Blood pressure management in children on dialysis.

Hypertension is a leading cause of cardiovascular complications in children on dialysis. Volume overload and activation of the renin-angiotensin-aldosterone system play a major role in the pathophysiology of hypertension. The first step in managing blood pressure (BP) is the careful assessment of ambulatory BP monitoring. Volume control is essential and should start with the accurate identification of dry weight, based on a comprehensive assessment, including bioimpedance analysis and intradialytic blood volume monitoring (BVM). Reduction of interdialytic weight gain (IDWG) is critical, as higher IDWG is associated with a worse left ventricular mass index and poorer BP control: it can be obtained by means of salt restriction, reduced fluid intake, and optimized sodium removal in dialysis. Optimization of peritoneal dialysis and intensified hemodialysis or hemodiafiltration have been shown to improve both fluid and sodium management, leading to better BP levels. Studies comparing different antihypertensive agents in children are lacking. The pharmacokinetic properties of each drug should be considered. At present, BP control remains suboptimal in many patients and efforts are needed to improve the long-term outcomes of children on dialysis.

A comprehensive cooperative project for children with renal diseases in Nicaragua.

In low-income countries renal diseases generally and chronic kidney disease (CKD) in particular represent a wide-spread and often underdiagnosed clinical problem. The aim of the cooperative project between the pediatric nephrology units of Milan, Italy, and Managua, Nicaragua was to improve the diagnosis and treatment of renal diseases and CKD in Nicaraguan children. When the project started, in 2000, there were many constraints in human and material resources in the Children's Hospital in Managua. Since 2001, a specialized Unit of Pediatric Nephrology and Urology has developed, offering free of charge basic clinical assistance to hospitalized children, and training abroad of the whole staff. Shared protocols, renovation of infrastructure and an information technology (IT) program were implemented. In 2003, renal replacement therapy (RRT) for selected children was initiated, along with a network of six department hospitals in 2005 and, in 2007, a CKD prevention program in the most peripheral Health Units, so that 61% of the Nicaraguan pediatric population is now covered by the project. To ensure implementation of the project, applications for funds to Italian private and public institutions were made and a Nicaraguan charity foundation was activated. The Nicaraguan Ministry of Health and the hospital directors were always involved in the plans of the development of the project and accepted the progressive transfer of the costs to the government, throughout the 9-year duration of the project. The IT program, inclusive of a database of children with kidney and other urinary tract (UT) diseases and a web connection between Milan and Managua, was crucial in monitoring the activities and providing epidemiological data, in order to better allocate resources. The clinical activities and the number of children managed in Managua in 2008 are similar to those of pediatric nephrology units worldwide and depict the level of clinical autonomy achieved. The sister-center model of cooperation and the top-down strategy we applied, along with the careful consideration of all the economic, logistic and political issues, were and are the key factors which explain the favorable results of this cooperative project.

Pediatric kidney transplantation: a snapshot 10 years later.

Herein we report the outcomes of pediatric kidney recipients who underwent transplantation at least 10 years prior. A cohort of 36 patients (mean age, 26.4+/-6 years) with a mean follow-up time of 14.2+/-4 years was selected for the study. Immunosuppression consisted of cyclosporine and steroids. Actuarial patient and graft survivals 15 years after the transplantation were 97% and 86%, respectively. Only 1 patient died due to a complicated sclerosant peritonitis. Graft function was good with a mean serum creatinine of this selected cohort of 1.5+/-0.6 mg/dL. Eighteen percent were class 1, 33% class 2, and 49% chronic kidney disease. Hypertension was treated in almost 80% of the patients. The majority of patients were smaller than the average population with a final height (between 0 and -2) standard deviation score (HSDS) but only 27% had a severe growth impairment (HSDS>-2). Regarding nutritional status, fewer than 30% were overweight and only 1 patient was obese with a body mass index (BMI) >30. The majority of patients, except 2 mentally retarded individuals, are or have been attending normal school and achieved full-time employment. In conclusion, long-term survivors of a kidney transplant received during childhood reached a high degree of rehabilitation despite a long period of immunosuppression.

[Diagnostic and therapeutic criteria of arterial hypertension in childhood]. / Criteri diagnostici e terapeutici dell'ipertensione arteriosa in età pediatrica.

