Blood Volume Monitoring to Assess Dry Weight in Pediatric Chronic Hemodialysis Patients.

OBJECTIVE: Volume overload from an incorrect assessment of dry weight leads to cardiovascular diseases in chronic hemodialysis patients. Dry weight assessment in pediatric is difficult for a number of reasons including growth. Blood volume monitoring (BVM) has been proposed as an accurate method of estimating dry weight in adult. However, there is very scant data regarding B VM assessment in pediatric. Therefore, the authors conducted a study to compare dry weight, postdialytic body weight, predialytic blood pressure, intradialytic blood pressure, and intra dialytic symptoms between clinical adjustment and B VM method. MATERIAL AND METHOD: In pediatric chronic hemodialysis patient, B VM was performed to guide ultrafiltration to adjust dry weight compared with clinical adjustment. Data including dry weight, postdialytic body weight, predialytic blood pressure, intradialytic hypotension, and intradialytic symptoms were analyzed over each 1-month period of treatment course. RESULTS: Ten patients (5 males/5 females, age 16.55 ± 2.49 years) were enrolled. Comparing clinical adjustment to assess dry weight with BVM, there were no differences in dry weight (38.38 ± 7.43 vs. 38.12 ± 7.58 kg) and postdialytic body weight (38.54 ± 7.61 vs. 38.23 ± 7.35) of both methods. Dry weight adjusted by clinical adjustment trends to higher than by BVM (0.14 ± 0.46 vs. -0.26 ± 0.57 kg). There is also no difference between predialytic blood pressure of both methods. There is no intradialytic hypotension during the study period. However, intradialytic symptoms in clinical adjustment diy weight is more frequent than B VM method, especially thirst. CONCLUSION: The use of BVM tends to decrease dy weight in pediatric chronic hemodialysis patients. Even though, no difference in predialytic blood pressure and intradialytic hypotension. BVM to assess dry weight reduces abnormal intradialytic symptoms, especially thirst. Sofar there is no gold standard to access the accurate dry weight in children.

Malignancy in renal transplant recipients: a single-center experience in Thailand.

BACKGROUND: Malignancy is the second most common cause of death in renal transplant patients with functioning graft and its incidence increases with time after organ transplantation. OBJECTIVE: To present the cumulative incidence and manifestations of malignancy among renal transplant recipients in Phramongkutklao hospital between 1987 and 2009. MATERIAL AND METHOD: To retrospectively review of the transplant charts and records of 168 kidney transplant recipients from October 1, 1987 to November 15, 2009 at Phramongkutklao Hospital. The data related to malignancy were recorded. RESULTS: The cumulative incidence of malignancy was 4/168 (2.4%) recipients with a median age of 45 years (range, 8-55 years). The median time of diagnosis of malignancy after transplantation was 7.3 years (range, 0.8-10.4 years). All four patients had posttransplantation malignancy. The diagnosis was based on pathological specimens. All of them received cyclosporine, prednisolone and azathioprine or mycophenolate mofetil as immunosuppressive regimen. Two patients had native renal cell carcinoma (RCC), one had post-transplant lymphoproliferative disorder (PTLD), the other had a malignant hemangiopericytoma. Two patients (PTLD and advanced RCC cases) are alive, one patient died of malignancy (malignant hemangiopericytoma) and the other died of infection (Pseudallescheria boydii brain abscess). CONCLUSION: The incidence of malignancies in the present study was increased among renal transplant recipients compared to the general population especially renal cell carcinoma. Because of the higher risk to develop malignancy in transplant recipients, a close surveillance for early detection of malignancy is necessary in the long term follow-up.

A simplified clinical prediction score of chronic kidney disease: a cross-sectional-survey study.

