Pediatric lupus nephritis presenting with terminal renal failure.

A 12-year-old Congolese girl presented with acute renal failure, edema, hypertension, hemoptysis, hematuria, and proteinuria after a history of throat infection. Renal ultrasound showed kidneys of normal size, with increased echogenicity of the cortical parenchyma and decreased corticomedullary differentiation. Other additional investigations showed pancytopenia with decreased complement (low C3 and C4). Antinuclear antibodies were strongly positive, including anti-double stranded DNA. Renal biopsy confirmed severe grade IV lupus nephritis. She was treated with high-dose steroids, mycophenolate mofetil and hydroxychloroquine, in addition to hemodialysis. After one week of intensive treatment, diuresis recovered and dialysis could be stopped after six sessions. We describe an uncommon case of severe lupus nephritis, presenting with terminal renal failure. Since the rarity of this disease presentation, other more common diagnoses have to be considered. Once the diagnosis of lupus nephritis is established, a choice has to be made between the different induction treatment protocols. The patient's ethnic background and other supportive therapies, such as the need for dialysis, can help to make this choice.

Desmopressin resistant nocturnal polyuria secondary to increased nocturnal osmotic excretion.

PURPOSE: We investigated the role of increased solute excretion in children with desmopressin resistant nocturnal enuresis and nocturnal polyuria. MATERIALS AND METHODS: A total of 42 children with monosymptomatic nocturnal enuresis and significant nocturnal polyuria with high nocturnal urinary osmolality (more than 850 mmol/l) were not responding to desmopressin. A 24-hour urinary concentration profile was obtained with measurement of urine volume, osmolality, osmotic excretion and creatinine. The control group consisted of 100 children without enuresis. RESULTS: Based on osmotic excretion patients were classified into 3 groups. Group 1 had 24-hour increased osmotic excretion, most likely secondary to a high renal osmotic load. This was probably diet related since 11 of these 12 patients were obese. Group 2 had increased osmotic excretion in the evening and night, probably due to a high renal osmotic load caused by the diet characteristics of the evening meal. Group 3 had deficient osmotic excretion during the day, secondary to extremely low fluid intake to compensate for small bladder capacity. CONCLUSIONS: Nocturnal polyuria with high urinary osmolality in our patients with desmopressin resistant monosymptomatic nocturnal enuresis is related to abnormal increased osmotic excretion. This may be explained by their fluid and diet habits, eg daytime fluid restriction, and high protein and salt intake.

Desmopressin toxicity due to prolonged half-life in 18 patients with nocturnal enuresis.

PURPOSE: Desmopressin has been used extensively for primary nocturnal enuresis and it is associated with a low incidence of adverse effects. The only reported serious side effect is seizure or altered levels of consciousness resulting from water intoxication, which has been reported for the nasal spray. We describe 18 children with clinical symptoms of water intoxication due to the prolonged bioactivity of desmopressin nasal spray. MATERIALS AND METHODS: We evaluated 18 patients with clinical suspicion of prolonged desmopressin bioactivity during treatment with intranasal desmopressin for primary nocturnal enuresis. The control group consisted of 50 children with primary nocturnal enuresis and proven nocturnal polyuria who were treated with the same desmopressin regimen. RESULTS: All patients had prolonged maximal urinary concentration capacity and delayed restoration of daytime diluting capacity (p <0.01). Of the patients 15 had the characteristic clinical symptoms of water intoxication with vomiting, headache, decreased consciousness and hyponatremia. We suspect that these symptoms are secondary to prolonged desmopressin bioactivity. CONCLUSIONS: Prolonged desmopressin bioactivity may increase the risk of water intoxication.

Need for low sodium concentration and frequent cycles of 3.86% glucose solution in children treated with acute peritoneal dialysis.

In acute renal failure (ARF) in the setting of a pediatric intensive care unit, most authors report the use of frequent cycles of (often low-volume) high-glucose solutions. That approach results in appropriate H2O ultrafiltration, but not in appropriate sodium removal, as a consequence of the sieving coefficient of sodium. That in turn leads not only to inefficient treatment of intravascular fluid overload, but also frequently to hypernatremia. The problem can be resolved by the use of low-sodium (127 mmol/L) dialysis solution. In the present prospective study in children, we performed peritoneal dialysis using a pharmacy-made solution containing 127 mmol/L sodium and 3.86% glucose, comparing that solution with conventional glucose solution. We calculated the ultrafiltration rate and the sodium removal. We observed no statistical difference in ultrafiltration rate, but a significantly increased sodium extraction. Children with acute overload during ARF may benefit if low-sodium solution is used in place of conventional dialysate. A low-sodium solution does not attenuate the pure ultrafiltration rate, but does result in higher sodium extraction, reducing intravascular volume and plasma sodium levels.

Use of bicarbonate/lactate-buffered dialysate with a nighttime cycler, associated with a daytime dwell with icodextrin, may result in alkalosis in children.

The aim of peritoneal dialysis (PD) remains to deliver "appropriate" renal replacement therapy, including sufficient ultrafiltration, correction of acid-base balance, and adequate dialysis dose. We switched our pediatric patients on automated PD from standard lactate-buffered glucose solution (Dianeal: Baxter Healthcare SA, Castlebar, Ireland) to bicarbonate/lactate-buffered solution (Physioneal: Baxter Healthcare SA) as soon as it became available in our country. We also decided to deliver "optimal" dialysis in children by prescribing a long daytime dwell with icodextrin solution (Extraneal: Baxter Healthcare SA). But, adding those three benefits together--APD, Physioneal, and a long dwell with icodextrin--the result, at least in children, was a possible overcorrection of acidosis and an evolution to alkalosis. Thought must be given to developing solutions with varying bicarbonate concentrations for various treatment modalities.