Arterial hypertension (AH), either primary or secondary, is an important issue in childhood for its short- and long-term cardiovascular morbidity. Renal diseases are the most frequent causes of AH in children, but essential hypertension can also be detected early in life. It is important for blood pressure (BP) to be checked regularly (at least once every 5 years) in healthy children and adolescents and every year in those belonging to at-risk categories (family history of AH, low birth weight, obesity, etc). In children, AH is defined as BP recorded in three non-consecutive measurements with an appropriate device and cuff size > or = 95th centile for age, gender and height. Ambulatory BP monitoring is a valuable diagnostic tool and once AH is confirmed, a specific primary cause should always be ruled out (renovascular, cardiac, vascular, endocrine, pharmacologic, other). In case of border-line or significant AH (between 90th and 99th centile) a non-pharmacological treatment should be considered, whereas severe hypertension (>99th centile for height and age) will require pharmacological treatment (Diuretics, Angiotensin Converting Enzyme Inhibitors, Angiotensin Receptor Blockers, beta - and Calcium blockers).

Mycophenolate mofetil pharmacokinetic monitoring in pediatric kidney transplant recipients.

This open-label, longitudinal, long-term study of de novo pediatric renal transplant recipients was designed to investigate the pharmacokinetics (PK) of mycophenolic acid (MPA) and its possible interaction with cyclosporine (CsA). Thirty-four children on an immunosuppressive regimen of CsA, prednisone, and mycophenolate mofetil (MMF, 300-400 mg/m2 twice daily) were investigated at 6, 30, 180, and 360 days after transplantation. Considerable interindividual variability in the areas under the concentration curve (AUC(0-12)) of MPA was observed during the follow-up, although the dose of MMF remained the same over the same time. Predose levels (C0) increased significantly during the first 6 months after transplantation: C0 at 6 and 180 days after transplantation was 0.8 +/- 0.6 and 1.9 +/- 1.1 microg/mL (P < .0001). A significant time-dependent increase in the AUC of MPA was also observed during the first 6 posttransplant months: AUC(0-12) at 6 and 180 days after transplantation was 23.3 +/- 10.8 and 40 +/- 11.6 mg*h/L (P = .003). MPA concentrations 3 and 4 hours after MMF intake were the individual time points that best correlated with the full MPA AUC (r = 0.8 and 0.79; P < .001). The abbreviated MPA AUC (0-4 hours) correlated reasonably with the full AUC (r = 0.87; P < .001). Finally, a significant reduction in CsA dose during the first 6 posttransplant months (P < .001) matched the significant increases in both MPA C0 and full MPA AUC, thus demonstrating the interaction of the 2 immunosuppressive drugs. These observations suggest the need for therapeutic drug monitoring when adjusting the dose of MMF in children.

Betaxolol kinetics in hypertensive children with normal and abnormal renal function.

The kinetic and clinical profile of betaxolol--a beta 1-selective blocker with 80% to 90% bioavailability and a 16 to 20 hr t1/2--were studied in ten children aged 5 to 13 yr with chronic renal hypertension and mild to severe renal failure. An IV dose of 20 mg of betaxolol per 1.73 m2 body surface area (BSA) was followed by six daily oral doses. Six patients were maintained on combination therapy and four on betaxolol alone; two of these were newly treated. After the intravenous dose, t1/2 (mean +/- SE) was 19.9 +/- 1.7 hr, total clearance 0.30 +/- 0.03 l/kg/hr, and volume of distribution 8.2 +/- 0.7 l/kg. Clearance adjusted for BSA was 7.9 +/- 0.6 l/hr. The t1/2 correlated linearly to serum creatinine levels. After the last dose, peak concentration was 97.4 +/- 7.6 ng/ml, and t1/2 19.4 +/- 2.7 hr. Betaxolol 24-hr blood levels were twice as high as after the first dose. Blood pressure was reduced in two newly treated patients and two patients on combination therapy; previous responses were maintained in the others. The maximum effect was reached after the first dose and was maintained throughout the study week. Our results indicate that betaxolol disposition in children aged 5 to 13 yr with different degrees of renal failure is of the same order as that in young healthy adults, implying that there may be a higher rate of non-renal clearance. Renal failure-induced modification led to a doubling of the t1/2 in the most severe cases, again as in adult renal patients. There is an antihypertensive effect.

