Arteriovenous fistula for chronic hemodialysis in children

Each year, three to five children per million develop chronic renal failure. Of these one to two will require long-term hemodialysis support. From July 1992 to July 2000, we performed 19 surgical procedures to provide chronic hemodialysis access for a group of 14 children. There were 8 boys and 6 girls, with a mean age of 7.9 years (range 2.5-13). Ten of the children were between 2.5 and 10 years old. The mean weight of the children was 20.3 kg (range 12-49). Four children were only 12 kg in weight. The mean follow-up period was 42.1 months (range 10-96). Surgical technique was varied. Polytetrafluoroethylene (PTFE) grafts were used in 5 cases. The overall mean functional primary patency of the fistula was 30.2 months and secondary patency 31.6 months. Primary and secondary patency were better with autologous (39 and 40.6 months) than with PTFE graft (3.75 and 4.75 months). Providing dialysis access in the pediatric population is a time-consuming and frustrating challenge. We advocate the use of autologous material whenever possible. In children less than 12 kg in weight, brachiobasilic fistula is our first choice for angioaccess.     

Improving Outcomes of Liver Retransplantation: An Analysis of Trends and the Impact of Hepatitis C Infection

Retransplantation (RT) in Hepatitis C (HCV) patients remains controversial. Aims: To study trends in RT and evaluate the impact of HCV status in the context of a comprehensive recipient and donor risk assessment. The UNOS database between 1994 and October 2005 was utilized to analyze 46  982 LT and RT. Graft and patient survival along with patient and donor characteristics were compared for 2283 RT performed in HCV and non-HCV patients during 1994–1997, 1998–2001 and 2002–October 2005. Overall HCV prevalence at RT increased from 36% in the initial period to 40.6% after 2002. In our study group, 1-year patient and graft survival post-RT improved over the same time intervals from 65.0% to 70.7% and 54.87% to 65.8%, respectively. HCV was only associated with decreased patient and graft survival with a retransplant (LT-RT) interval (RI) >90 days. Independent predictors of mortality for RT with RI >90 days were patient age, MELD score >25, RI <1 year, warm ischemia time ≥75 min and donor age ≥60 (significant for HCV patients only). Outcomes of RT are improving, but can be optimized by weighing recipient factors, anticipation of operative factors and donor selection.     

Overt hepatic encephalopathy: development of a novel clinician reported outcome tool and electronic caregiver diary

Clinical management and clinical trials of patients with overt hepatic encephalopathy (OHE) are compromised by lack of standardized and reproducible tools for its clinical diagnosis or for caregiver (CG) identification of OHE manifestations which merit medical evaluation. Using an iterative Delphi method, Steering Committee and international hepatologist panel, the West Haven (WH) scale was modified to develop and operationalize a clinician tool for OHE identification and grading (HE Grading Instrument, HEGI?). Major diagnostic criteria included disorientation to time, place, and person, asterixis, lethargy, and coma. Minimum HEGI requirements for OHE diagnosis included: (1) disorientation, or (2) presence of both lethargy and asterixis, or (3) coma. Inter- and intra-rater HEGI reproducibility were 97 % and 98 %, respectively. When applied to a phase II clinical trial population of 178 patients with 388 OHE episodes, HEGI demonstrated excellent concordance with investigator judgement. Additionally, a multi-stage study was conducted to develop a daily CG e-diary, based on OHE manifestations recognizable by CG including speech difficulties, unusual behavior, forgetfulness, confusion, disorientation and level of consciousness. The e-diary was designed for use on smart phone, laptop or desktop, utilized branching logic and skip patterns, incorporated automatic daily completion reminders and real time alerts to clinical sites to facilitate daily standardized CG input and was found to be user friendly and understandable. The HEGI and e-diary, which were developed using methodology accepted by regulatory authorities, are designed to facilitate the design and interpretation of clinical trials for OHE and improve outcomes for OHE patients in clinical practice.     

Renovascular hypertension in children

Renovascular disease accounts for 5 to 10% of all cases of hypertension in children. It is a serious, but potentially curable disease. The presenting blood pressure is usually very high and difficult to control. Renal angiography is the gold standard for diagnosis. Treatment with various antihypertensive drugs, angioplasty and surgery, provided by a multidisciplinary team of pediatric nephrologists, interventional radiologists and vascular surgeons offer a good long-term outcome for most affected children.