Systolic and diastolic left ventricular function in children with primary hypertension: a systematic review and meta-analysis.

OBJECTIVE: Evaluation of left ventricular function provides early evidence of target-organ damage in children with primary hypertension. We performed a systematic review and meta-analysis of left ventricular systolic and diastolic function in children and adolescents with primary hypertension. METHODS: Literature search was performed in PubMed database and out of 718 articles (published between 2000 and 2021) 22 studies providing comparison of left ventricular function parameters between children with primary hypertension and normotensive controls were selected. RESULTS: Overall, 3460 children (5-21 years) with primary hypertension were analyzed. Meta-analysis showed that hypertensive patients when compared with normotensives, had an increased heart rate (mean difference [MD] 5.59; 95% confidence interval [CI] 3.28, 7.89; 10 studies) and increased fractional shortening (MD 1.04; 95% CI 0.48, 1.60; 9 studies) but did not differ in ejection fraction (MD -0.03; 95% CI -1.07, 1.02; 12 studies). Stroke volume was higher in one out of three studies, whereas no differences in cardiac output were found in two studies with available data. Hypertensive children had also lower E/A values (MD -0.21; -0.33, -0.09; 14 studies), greater values of E/e' (MD 0.59; 0.36, 0.82; 8 studies) and greater global longitudinal stress (MD 2.50; 2.03, 2.96; 4 studies) when compared to those with normotension. CONCLUSION: Our results indicate that hypertensive children and adolescents present with signs of hyperkinetic function of the left ventricle, demonstrate evidence of increased left ventricular strain and impaired diastolic function compared to normotensive controls.

Aetiology, course and treatment of acute tubulointerstitial nephritis in paediatric patients: a cross-sectional web-based survey.

BACKGROUND: Acute tubulointerstitial nephritis (TIN) is a significant cause of acute renal failure in paediatric and adult patients. There are no large paediatric series focusing on the aetiology, treatment and courses of acute TIN. PATIENTS, DESIGN AND SETTING: We collected retrospective clinical data from paediatric patients with acute biopsy-proven TIN by means of an online survey. Members of four professional societies were invited to participate. RESULTS: Thirty-nine physicians from 18 countries responded. 171 patients with acute TIN were included (54% female, median age 12 years). The most frequent causes were tubulointerstitial nephritis and uveitis syndrome in 31% and drug-induced TIN in 30% (the majority of these caused by non-steroidal anti-inflammatory drugs). In 28% of patients, no initiating noxae were identified (idiopathic TIN). Median estimated glomerular filtration rate (eGFR) rose significantly from 31 at time of renal biopsy to 86 mL/min/1.73 m2 3-6 months later (p<0.001). After 3-6 months, eGFR normalised in 41% of patients (eGFR ≥90 mL/min/1.73 m2), with only 3% having severe or end-stage impairment of renal function (<30 mL/min/1.73 m2). 80% of patients received corticosteroid therapy. Median eGFR after 3-6 months did not differ between steroid-treated and steroid-untreated patients. Other immunosuppressants were used in 18% (n=31) of patients, 21 of whom received mycophenolate mofetil. CONCLUSIONS: Despite different aetiologies, acute paediatric TIN had a favourable outcome overall with 88% of patients showing no or mild impairment of eGFR after 3-6 months. Prospective randomised controlled trials are needed to evaluate the efficacy of glucocorticoid treatment in paediatric patients with acute TIN.

Is renal scintigraphy really a necessity in the routine diagnosis of congenital solitary kidney?

BACKGROUND: For a definitive diagnosis of congenital solitary kidney, renal scintigraphy is suggested as being the gold standard of ruling out ectopic functioning renal tissue, possibly missed by ultrasound. The aim of our study was to test ultrasonography precision in comparison with renal scintigraphy on a larger cohort of congenital solitary kidneys. METHODS: We performed a retrospective unicenter study of children with congenital solitary kidney with no contralateral tissue, who were treated in the period from 1980 to 2017. The findings in children who underwent both abdominopelvic ultrasound and nuclear renal scintigraphy were compared and the accuracy of ultrasound was assessed. RESULTS: 99 children met the inclusion criteria of congenital solitary kidney confirmed with abdominopelvic ultrasound and nuclear renal scintigraphy. The children were predominantly male (61.6%), and the congenital solitary kidney was largely right-sided (55.5%). In 97 cases (98%), ultrasound correctly predicted the absence of functional renal tissue on one side in the renal fossa or in an ectopic location (pelvis or ipsilateral side). The calculated accuracy of abdominopelvic ultrasound in diagnosing congenital solitary kidney was therefore 98%. CONCLUSIONS: Our findings confirm that abdominopelvic ultrasound alone is accurate enough to diagnose congenital solitary kidney. It gives enough information for consideration if further radiological evaluation is still needed.

Does Guidewire Exchange Influence Infection Rate Related to Catheters Used for Vascular Access in Children on Chronic Hemodialysis?