BACKGROUND: Knowing the risk factors of CKD should be able to identify at risk populations. We thus aimed to develop and validate a simplified clinical prediction score capable of indicating those at risk. METHODS: A community-based cross-sectional survey study was conducted. Ten provinces and 20 districts were stratified-cluster randomly selected across four regions in Thailand and Bangkok. The outcome of interest was chronic kidney disease stage I to V versus non-CKD. Logistic regression was applied to assess the risk factors. Scoring was created using odds ratios of significant variables. The ROC curve analysis was used to calibrate the cut-off of the scores. Bootstrap was applied to internally validate the performance of this prediction score. RESULTS: Three-thousand, four-hundred and fifty-nine subjects were included to derive the prediction scores. Four (i.e., age, diabetes, hypertension, and history of kidney stones) were significantly associated with the CKD. Total scores ranged from 4 to 16 and the score discrimination was 77.0%. The scores of 4-5, 6-8, 9-11, and ≥ 12 correspond to low, intermediate-low, intermediate-high, and high probabilities of CKD with the likelihood ratio positive (LR+) of 1, 2.5 (95% CI: 2.2-2.7), 4.9 (95% CI: 3.9 - 6.3), and 7.5 (95% CI: 5.6 - 10.1), respectively. Internal validity was performed using 200 repetitions of a bootstrap technique. Calibration was assessed and the difference between observed and predicted values was 0.045. The concordance C statistic of the derivative and validated models were similar, i.e., 0.770 and 0.741. CONCLUSIONS: A simplified clinical prediction score for estimating risk of having CKD was created. The prediction score may be useful in identifying and classifying at riskpatients. However, further external validation is needed to confirm this.

Electrolyte disturbances and abnormal urine analysis in children with dengue infection.

Serum electrolytes and urine analysis results were retrospectively reviewed in children with either dengue fever (DF) or dengue hemorrhagic fever (DHF). Children who had positive serology for dengue infection and serum electrolytes determined before starting intravenous fluid were included in the study. During the years 2004-2007, 73 DF patients, age 9.29 +/- 3.62 years, and 77 DHF patients, age 10.04 +/- 3.64 years were enrolled in the study. The patients were admitted to the hospital on average on days 4.12 +/- 1.1 and 4.25 +/- 1.4 of febrile illness for DF and DHF, respectively. The prevalence of hyponatremia in patients with DF was 61% and DHF was 72% (p = 0.149). The mean serum sodium levels in patients with DF and DHF were 133.5 +/- 3.52 and 133.5 +/- 3.20 mEq/l (p = 0.938), respectively. The prevalence of hyponatremia in patients with mild (grade I), moderate (grade II) and severe (grade III-IV) DHF were 70, 77, and 78% (p = 0.729), respectively, and the mean serum sodium levels were 134.1 +/- 3.05, 132.9 +/- 3.33, and 132.5 +/- 3.28 (p = 0.189), respectively. The prevalence of hypokalemia in patients with DF was 14% and 17% in patients with DHF (p = 0.588). A high urine specific gravity reflecting dehydration was found in 63% of patients with DF and 60% of patients with DHF (p = 0.77). The prevalences of hematuria in patients with DF and DHF were 18% and 27% (p = 0.182), respectively and proteinuria were 15% and 27% (p = 0.072), respectively. The prevalences of hematuria and proteinuria were not different among patients with mild, moderate and severe DHF. No patients had gross hematuria or developed acute renal failure requiring dialysis. Mild hyponatremia is a common electrolyte disturbance and renal involvement is mild in patients with DF and DHF.

Prevalence and risk factors of chronic kidney disease in the Thai adult population: Thai SEEK study.

BACKGROUND: Previous reports of chronic kidney disease (CKD) prevalence in Thailand varied from 4.3% to 13.8%. However, there were methodological concerns with these reports in terms of generalization and the accuracy of estimation. This study was, therefore, conducted to determine CKD prevalence and its risk factors in Thai adult populations. METHODS: The population-based Thai Screening and Early Evaluation of Kidney Disease (SEEK) study was conducted with cross-sectional stratified-cluster sampling. Serum creatinine was analysed using the modified Jaffe method and then standardized with isotope dilution mass spectrometry. RESULTS: The study included 3,459 subjects were included in the study. The mean age was 45.2 years (SE = 0.8), and 54.5% were female. Six hundred and twenty-six subjects were identified as having CKD, which evidenced an overall CKD prevalence of 17.5% [95% confidence interval (95% CI) = 14.6-20.4%]. The CKD prevalence of Stages I, II, III and IV were 3.3% (95% CI = 2.5%, 4.1%), 5.6% (95% CI = 4.2%, 7.0%), 7.5% (95% CI = 6.2%, 8.8%) and 1.1% (95% CI = 0.7%, 1.5%), respectively. The prevalence of CKD was higher in Bangkok, the Northern and Northeastern regions than in the Central and Southern regions. Seven factors (i.e. age, gender, diabetes, hypertension, hyperuricaemia, history of kidney stones and the use of traditional medicines) were associated with CKD. Only 1.9% of the subjects were aware that they had CKD. CONCLUSIONS: CKD prevalence in the Thai population is much higher than previously known and published. Early stages of CKD seem to be as common as later stages. However, albuminuria measurement was not confirmed and adjusting for persistent positive rates resulted in the prevalence of 14.4%. Furthermore, the awareness of CKD was quite low in the Thai population.