Advantages of cyclosporine as sole immunosuppressive agent in children with transplanted kidneys.

A prospective study of intentional stopping of steroids 6 months after transplantation was done with 29 pediatric renal transplant recipients with a mean age of 10.4 +/- 3.4 years. Immunosuppression consisted of cyclosporine and methylprednisolone. We stopped giving MP to 24 children: to twenty after six months, four after 11-20 months. "Crude graft survival" was 97% during a mean follow-up of 36.7 +/- 15 months. The rejection rate was 48% during the first 6 months and 29% in the period after stopping MP. At present, 20/24 children (83%) have remained on CsA alone (18 patients) or CsA and azathioprine (2 patients) during a mean follow-up of 30 +/- 17 months. CsA nephrotoxicity occurred in 20.6% of patients, gum hypertrophy in 45%, hypertrichosis in 24%, and neurological symptoms in two patients (6.8%). Linear growth significantly improved after stopping MP: mean catch-up growth for prepuberal children 1.38 height standard deviation score (HSDS) and for pubertal children 1.6 HSDS. Bone age did not increase more rapidly than chronologic age. Weight/height index (W/HI) also improved. There was also a significant reduction in the use of antihypertensive drugs. Calculated glomerular filtration rate was decreased, though not significantly, after stopping MP. Thus, when graft survival is good, stopping corticosteroids corrects the major handicap of children with irreversible uremia--the poor linear growth--and improves the W/HI and control of arterial pressure. Longer follow-up periods are necessary to exclude significant worsening of renal function and an increased incidence of chronic rejection after stopping the steroid.

Normal values of the bioelectrical impedance vector in childhood and puberty.

The purpose of this study was to determine the reference, bivariate, and tolerance intervals of the whole-body impedance vector in Italian children. This was a cross-sectional, multicenter study, and participants were chosen from the general school population. The impedance vector (standard, tetrapolar analysis at 50-kHz frequency) was measured in 3110 subjects, ages 2 to 15 y, and 2044 healthy children (1014 male and 1030 female) with weight and height within the 95th percentile were selected for the analysis (resistance-reactance graph method). The age-specific 95% confidence intervals of mean vectors and the 95%, 75%, and 50% tolerance intervals for individual vector measurements were plotted using resistance and reactance components standardized by the subject's height. Mean vectors from both sexes with separate 95% confidence ellipses were considered as representative of eight different age groups, from 2 to 13 y. There was a statistically significant sex effect on vector distribution from boys and girls in the age group of 14 to 15 y. The impedance vector distribution of children was also compared with healthy adult subjects (354 male and 372 female, age 15 to 85 y). There was a progressive, statistically significant vector shortening from age 2 to 15 y toward the adults' vector position. In conclusion, we established the trajectory followed by the mean impedance vector in children over ages 2 to 15 y and also obtained the reference, bivariate, and 95%, 75%, and 50% tolerance intervals of the impedance vector by age for healthy children, with which the vectors from children with altered body composition can be tested.

Ex novo episodes of acute glomerulonephritis and Guillain-Barré syndrome: a case report.

A nine-year-old girl had several ex novo episodes of acute glomerulonephritis with clinical evidence of rapid progression in two of them. Guillain-Barré syndrome was diagnosed 10 days after the second episode of acute glomerulonephritis. Two renal biopsies (performed at about a four-year interval) gave morphological evidence of new episodes of acute glomerulonephritis. To our knowledge this is the first report of an association between ex novo episodes of acute glomerulonephritis and Guillain-Barré syndrome.

Intraplatelet serotonin (I5HT) in children with the hemolytic uremic syndrome.

I5HT levels were investigated in 14 children with Hemolytic Uremic Syndrome (HUS). Low levels of I5HT were demonstrated in all the children studied during the early phase of the disease, indicating reversible platelet aggregation and recirculation of degranulated platelets. Three months after the onset of HUS, only 2 children with a pathological picture of cortical necrosis and a mild degree of chronic renal failure had low I5HT levels. On the contrary, normal I5HT levels were present in the other children completely recovered from HUS and with a renal biopsy picture of thrombotic microangiopathy with predominant glomerular involvement. We conclude that normal values of I5HT, after the acute stage of HUS, are a good index of complete recovery from the disease. Further observations are required to assess the prognostic value of low I5HT levels in children with chronic renal failure secondary to HUS.