A central venous catheter (CVC) can either be inserted "de novo" or placed by guidewire exchange (GWE). From September 1998 to September 2015, 32 children (19 boys, 13 girls) were hemodialyzed in our unit by using a CVC. The mean age at CVC insertion was 12.6 ± 0.5 years. A total of 121 uncuffed catheters were placed, either "de novo" or by GWE in 64 (52.9%) and 57 (47.1%) cases, respectively. The most frequent cause for line revision was catheter dysfunction in 40/121 (33.1%) patients. The overall incidence of bacteremia was 1.5/1000 catheter-days. The incidence in newly inserted and GWE catheters was 1.4 and 1.7/1000 catheter-days, respectively. The difference did not reach statistical significance (P = 0.939). The infection rate correlated with patient age, and was higher in younger children (P = 0.006). GWE is an effective option of line revision, and did not influence the infection rate in our study.

Chronic Hemodialysis in Small Children.

When peritoneal dialysis is inapplicable, chronic hemodialysis (HD) becomes the only available treatment option in small children. Due to small patient size, central venous catheters (CVC) are mainly used for vascular access. Over the past 4 years, four children weighing less than 15 kg received chronic HD in our unit. A total of 848 dialysis sessions were performed. Altogether, 21 catheters were inserted. In all but one occasion, uncuffed catheters were used. Catheter revision was performed 15 times during the study period, either due to infection or catheter malfunction. The median number of catheter revisions and the median line survival was 3.0/patient-year and 53 days (range; 6-373 days), respectively. There were 14 episodes of catheter related infections requiring 11 CVC revisions (78.6%). The median rate of line infections was 2.8/patient-year. Chronic HD in small children is demanding and labor intensive. Issues pertain mainly to CVCs and limit its long-term use.

Fate of Central Venous Catheters Used for Acute Extracorporeal Treatment in Critically Ill Pediatric Patients: A Single Center Experience.

Renal replacement treatment (RRT) is required in severe acute kidney injury, and a functioning central venous catheter (CVC) is crucial. Twenty-eight children younger than 16 years have been treated at the University Medical Centre Ljubljana between 2003 and 2012 with either acute hemodialysis (HD) and/or plasma exchange (PE), and were included in our study. The age of the patients ranged from 2 days to 14.1 years. Sixty-six CVCs were inserted (52% de novo, 48% guide wire). The sites of insertion were the jugular vein in 20% and the femoral vein in 80%. Catheters were in function from 1 day to 27 days. The most common cause for CVC removal or exchange was catheter dysfunction (50%). CVCs were mostly inserted in the femoral vein, which is the preferred site of insertion in acute HD/PE because of the smaller number of complications.

IgA-dominant acute poststreptococcal glomerulonephritis with concomitant rheumatic fever successfully treated with steroids: a case report.

There are only a few reports of the co-occurrence of acute poststreptococcal glomerulonephritis (APGN) and acute rheumatic fever. We report an unusual case of a 3-year-old boy with nephrotic syndrome and acute renal failure with the transitional need for peritoneal dialysis, biopsy-proven atypical IgA-dominant APGN, and concomitant acute rheumatic fever, successfully treated by steroids. Aggressive treatment with pulses of methylprednisolone proved to be successful and we recommend its use in this type of cases.

Partial remission of resistant nephrotic syndrome after oral galactose therapy.

Focal segmental glomerulosclerosis is sometimes associated with a circulating permeability factor. It was proposed that this factor interacts with the sugars of the glycocalyx, and its high affinity for galactose was shown on the basis of chromatographic studies. Galactose inactivates it and seems to lead to its clearance from plasma. A toddler with a nephrotic syndrome resistant to corticosteroids was admitted. A renal biopsy revealed minimal change disease with deposition of immunoglobulin M. Immunosuppressive therapy with pulses of cyclophosphamide, low-dose combination immunosuppressive therapy, and later with mycophenolate mofetil failed to induce remission. A renal biopsy six years later showed transformation to FSGS. After unsuccessful treatment with monthly pulses of cyclophosphamide, we began therapy with tacrolimus, which showed no effect. After two months, we added oral galactose to tacrolimus for one month, after which proteinuria decreased by 50%. Seven months later, galactose was again added for six months, after which proteinuria remained below 2 g/24 h and the plasma albumin and cholesterol concentrations normalized. An adolescent girl with a nephrotic syndrome resistant to corticosteroids was admitted. A renal biopsy revealed mesangioproliferative glomerulonephritis with C1q nephropathy. Therapy with tacrolimus failed to induce remission. After six months, we added galactose for three months, which reduced proteinuria to 0.76 g/24 h. After the discontinuation of galactose therapy, proteinuria increased to 2.48 g/24 h, despite further treatment with tacrolimus. It seems that oral galactose at a dose of 0.2 g/kg twice a day could be a promising new and nontoxic therapy for the treatment of resistant nephrotic syndrome.

Vascular access in children on chronic hemodialysis: a Slovenian experience.