Rare F311L CFTR gene mutation in a child presented with recurrent electrolyte abnormalities and metabolic alkalosis: case report.

Delta F508 mutation is recognized as the most common genotype of cystic fibrosis (CF) however, there are small numbers of CF patients having Delta F508/F311L. In the present study, the authors report a 2-year-old Thai boy, originating from North India, presenting with recurrent episodes of febrile illness, hyponatremia, hypokalemia, and metabolic alkalosis since 4 months of age. He was transferred to our hospital for further investigation. Blood chemistry revealed the following serum electrolytes, sodium 122, potassium 3.69, chloride 79.7, and bicarbonate 33.8 mEq/L, and the following urine electrolytes, sodium < 10, potassium 45.7 and chloride < 10 mEq/L. After intravenous fluid administration, hyponatremia and metabolic alkalosis improved DNA sequencing analysis of his blood demonstrates compound mutation for Delta F508 and F311L in CFTR gene. In conclusion, the authors report a rare case of CF with Delta F508/F311L genotype presented with recurrent hyponatremia and metabolic alkalosis. Awareness of electrolyte abnormalities during febrile illness, proper genetic counseling, and long-term follow up are necessary in this patient.

Assessment of the different methods to predict equilibrated Kt/V in pediatric hemodialysis.

OBJECTIVES: To determine the degree of urea rebound in children on hemodialysis and compare the different calculation models for Kt/V. MATERIAL AND METHOD: The present study was performed in 50 hemodialysis sessions of 5 pediatric patients, 2 males and 3 females, aged 5-18 years, who had received hemodialysis for 7-48 months. Blood urea samples were obtained at the beginning, 70 minutes intradialysis, the end and every 10 minutes for 1 hour post- dialysis. The compared 6 different models of Kt/V were single pool, Daugirdas, equilibrated, rate equation, Maduell and Smye method. RESULTS: Urea rebound was found to be completed at least 60 minutes post- dialysis and mean percentage value was 30.68 +/- 9.663. Mean value of equilibrated Kt/V was 1.442 +/- 0.259 while that of single-pool Kt/V calculated by InC1/C2 was 1.705 +/- 0.252 leading to overestimation of Kt/V by 0.265 +/- 0.075. Mean value calculated by Daugirdas method was 2.083 +/- 0.336. Mean values obtained by rate equation, Maduell and Smye methods were 1.485 +/- 0.209, 1.442 +/- 0.209 and 1.379 +/- 0.343 which differed from equilibrated Kt/V by 0.086 +/- 0.058 (p = 0.002), 0.069 +/- 0.063 (p = 0.967) and 0.132 +/- 0.132 (p = 0.015), respectively. CONCLUSION: Urea rebound in pediatric patients is completed at least 60 minutes after cessasion of hemodialysis. Kt/V calculated from single-pool is not suitable for children. The Maduell model gives the best correlation to equilibrated Kt/V when compared to rate equation and Smye models.

Left ventricular hypertrophy and LV geometry in chronic dialysis children and adolescents.

Data from USRDS and Thai Renal Replacement Therapy revealed cardiovascular disease is a common cause of death in ESRD patients. Left ventricular hypertrophy (LVH) is one of the risk factors however there are few studies about this in chronic dialysis children. In the present study, the authors retrospectively reviewed the prevalence of LVH and variable parameters correlated with LVMI in chronic dialysis patients in Phramongkutklao Hospital. Eleven hemodialysis and three peritoneal dialysis patients, aged 12.1 +/- 5 years, were included. LVH was diagnosed by calculating LVMI from echocardiographic study. Clinical and laboratory data were reviewed to compare parameters between LVH and without LVH groups. Prevalence of LVH was 57%. In the LVH group, 7 patients had eccentric LVH and 1 patient had concentric LVH. LVH patients had significantly high systolic BP (SBP), diastolic BP (DBP), index of SBP and index of DBP. Blood pressure also had positive correlation and patients age had negative correlation with LVMI. In conclusion, high blood pressure is associated with left ventricular hypertrophy. Serial echocardiography and long term follow up should be done in this patient group to prevent cardiovascular morbidity and mortality.