Immunoelectron microscopy of different forms of glomerulonephritis in routine biopsy material.

Renal biopsies were investigated of patients with IgA or membraneous glomerulonephritis or with systemic lupus erythematosus by light microscopy, electron microscopy, light microscopic immunohistology and by immunoelectron microscopy using the post-embedding technique applied to LR-White embedded tissue. Aim of the study was to explore whether immunoelectron microscopy is reproduced on routine biopsy material and in accordance with light microscopic immunohistological findings. The study shows that immunoelectron microscopy can be applied to routine biopsy material and gives reproducible results. The applied method proved to be reliable, and, hence, routine biopsy material may be used for further studies concerning subcellular mechanisms in immunocomplex deposition and removal.

Prescription and assessment of tidal peritoneal dialysis delivery with a specific equilibration test.

OBJECTIVE: To propose a simplified equilibration test specific for tidal peritoneal dialysis (TPD) that will overcome the inconveniences of the measurement of TPD peritoneal solute clearances through whole dialysate collection. This will enable the prediction of peritoneal creatinine and urea clearances, the suitability of patients for TPD, and routine assessment of TPD delivery. DESIGN: In a prospective study, patients had a standardized TPD run, and dialysate-to-plasma (D/P) ratios for creatinine and urea were calculated at various TPD and peritoneal equilibration test (PET) time points and on total TPD dialysate. Solute clearances were estimated and measured, and correlation coefficients were obtained among all these variables. SETTING: Dialysis unit of a pediatric nephrology department and patients' homes. PATIENTS: Eleven pediatric patients with end-stage renal disease in stable clinical conditions treated with TPD. INTERVENTIONS: Dialysate and blood sample collections. MAIN OUTCOME MEASURES: D/P ratios for creatinine and urea at the fifth and seventh TPD exchanges, at 15-, 30-, 60-, and 120-minute PET times, and on total TPD dialysate and TPD peritoneal creatinine and urea clearances. RESULTS: Correlation coefficients between PET-derived and total TPD dialysate-derived D/P ratios, and those between PET-derived and measured creatinine and urea clearances were more significant at the 120-minute PET time point compared with the other PET time points. Best correlations were obtained at the fifth and seventh TPD exchanges. D/P ratios for creatinine and urea of the fifth and seventh TPD exchanges correlated significantly with the D/P ratios calculated from total TPD dialysate. A significant correlation was also found between peritoneal creatinine and urea clearances on total dialysate volume (measured clearances) and those derived from the dialysate collection of the fifth and seventh TPD exchanges (estimated clearances)--that based on the seventh exchange being slightly more significant. Moreover, the estimated clearances derived from the seventh exchange were within 10% of the measured value in 90.9% of patients both for creatinine and urea. CONCLUSION: The significant correlation between measured and estimated peritoneal creatinine and urea clearances and the low percentage of underestimates of measured clearances obtained using the seventh TPD exchange-derived indices confirm the accuracy of the D/P ratios for creatinine and urea derived from any exchange after the fifth (preferably the seventh) of a standardized TPD run in estimating peritoneal creatinine and urea clearances. This method could represent a simple and accurate means for prescribing TPD and routinely assessing TPD delivery.

Prevalence of malnutrition assessed by bioimpedance analysis and anthropometry in children on peritoneal dialysis.