The aim of our study was to report our experience with arteriovenous fistulas (AVFs) and non-cuffed central venous catheters (CVCs) in children and adolescents with end-stage renal disease (ESRD) on hemodialysis (HD). The children with ESRD (18 years or younger) who were hemodialyzed at the Center of Dialysis and Transplantation, Children's Hospital, Ljubljana, in the period between December 1998 and December 2010 were included in our retrospective study. We recorded the data considering the CVCs and AVFs used for HD. Thirty-one children (13 females, 18 males) with ESRD received HD treatment. The mean patient age when HD was started was 13.3 ± 3.4 years. Altogether, 35 AVFs were created, and the primary failure rate was 25.7% (9/35). The time to maturation was 4.0 ± 2.5 months. The mean patency of the AVF was 42.5 ± 51.9 months. Seventy-seven CVCs (non-cuffed) were inserted in the observation period; 89.6% of the CVCs were inserted in the jugular vein, and citrate locking was used in the interdialysis period. The CVCs were removed after 0.1-17.4 months (3.6 ± 3.7 months). The incidence of bacteremia was 0.9 episodes per 1000 catheter days. The preferred vascular accesses for pediatric hemodialysis are native AVFs; however, a single lumen, non-cuffed, citrate-locked CVC placed in a jugular vein can be acceptable as a long-term vascular access when AVF cannot be constructed or used.

Detection of dialysis access induced limb ischemia by infrared thermography in children.

High arteriovenous fistula (AV fistula) blood flow may impair distal limb perfusion and cause irreversible ischemic damage. Since tissue temperature reflects blood perfusion, we tried to assess distal blood flow using an infrared camera. We examined all 12 patients with an AV fistula in our dialysis unit. Seven were pediatric patients aged 11.0-18.9 years (mean 14.9 years) and five were adults aged 26.9-62.1 years (mean 38.6 years). Infrared thermal imaging (thermography) of their hands was performed after the completion of their regular dialysis sessions. In each patient, the spot temperature of each fingertip on both hands was assessed separately, with three measurements being performed for each measuring point. The mean spot temperature of all fingertips was calculated for each hand and the results compared. A statistically significant difference (P < 0.05) indicated distal perfusion insufficiency. Perfusion of the hands was also assessed by inspecting the visualized temperature distribution on the thermal image. Finally, we compared the results to the clinical findings in relevant patients. In 8/12 patients (66.7%), the mean spot temperature of the fingertips was statistically significantly lower on the fistula side (P < 0.05). Only 4/12 patients (33.3%) had clinical symptoms, and all were detected by thermography. Abnormal findings were more frequent in elderly patients. Although we realize that the diagnosis of steal syndrome is primarily clinical, thermography might be a safe, noninvasive, cheap tool for the timely detection of children at risk of developing symptoms of hand ischemia.

Effect of intermittent compression of upper arm veins on forearm vessels in patients with end-stage renal disease.

Native arteriovenous fistula is the best vascular access for chronic hemodialysis. Primary and long-term success depends, in part, on the state of arteries and veins at the time of the operation. The aim of our study was to investigate the effects of intermittent compression of upper arm veins on forearm vessels in patients with terminal renal disease. The study group was composed of 16 chronic hemodialysis patients who performed daily intermittent compression of the upper arm without vascular access by elastic band (Eschmarch). Ten chronic hemodialysis patients were included in the control group, which performed no specific activity. Forearm measurements were obtained at the beginning of the study and 4 and 8 weeks later during the course of intermittent compression of the upper arm veins. The forearm circumference and maximal handgrip strength were measured. The artery measures, including endothelium-dependent vasodilatation and forearm vein variables, were obtained by ultrasonography measurements. The forearm circumference, maximal handgrip strength, and artery variables, including endothelium-dependent vasodilatation, remained unchanged. The basal venous diameters (2.29 +/- 0.19 mm at the beginning, 2.46 +/- 0.19 mm after 4 weeks, and 2.53 +/- 0.18 mm after 8 weeks) were significantly increased in the study group. The distensibility of veins was preserved in the study group. There were no significant changes in the control group. Our study demonstrated that daily intermittent compression of the upper arm veins increases the forearm vein diameter and preserves the distensibility of veins in patients with end-stage renal failure.

Effect of local physical training on the forearm arteries and veins in patients with end-stage renal disease.

AIM: We investigate the effects of local training on the forearm vessels in patients with end-stage renal disease. METHODS: Fourteen hemodialysis patients were included. Handgrip training was performed for 8 weeks. The following parameters were measured at the beginning of the study and 4 and 8 weeks later: forearm circumference, maximal handgrip strength, and artery and vein parameters, including endothelium-dependent and endothelium-independent vasodilatation (using ultrasound and duplex Doppler scanning). RESULTS: The maximal handgrip strength increased significantly. The radial artery diameters were significantly higher after 8 weeks of training. The endothelium-dependent vasodilatation was found to be significantly increased after 4 and 8 weeks of training. The maximal vein diameters increased significantly with training, with preserved distensibility. CONCLUSIONS: The present study suggests that regular handgrip training increases the diameters of forearm vessels. It also improves endothelium-dependent vasodilatation. These changes point to the possible beneficial effects of daily handgrip training in chronic renal failure patients before arteriovenous fistula construction.