implanted between January 1986 and December 2002 are reviewed to analyse the major causes of complications and/or PD failure and to ascertain their optimal management. A total of 89 catheters were implanted in 78 patients at the start of chronic PD: 26 in children under 2 years of age, 14 in children aged 2–5 years and 49 in patients over 5 years. Mean age of patients was 76.1 ± 73.0 months and median treatment time 14.5 ± 13.1 months. All catheters were surgically implanted and partial omentectomy was performed in 70% of cases. Straight Tenckhoff catheters were used in 70 cases (78%), curled ones in 19 (22%). Sixty-three catheters (71%) had two cuffs, 26 (29%) a single cuff. The entry-site was the midline in 34 patients (38%) and the paramedian line in 55 patients (62%). Catheter survival rate was 80% at 12 months, 62% at 24 months and 58% at 36 and 48 months, respectively. The incidence of catheter-related complications was one episode every 6.4 PD-months, and they were mainly represented by peritonitis (61%), exit-site infections and tunnel infection (ESI + TI: 23%), catheter obstruction (5%), dislocation (3.5%), leakage (2.5%). After the introduction of curled single-cuff catheters, a considerable reduction in the peritonitis incidence was observed during the last 7 years. A more prolonged catheter survival was observed in older children (>5 vs. <2 years: P < 0.05). Leakage was less common in catheters with paramedian entry-site compared with catheters implanted on the midline. In 7 out of 11 (64%) patients with catheter obstruction, omentectomy had not been performed. Single-cuff catheters had a lower infection-rate than double-cuff catheter (P < 0.01). Single cuff-curled Tenckhoff catheter can be considered the first choice catheter. Single cuff-catheters are not associated with an increase of infections. The surgical technique requires a strict adherence to a standardized procedure and a dedicated team, in order to obtain a reduction of the complications, a prolonged catheter duration and a better quality of life.