OBJECTIVE: To evaluate the sensitivity of anthropometry and bioelectrical impedance analysis (BIA) in detecting alterations in body composition of children treated with peritoneal dialysis (PD), and to determine the prevalence of malnutrition in this population, in short- and long-term PD duration, using anthropometric and BIA-derived indices. PATIENTS: Eighteen children treated with automated PD (11 males, 7 females; mean age 8.7 +/- 4.7 years). DESIGN: Eighteen patients were studied using anthropometry and BIA at the start (t0) and after 6 months (t1) of PD, 15 of these patients at 12 months (t2), and 8 at 24 months (t3) of PD. Midarm muscle circumference (MAMC), arm muscle area (AMA), and arm fat area (AFA) were calculated from anthropometric measures according to Frisancho (FrisanchoAR. New norms of upper limb fat and muscle areas for assessment of nutritional status. Am J Clin Nutr 1981; 34:2540-5.). The bioelectrical measures of resistance (R) and reactance (Xc) were obtained directly from the impedance signal; phase angle (PA) and distance (D) were calculated using mathematical formulas. Nutritional status was assessed by anthropometric measurements and BIA-derived indices, expressed as standard deviation scores (SDS), and by a score system based on BIA and anthropometric parameters. The percentage of children with values of anthropometric and BIA-derived indices below the 3rd percentile or between the 3rd and 25th percentiles, and the percentage of children with scores of 7-12 and 4-6 were calculated in order to detect patients with severe or moderate derangement of nutritional status. RESULTS: The mean SDS values of Xc, PA, and D significantly improved (p = 0.05, p = 0.001, p = 0.02) during the first 6 months of PD and remained almost stable during the following months. The SDS values of the anthropometric indices were less compromised than those of the BIA-derived indices, particularly at the start of dialysis. By 6 months, the percentages of children with values of BIA and anthropometric indices below the 3rd percentile had decreased. The percentages of patients with moderate and severe derangement of BIA and anthropometric indices remained substantially unchanged after 12 months. However, at 24 months, the percentage of patients with moderate derangement of BIA indices increased. All these findings were confirmed by the nutritional score system. CONCLUSION: BIA is more sensitive than anthropometry in detecting alterations in body composition of children on PD. The prevalence of malnutrition, high at the commencement of PD, decreases during the first year of treatment but not over the long term.

Chronic peritoneal dialysis catheters in pediatric patients: experience of the Italian Registry of Pediatric Chronic Peritoneal Dialysis.

During the period 1986-1991, 140 pediatric patients [age < or = 15 years at the start of chronic peritoneal dialysis (CPD)], belonging to 15 dialysis centers, were enrolled in the Italian Registry of Pediatric Chronic Peritoneal Dialysis. Data on 188 peritoneal catheters were collected: 161 catheters were Tenckhoff (144 double-cuff, 17 single-cuff), and 27 were two-cuff Valli-type catheters. All catheters were surgically inserted; the entry site was in the midline in 84 cases and paramedian in 104. An omentectomy was performed in 78.8% of the cases. Apart from peritonitis, there were 161 catheter-related complications (103 exit-site infections, 17 leakages, 15 obstructions, 15 outer-cuff extrusions, 5 hemoperitoneum, 6 others) observed during 2687.5 dialysis-months, with an incidence of one complication every 16.7 dialysis-months. Fifty-five catheters (29.2%) were removed; infection (39 cases) was the main cause for removal, followed by obstruction (9 cases), dislocation, and outer-cuff extrusion (2 cases each). Actuarial survival of all catheters was 79.7% at 1 year, 66.6% at 2 years, 42.8% at 3 years, and 39.8% at 4 years. No difference in catheter survival was observed according to the entry site. When considering the age of the patients at catheter insertion, a difference close to statistical significance was found (p = 0.06).

Analysis of complications in a chronic peritoneal dialysis pediatric patient population. The Italian Registry of Pediatric Chronic Peritoneal Dialysis.

During the period 1986-1991, the Italian Registry of Pediatric Chronic Peritoneal Dialysis collected data from 140 patients younger than 15 years at the start of chronic peritoneal dialysis (CPD). In this study we review the Registry's complications and patient hospitalization data. A total of 395 complications directly related to CPD were registered during 2722 dialysis-months. There were 176 episodes of peritonitis (44.5%), 161 catheter-related complications (40.7%) (103 exit-site infections, 17 leakages, 15 obstructions, 15 cuff extrusions, 5 hemoperitoneum, and 6 other complications), and 58 technique-related complications (14.8%) (39 abdominal hernias, 10 hydroceles, 5 with abdominal pain, 4 hydrothorax complications). The patient hospitalization rate during the period 1989-1991 was evaluated; the analysis referred to 106 patients who underwent treatment for a total of 1520.5 dialysis-months. Patients starting CPD in the year and patients already on CAPD spent 5.8 and 2.1 days per patient-month in the hospital, respectively; the difference was not statistically significant. The evaluation of complications (both technical and systemic) causing patient hospitalization showed that peritonitis was responsible for 43.2% of patient admissions and 36.3% of days hospitalized, catheter-related complications for 22% and 19.8%, technique-related complications for 8.3% and 5.1%, and other clinical complications for 26.5% and 38.8%, respectively.

