Use of intraperitoneal pressure, ultrafiltration and purification dwell times for individual peritoneal dialysis prescription in children.

Tolerance of peritoneal dialysis is, in a part, dependent on intraperitoneal dialysate volume. Measurement of intraperitoneal pressure (IPP) in cm of water is easy to perform especially with the twin bag Y set (Baxter). Today we use IPP for following surgical catheter implantation (delaying, starting and progressing with peritoneal dialysis) and for optimizing ultrafiltration and purification. Efficiency of peritoneal dialysis is dependent on adequate ultrafiltration (UF) and on adequate purification (solute clearances). These two goals seem apparently conflicting in terms of duration of dwells: short dwell time enhances UF capacity and conversely long dwell time enhances solute clearance. Peritoneal equilibration test (PET) allows an approach to the ultrafiltration time: the point at which the overtime dialysate urea saturation and glucose desaturation curves cross, called APEX time. PET allows also an approach of the purification time: the point at which dialysate (D) to plasma (P) concentration ratios over time are high. Because the value of phosphate as uremic factor of morbidity, we have chosen the time for D/P phosphate equal to 0.6 as a purification phosphate dwell time (PPT). A total of 17 patients were studied, over a five-year period allowing 142 determinations. APEX times (range 18 to 71 min) and PPT (range 105 to 238 min) were spread over a wide distribution. PPT and APEX times were significantly shorter in children younger than 3 years of age than in children older than 10 years of age. PPT were nearly four times longer than APEX times. The knowledge of these conflicting ultrafiltration and purification times should help, in our view, in the individual choice of the PD modality: if UF is the major goal, short dwell times should be used (automatic PD); if purification is the major goal, long dwell times should be used (CAPD); if both are the target goal, tidal PD should be discussed.

Solute equilibration curves, crossing time for urea and glucose during peritoneal dialysis: a function of age in children.

Glucose is absorbed from the dialysate more rapidly in younger than in older children on CAPD leading to a relatively early loss of ultrafiltration during dwell time. In order to assess peritoneal permeability and in term to prescribe optimal management of CAPD, we tested peritoneal equilibration curves (EC) for urea and glucose, especially the crossing time point of these two ECs. Baseline values were obtained from 8 patients divided in two groups by age at start of CAPD: group I (N = 4) mean age 1 year 6 months, mean body weight 8.25 +/- 3.17 kg, group II (N = 4) mean age 12 years 6 months, mean body weight 33.5 +/- 1.5 kg. The crossing time point is earlier in group I (49 +/- 14 min) than in group II (101 +/- 20 min) (p less than 0.001). Followup of each patient, during a mean time of 20 months in group I and 23 months in group II, establishes that the curves crossing time point for each patient remains stable.

[Gitelman syndrome in children: true hypokalemia but false Bartter syndrome]. / Syndrome de Gitelman chez l'enfant: vraie hypokaliémie mais faux syndrome de Bartter.

BACKGROUND: Gitelman's syndrome or familial hypokalemia-hypomagnesemia and Bartter syndrome share some common features but their prognosis is quite different. CASE REPORT: Four unrelated children, aged 5 to 12 years, were studied because they suffered from muscle cramps and/or abdominal pain. Supportive findings included: hypokalemia (2.1 to 2.9 mmol/l), metabolic alkalosis (31 to 34 mmol/l), hyperkaliuresis (5.8 to 7.1 mmol/kg/day), hypomagnesemia (0.58 to 0.64 mmol/l), hypermagnesuria (0.19 to 0.23 mmol/kg/day), hypocalciuria (0.012 to 0.021 mmol/kg/day). Blood pressure contrasting with high renin activity (19.04 to 20.03 ng/ml/hr) was normal. Chloride fractional excretion after oral water supplementation was only slighty decreased and hypercalciuric response to furosemide administration was not observed. Supplementation with magnesium chloride failed to correct hypomagnesemia while potassium chloride improved hypokalemia. CONCLUSIONS: Age of onset, tetany manifestations, absence of growth retardation, hypermagnesuria despite, hypomagnesemia, hypocalciuria not improved by furosemide favor the diagnosis of Gitelman's syndrome rather than that of Bartter syndrome initially considered.

