Renal replacement therapies in pediatric intensive care patients: Experiences of one center in Turkey

BACKGROUND: Despite constant improvements in caring for critically ill neonates and infants with congenital cardiac disease, sepsis, bone marrow and solid organ transplantation, acute renal failure (ARF) is an important problem in these children. ARF, severe fluid overload and inborn errors of metabolism are some of the indications for acute dialysis in infants and children. METHODS: The authors had retrospectively evaluated the medical records of Pediatric Intensive Care Unit, Ankara University School of Medicine, Ankara, Turkey patients who had required acute renal replacement therapy between the dates of January 2002 to February 2005. RESULTS: Medical records of 332 patients were reviewed. Acute renal replacement therapy was performed in 21 patients (6.3%; mean age, 9.6 +/- 7.4 years). Dialysis modalities were peritoneal dialysis in 15 patients (71.4%; mean age, 3.9 +/- 5.6 years) and hemodialysis in six patients (28.6%; mean age, 12.1 +/- 3.2 years). A total of 90% of patients had severe systemic disease leading to ARF. A total of 95% of patients had multiple organ dysfunction syndrome. The most common cause of ARF was refractory shock. At the beginning of renal replacement therapy, 10 patients were anuric, nine patients had volume overload, seven patients had decompensated metabolic acidosis and nine patients had hypotension. The average dialysis period was 4.7 +/- 6.4 days. Mortality rate was 66.7%. Eight patients recovered from ARF and chronic renal failure had developed in one patient. CONCLUSION: In the Pediatric Intensive Care Unit, ARF is frequently seen together with multiple organ dysfunction syndrome and the mortality rate is high. Both peritoneal dialysis and hemodialysis are important renal replacement treatment modalities in patients with ARF. The age and hemodynamic status of the patients are important when choosing treatment modality; generally peritoneal dialysis is preferred in infants and toddler, while hemodialysis is preferred in older children.     

Advanced oxidative protein products are independently associated with endothelial function in peritoneal dialysis patients

Aim:   Oxidative stress (OS) and asymmetric dimethylarginine (ADMA) are accepted as non-classical cardiovascular risk factors in end-stage renal disease patients. To clarify the role of these factors in the atherosclerotic process, we investigated if OS and ADMA are associated with endothelial function (EF) in peritoneal dialysis (PD) patients.
Methods:   Fifty-two non-diabetic PD patients without known atherosclerotic disease as well as 30 age- and sex-matched healthy individuals were included. We measured serum thiobarbituric acid-reactive substances (TBARS), malondialdehyde (MDA), advanced glycation end-product (AGE), pentosidine, advanced oxidation protein products (AOPP), ADMA and EF as described by Celermejer et al. in all subjects.
Results:   TBARS, MDA, AOPP, AGE, pentosidine and ADMA levels were significantly higher in PD patients than in controls ( P  < 0.001). Flow-mediated dilatation (FMD)% and nitrate mediated dilatation (NMD)% in PD patients were lower than in the control group (7.7 ± 4.0% vs 11.70 ± 5.50%, P  < 0.01 and 17.6 ± 8.3% vs 26.4 ± 4.6%, P  < 0.01). Additionally, it was found that AOPP are independently correlated with FMD% and NMD% in PD patients (β = −463, P  < 0.01 and β = −420, P  < 0.05).
Conclusion:   This study shows that PD patients without known atherosclerotic disease can also be characterized by endothelial dysfunction and AOPP levels independently predict endothelial function level in PD patients.     

Imipenem for treatment of relapsing Salmonella meningitis in a newborn infant

Salmonella meningitis is a rare clinical entity that occurs mainly during early infancy. Treatment of Salmonella infections may be complicated by the bacteria's growing resistance to clinically important antimicrobial agents, especially third-generation cephalosporins. A report is presented of a newborn infant with Salmonella meningitis who relapsed after 4 weeks of cefotaxime treatment and was cured completely with imipenem cilastatin therapy.     