Evaluation of the peritoneal equilibration test in children on chronic peritoneal dialysis.

The peritoneal equilibration test (PET) is routinely performed in adults treated with chronic peritoneal dialysis to assess the peritoneal transport rate and to optimize treatment prescription. Only a few and not well-standardized studies on the PET have been reported in children. Twenty-six PET's were performed in 16 children, mean age 10.9 +/- 4.9 years, mean body weight (BW) 26.8 +/- 11.9 kg, treated with nightly intermittent peritoneal dialysis (NIPD). The PET was performed according to Twardowski. Forty mL/kg BW of 2.27% glucose solution were infused at a rate of 10 mL/kg BW every 2 minutes. In the simplified test, dialysate samples were taken at dwell times 0, 2 and 4 hours for glucose and creatinine. A blood sample was taken after a 2-hour dwell time for the same parameters. The standard PET (8 patients) consisted of dialysate samples at 0, 15, 30, 60, 120, and 240 minutes and blood samples at 0 and 240 minutes. Mean D/P ratio for corrected creatinine and D/D0 ratio for glucose at 2 hours were 51.6 +/- 11.6 and 50.4 +/- 9, respectively; at 4 hours 69.6 +/- 12 and 34.4 +/- 9.8, respectively. There was good correlation between D/P creatinine and D/D0 glucose at 4 hours (p < 0.0001). Patients were classified as high (3 cases), high-average (5), low-average (6), and low (2) transporters. A statistically significant difference was found between the curves obtained by the simplified PET and those of the standard PET in the first hour (r = 0.66; p < 0.05). In conclusion, the PET, modified for use in children, gave reliable and reproducible results.(ABSTRACT TRUNCATED AT 250 WORDS)

Cardiovascular function in a chronic peritoneal dialysis pediatric population on recombinant human erythropoietin treatment.

Anemia, through a hyperkinetic state, is an important contributor to myocardial function impairment. To determine the cardiovascular effects of recombinant human erythropoietin (rHuEPO) therapy, 10 chronic peritoneal dialysis (CPD)-treated anemic children were studied before and during 18 months of treatment. The following parameters were recorded: hemoglobin (Hb) [percent of target level (TL) = x-2 standard deviations of normal Hb values for age and sex], heart rate (HR, beats/minute), mean arterial pressure (MAP, mmHg), end-diastolic left ventricular diameter (EDLVD, mm/sm BSA), shortening fraction (SF, percent), and interventricular septal thickness (IVS, mm/sm BSA). Student's t-test for paired data showed (vs time before treatment, T0) a progressive increase in Hb, a progressive decrease in HR, and a progressive increase in MAP. EDLVD progressively decreased, while SF and IVS remained unchanged throughout the study. Regression analysis showed a close correlation between anemia correction and decrease of HR (p < 0.01), while no correlation was found between Hb and EDLVD or SF, IVS, or MAP. Our data indicate that anemia correction in these patients is mainly associated with a decrease in hyperkinetic state (HR reduction with SF unvaried), while left ventricular function and dimensions remain normal, despite an increase in MAP.

Complications linked to chronic peritoneal dialysis in children after kidney transplantation: experience of the Italian Registry of Pediatric Chronic Peritoneal Dialysis.

Our objective was to evaluate the infectious complications of the post-transplant period attributable to the persistence of catheter and other complications when chronic peritoneal dialysis (CPD) was performed post-transplantation. The design was a retrospective study, and the setting was an Italian registry of pediatric chronic peritoneal dialysis. There were 86 pediatric renal transplants (9/86 from living related donors, 2/86 simultaneous liver and kidney transplantation for oxalosis). Six of 86 transplants were lost at follow-up. Mean age of the children (n = 80) at transplantation was 9.3 years (range: 1.7-21 years). They had been on CPD for a mean period of 1.7 years (range: 0.2-4.6 years). During CPD, 67 peritonitis episodes (80% related to exit-site and/or tunnel infections) were observed, with an incidence of peritonitis of one episode per 16 months CPD. The mean safe interval of peritonitis and/or exit-site or tunnel infection was 208 days (range: 36-1897 days). The mean time of catheter removal was 80.3 days (range: 0-216 days) post-transplantation. During the first month post-transplantation, one episode of peritonitis secondary to a sepsis occurred in one child. No other episodes of peritonitis or exit-site and/or tunnel infections were observed. Two of 80 children returned to CPD (at four and at 12 months, respectively) because of persistent allograft failure. Furthermore, 12 patients were on CPD because of temporary graft failure. In all these patients the pretransplant peritoneal dialysis (PD) catheter was utilized, with no complications. These data show that the persistence of the PD catheter after kidney transplantation has produced no infections or other complications. What is more, the catheter was safely utilized during acute rejection or primary allograft nonfunction.