[Role of peritoneal dialysis for the treatment od terminal renal insufficiency in the child]. / Place de la dialyse péritonéale pour le traitement de l'insuffisance rénale terminale chez l'enfant.

Peritoneal dialysis (PD) is the most common used method of treatment for end stage renal failure, specially adapted for home dialysis, easily applicable even for infants. PD creates a degree of independence but also of responsibility. PD failed out with time (transfered to hemodialysis) secondary to familial and medical (peritonitis) exhaustions. Anyway PD has become in children under 15 years old, the more used dialysis modality in many countries (Canada, USA, Australia, England, Italy, Germany, Holland, ...) but remained rarely performed in France (economical, political, social or medical environment reasons). Reduction of waiting time for transplantation should favor the development of PD. Home treatment by PD is without doubt the best dialysis condition in terms of optimal children development but is really a familial charge.

[Urinary infections in children]. / Infections urinaires chez l'enfant.

Urinary tract infection is frequent in childhood, usually without major consequences. Its diagnosis is often overestimated and needs precise bacteriological and cytological tests; systematic exploration of the urinary tract must be proposed if these tests are positive. The clinical presentation and the incidence of uropathies is strongly related to age. The therapeutic protocol will depend on germ, age, symptoms and results of morphological examinations.

A Weaver-like syndrome with endocrinological abnormalities in a boy and his mother.

A boy and his mother had dysmorphic features and accelerated growth of prenatal onset suggestive of the Weaver syndrome. Both had endocrinologic abnormalities. The boy had very low, hGH, which did not respond to stimulation. The mother had low, non-stimulate hGH hyperprolactinemia with secondary amenorrhea and galactorrhea. This is the first report of a mother to son transmission of the condition.

Urinary tract infections with tissue penetration in children: cefotaxime compared with amoxycillin/clavulanate.

In children, the site of urinary tract infection (acute pyelonephritis or cystitis) cannot usually be accurately determined from the clinical presentation. The severity of the urinary tract infection (risk of renal scars) is best correlated with its estimated degree of tissue penetration clinically (fever, general condition) and on laboratory tests (sedimentation rate, C-reactive protein). The duration of parenteral antibiotic therapy, especially in children (taking account of difficult venous access and the cost of hospitalization) needs to be specified beyond the initial period required for sterilization of the urine (usually less than 48 h). We conducted a study in children older than one year to compare the efficacy and tolerance of two treatment regimens for urinary tract infection with tissue penetration: cefotaxime 100 mg/kg/d in four divided iv doses for 14 days (group I) and amoxycillin/clavulanate 100 mg/kg/d in four divided iv doses for seven days with conversion to the oral route at a dosage of 50 mg/kg/d for seven days (group II). The randomised protocol included ten patients in each group, comparable with respect to sex, age and history. Clinical efficacy (time until the patient became afebrile), bacteriological efficacy (sterilization of the urine), and biological efficacy (time to normalization of the indices of the acute inflammatory response) were identical for both groups regardless of the duration of iv antibiotic treatment (seven days for amoxycillin/clavulanate; 14 days for cefotaxime). The only side effect was diarrhoea, which affected three patients and did not require modification of the oral treatment regimen.(ABSTRACT TRUNCATED AT 250 WORDS)

[Double profile dialysis: ultrafiltration and sodium variable description and clinical validation in the child]. / Dialyse à double profil: ultrafiltration et sodium variables description et validation clinique chez l'enfant.

Despite significant technical improvements (bicarbonate dialysate, volumetric ultrafiltration control) high intradialytic ultrafiltration is troublesome in children, specially in the proportion of patients presenting a normal or low blood pressure even with overweight. We used, in this group of children (overhydratated without vascular repercution) a modelling of both sodium and ultrafiltration during dialysis, in order to achieve dry body weight without increasing session time despite hypotension risks. The usefulness and practicability of sodium and ultrafiltration modelling together during dialysis in children is analysed in a short time study (for plasma volume changes calculation) and in a long term follow up study over a year (for clinical tolerance). Today, we reserve this form of dialysis only for a single session needed by overhydratation (more than 5% of dry body weight) in order to achieve dry body weight maintaining dialysis session time constant without increasing side effects (hypotension).