Histopathological changes and tumour necrosis factor-α, transforming growth factor-β and tenascin expression in patients with primary type I membranoproliferative glomerulonephritis in remission

Aim:   Primary type I membranoproliferative glomerulonephritis (MPGN) is a rare cause of glomerular disease with a high relapse rate and poor prognosis. The aim of this study was: (i) to evaluate the histopathological findings associated with remission; and (ii) to document the possible clinical and histopathological factors predicting relapses.
Methods:   Eleven type I MPGN patients (five men, six women; mean age, 38.8 ± 13.5 years) who were in remission for at least 1 year after the cessation of immunosuppressive drugs were re-biopsied. The intensity of immunostaining for tumor necrosis factor (TNF)-α, transforming growth factor (TGF)-β1, and tenascin was graded from 0 (no staining) to 3+ (maximum staining).
Results:   Mean baseline mesangial cellularity score and tubulointerstitial infiltration score were reduced and mesangial matrix expansion score was increased at protocol re-biopsies compared to baseline. The glomerular and tubulointerstitial staining scores for TGF-β1 and tenascin were higher than that of baseline. Reduced tubulointerstitial TNF-α expression was found in re-biopsy specimens compared to baseline. Patients have been followed for a mean time of 51.5 ± 22.2 months after the protocol biopsy. Eight patients had a relapse. Mesangial cellularity score and glomerular tenascin expression at re-biopsy specimens were higher in relapsed patients compared to those without a relapse.
Conclusion:   Our study shows that mesangial cellularity and tubulointerstitial cell infiltration are reducing whereas mesangial matrix expansion, glomerular and tubulointerstitial TGF-β1 and tenascin expression are increasing with remission. The higher mesangial cell proliferation and glomerular tenascin scores in remission are associated with the development of relapse.     

Prevalence of hypertension among schoolchildren aged 13-18 years in Gemlik, Turkey

Arterial hypertension is the permanent elevation of blood pressure(BP). Previous studies have documented that hypertension maybegin in adolescence, perhaps even in childhood. The purposeof this study was to determine the prevalence of hypertensionamong adolescents in the Gemlik Research and Training Area,Turkey. Between January and March 1994, all secondary and highschool students aged 13–18 years were included in thisstudy. An elevated BP was defined according to the Report ofthe Second Task Force on Blood Pressure Control in Children.Of the 3,641 students screened, 262 (7.2%) had elevated systolicand/or diastolic BP, 161 (4.4%) students had significant hypertensionand 101 (2.8%) students had severe hypertension. We found thatsystolic and diastolic BP increased with age, height and weight.BP measurements should be included in physical examinationsas part of the continuing care of the child.     

Evaluation of the pancreas reserve in siblings of type I diabetic children

INTRODUCTION: The purpose of this study was to determine the pancreas reserve in siblings of diabetic patients by screening islet cell antibodies (ICA), insulin auto antibodies (IAA), reduced C-peptide levels, first-phase insulin release and the derangement of cellular immunity (reduction of natural killer cells, abnormality of the T cell subpopulations). METHODS AND RESULTS: Twelve siblings (aged 9.3 +/- 2.8 years) of diabetic children were evaluated and results were compared with the control group (12.1 +/- 3.5 years). For siblings of the diabetic children, fasting, post-prandial and glucagon response C-peptide mean values were 2.2 +/- 1.2, 7.2 +/- 7.1 and 5.3 +/- 3.6 ng/mL, respectively, while in the control group they were 1.5 +/- 0.8, 3.6 +/- 2.0 and 5.1 +/- 2.9 ng/mL, respectively. There were no differences between the two groups. In 33%, postprandial C-peptide, and in 11% of the siblings, glucagon response C-peptide values were exaggerated. In siblings the first phase insulin release (FPIR) during an intravenous glucose tolerance test was 128.5 +/- 96.6 (above the 50th percentile) and stimulated insulin release (SIR) was 103.8 +/- 92.5 (above 25th percentile). Sibling values were significantly lower than the control group (FPIR 152.4 +/- 42.5, P = 0.01; SIR 134.9 +/- 38.2, P = 0.01). Values for FPIR (in two children) and SIR (three cases) were below the 5th percentile. In one, FPIR and SIR levels were both below the 1st percentile. Islet cell antibodies and IAA were also present in this subject. Treatment with nicotinamide was started in the cases with FPIR and SIR below the 5th percentile. We did not observe overt diabetic symptoms during the follow-up period of more than 3 years. CONCLUSION: We recommend that borderline insulin secretion be tested annually in siblings who show insufficient FPIR.