Comparison of patient hospitalization in chronic peritoneal dialysis and hemodialysis: a pediatric multicenter study.

Patient hospitalization was compared in 207 pediatric patients (age < or = 15 years at the start of dialysis) on chronic peritoneal dialysis (CPD) (127 patients) or center hemodialysis (HD) (80 patients), treated in 17 dialysis centers during the period 1989 to 1994, and followed up for at least three months. The hospitalization rate was expressed as hospital days per patient-month, and was calculated on the overall period of treatment and separately for the first and second year. Since the age at start of dialysis markedly differed between CPD (8.2 +/- 4.7 years) and HD (11.2 +/- 2.9 years) patients (with no HD patient younger than five years), results are separately presented in three patient groups: CPD patients aged < 5 years (A); CPD patients aged five to 15 years (B); HD patients (C). The duration of hospitalization was subdivided according to the following different causes: routine (monitoring of dialysis adequacy), complications of the modality, patient primary renal disease, and other causes. The results are presented in Table 1. A statistically significant difference in total days hospitalized was found between each of the two groups of CPD patients and the HD patients; the results for hospitalization for dialysis-related complications were higher in the group of younger children on CPD, while the difference between the two age-matched groups of patients on CPD and HD was not significant.

The Italian Registry of Pediatric Chronic Peritoneal Dialysis: a ten-year experience with chronic peritoneal dialysis catheters.

OBJECTIVE: To analyze the data from 347 peritoneal catheters implanted in 249 pediatric patients aged < or = 15 years at start of chronic peritoneal dialysis (CPD). DESIGN: Restrospective study of the data collected between 1986 and 1995, in 20 dialysis centers, from the Italian Registry of Pediatric Chronic Peritoneal Dialysis. Data collection for each pediatric catheter included: catheter type, site and technique of insertion, complications, duration, and reason for removal or replacement. RESULTS: Fifty catheters were inserted in patients under 2 years of age, 50 in patients aged 2 - 5 years and 247 in patients over 5 years of age. Catheter types included 307 (88.5%) Tenckhoff (286 double cuff, 21 single cuff) and 40 (11.5%), double-cuff, Valli-type catheters. All catheters were surgically implanted and omentectomy was performed in 83.5% of cases; the entry-site was in the midline in 136 cases (39.2%) and paramedian in 211 (60.8%). During 6076 CPD months we observed 274 catheter-related complications: 182 catheter infections (exit-site and/or tunnel infection), 23 leakages, 19 obstructions, 19 cuff-extrusions, 14 dislocations, 6 hemoperitoneum, 10 other (incidence of one complication every 21.8 dialysis-months). A significant reduction of catheter-related complications occurred in the last five years, compared with the first 5 years. One hundred and six catheters were removed due to catheter-related causes: infection (83 cases), obstruction (11), dislocation (4), outer-cuff extrusion (3), leakage (2), bowel incarceration (2), and bowel infarction (1). Catheter survival was 72.2% at 12 months, 52.3% at 24 months, 32.8% at 36 months, and 25.7% at 48 months. Significantly lower catheter survival was found in younger children (0 - 2 years) compared with two other age groups (2 - 5 years, and > 5 years). No significant correlation was found between catheter survival and catheter entry-site (midline vs paramedian). CONCLUSIONS: Catheter-related infections were confirmed to be the most common complication and most frequent cause of peritoneal catheter removal. In addition, catheter survival rate was worse in younger children, indicating that more effort should be made to improve peritoneal catheter survival particularly in this age group.