Long-term outcome of transplant ureterostomy in children: A National Review.

BACKGROUND: CAKUT are the most common cause of end-stage renal failure in children (Pediatr Nephrol. 24, 2009, 1719). Many children with CAKUT have poor urinary drainage which can compromise post-transplant outcome. Identifying safe ways to manage anatomical abnormalities and provide effective urinary drainage is key to transplant success. Much debate exists regarding optimum urinary diversion techniques. The definitive formation of a continent urinary diversion is always preferable but may not always be possible. We explore the role of ureterostomy formation at transplantation in a complex pediatric group. METHODS: We report six pediatric patients who had ureterostomy formation at the time of transplantation at the National Paediatric Transplant Centre in Dublin, Ireland. We compared renal function and burden of urinary tract infection to a group with alternative urinary diversion procedures and a group with normal bladders over a 5-year period. RESULTS: There was no demonstrable difference in estimated glomerular filtration rate between the groups at 5-year follow-up. The overall burden of UTI was low and similar in frequency between the three groups. CONCLUSIONS: Ureterostomy formation is a safe and effective option for temporary urinary diversion in children with complex abdominal anatomy facilitating transplantation; it is, however, important to consider the implications and risk of ureterostomy for definitive surgery after transplantation.

Chronic hemodialysis in children weighing less than 10 kg.

BACKGROUND: Hemodialysis (HD) in infants is usually used when peritoneal dialysis (PD) has failed. We describe our experience with HD, outlining the morbidity, complications, and outcomes for infants weighing less than 10 kg managed with HD for more than 6 months over a 10-year period. METHODS: A retrospective review of the clinical notes was conducted to collect demographic information, anthropometric data, dietary history, site and form of vascular access, details of HD prescription, complications, and outcomes. RESULTS: Nine patients weighing less than 10 kg were hemodialyzed for more than 6 months. Median age at commencement was 9 months. Median weight and height standard deviation score (SDS) at commencement of HD were -2.14 and -0.61, respectively, and at the end they were -1.56 and -1.61. Median energy intake was 96.6 kcal/kg/day and protein intake was 1.66 g/kg/day. Median number of line revisions was 0.32 line changes/patient year. Median central venous catheter (CVC) longevity was 13 months. Mean rate of line infection was 0.14/patient year. Median time on HD was 27 months. Median age at transplantation was 3.4 years. CONCLUSIONS: This case series shows that chronic HD is a viable management option in children <10 kg. Access issues can be minimized with good line care to maximize line longevity and minimize line infection rates.

Tinzaparin is safe and effective in the management of hemodialysis catheter thrombosis.

Children on hemodialysis are at increased risk of thrombosis, especially when dialyzed via a central venous catheter (CVC); there are limited published data regarding the safety and efficacy of tinzaparin in this group. We conducted a retrospective chart review of all children in the National Pediatric Hemodialysis Centre for Ireland diagnosed with a CVC thrombus and treated with subcutaneous tinzaparin over a 10 year period. Seven children were treated with subcutaneous tinzaparin for 10 CVC thrombi. Tinzaparin was commenced at 175 IU/kg/day and the dose was titrated by measuring anti-factor Xa levels, aiming for levels of 0.3-1.0 IU/ml. Treatment was continued until resolution of the CVC thrombus. Restoration of normal flows during dialysis occurred within 3 days in all patients. There were no episodes of bleeding and all children tolerated the treatment well.