Effects of acute exercise on markers of inflammation in pediatric chronic kidney disease: a pilot study.

BACKGROUND: Children and adolescents with chronic kidney disease (CKD) are chronically exposed to high levels of inflammation, placing them at an increased risk of secondary health complications. Regular exercise may represent an effective therapy to reduce inflammation. The aims of this pilot study were to determine the effects of acute exercise on inflammation and immune cell counts in CKD. METHODS: Nine children and adolescents (4 males) with CKD stages III-V performed a graded exercise test to determine peak oxygen uptake (VO2peak). Following a 10-min break, participants cycled for 20 min at 50 % of VO2peak. Blood samples were collected before and after the exercise period for the determination of complete blood counts, natural killer cells (NK(bright), NK(dim)) and circulating progenitor cell (CPC) counts, as well as interleukin-6 (IL-6), and tumor necrosis factor-α (TNF-α) concentrations. RESULTS: Complete blood counts and NK(dim) cell and CPC counts were unchanged with exercise. Following exercise, NK(bright) cell counts increased (7.4 ± 4.3 vs. 12.2 ± 8.3 × 10(6) cells/L; p = 0.02), while trends were observed for an increase in IL-6 (2.1 ± 2.2 vs. 2.7 ± 2.6 pg/mL; p = 0.08), decrease in TNF-α (4.5 ± 1.2 vs. 4.2 ± 1.0 pg/mL; p = 0.08) and an increase in the IL-6:TNF-α ratio (0.6 ± 0.7 vs. 0.8 ± 0.8; p = 0.07). CONCLUSIONS: Our findings suggest that acute exercise may create an anti-inflammatory environment in children and adolescents with CKD stages III-V.

Severe Ethanol Poisoning Among United States College Fraternity Pledges.

Hazing is a longstanding tradition in university and college fraternities. This practice often uses alcohol as a penalty during hazing rituals, resulting in severe ethanol poisoning and even death among pledges. Typically, the serum ethanol levels in these poisoned students are extremely high. Preventing severe ethanol poisoning is crucial, and can be achieved through education about the harms of these hazing activities. Hemodialysis is an effective treatment for severe ethanol poisoning as it removes the excess alcohol in a timely manner.

A lack of living donor renal transplantation for Asian children represents an opportunity to improve pediatric healthcare.

INTRODUCTION: The relationship between pediatric primary care practitioners and families provides an early opportunity to address ethnic/racial pediatric subspecialty health care disparities. Living donor pediatric renal transplantation is safe and more effective than deceased donor renal transplantation. The purpose of this study is to identify groups of children who may be less likely to receive living donor renal transplantation, as the first step in assisting pediatric clinicians to increase living donor renal transplantation. METHOD: We employed a retrospective cohort design. We analyzed data from the medical records of 80 children receiving renal transplantation over 20 years in a large pediatric medical center. RESULTS: The proportions of children receiving a living donor renal allograft differed by ethnicity/race (P = .04). Specifically, children of Asian ethnicity/ race were significantly less likely than children of White ethnicity/race to receive a living donor renal allograft (P = .01). There were no significant differences in age at transplantation or wait time for deceased donor transplantation. DISCUSSION: We discuss the possible reasons for the discrepancy and potential directions for family-centered pediatric practice, policy, and research to address this potential pediatric healthcare disparity.

Association of IgG co-deposition with serum levels of galactose-deficient IgA1 in pediatric IgA nephropathy.

OBJECTIVE: To determine whether the absence of mesangial IgG deposits is associated with the absence of elevated blood levels of galactose-deficient IgA1 (Gd-IgA1) in pediatric patients with IgA nephropathy (IgAN). DESIGN AND METHODS: Serum Gd-IgA1 levels were determined by ELISA using an N-acetylgalactosamine-specific lectin from Helix aspersa. Levels of Gd-IgA1 above the 90th percentile for healthy pediatric controls were considered to be elevated. Renal biopsy samples were examined by immunofluorescence for presence and intensity of staining for IgA, IgG, IgM, C3 and C1q and by light microscopy for histological changes. Findings were graded by a single pathologist (L. Gaber) at UTHSC until 2007 and by NephropathTM (Little Rock, AR, USA) thereafter. Staining for the mesangial deposits was considered negative when intensity was trace or less, and positive at greater intensity. Fisher's exact test was used to determine significance of 2 × 2 tables. RESULTS: Serum samples were obtained from 30 patients with IgAN diagnosed before age 18 years. Male:female ratio was 2.3:1. Twenty were Caucasian and 10 were African-American. Blood was obtained within 3 months of biopsy (incident cases) for 12, while 18 provided blood > 3 months after biopsy (prevalent cases). Serum Gd-IgA1 level was elevated in 23 (77%) of cases and 20 (67%) had a biopsy positive for IgG. Of those 20 patients, 18 (90%) had an elevated serum Gd-IgA1 level, whereas 5 (50%) of patients with biopsies without IgG had a normal serum Gd-IgA1 level (p = 0.026). SUMMARY: In this small study we found a weak association between the absence of IgG in the biopsy and normal serum Gd-IgA1 level.

The dangers of substance abuse in adolescents with chronic kidney disease: a review of the literature.

Although there exist no specific data on the prevalence of substance abuse among children and adolescents with chronic kidney diseases (CKD), the magnitude of this problem should not be underestimated, as almost half of twelfth-graders in the U.S. admit to a history of using illegal drugs at least once when asked (National Institute on Drug Abuse, 2011). According to the 2010 Canadian Alcohol and Drug Use Monitoring Survey (Health Canada, n.d.), the prevalence of drug abuse among Canadian youths and young adults aged 15 to 24 remains higher than in adults older than 25 years of age, and the rates of drug use (excluding cannabis) in the past years were 7.9% and 0.8%, respectively, illustrating an almost 10 times higher rate in the younger age group (Health Canada, n.d.). Drug abuse can lead to numerous medical problems, including renal injury, and it is clearly a major public health concern, especially in patients with subnormal kidney function (Vupputuri et al., 2004). As most of the children and adolescents that suffer from CKD have long-term and trustful relationships with the nephrology team, we have the obligation and are in an excellent position to address this particular health issue (Finkelstein & Finkelstein, 2000; Kimmel, 2002; Kimmel, Cohen, & Peterson, 2008). This review summarizes the available data on the nephrotoxic effects of various commonly abused drugs with special emphasis on the additional damage that occurs in patients with pre-existing CKD. These data were obtained from a thorough search of the available primary literature, specifically using the PubMed database. The purpose is to provide health professionals with a resource to properly educate their CKD patients on the dangers of these drugs.

[Management of children after renal transplantation: highlights for general pediatricians].

The number of children undergoing successful renal transplantations has been increasing steadily and as a result, general pediatricians are now more likely to encounter children with a kidney allograft in their practice. Although the medical care immediately after transplantation is mostly provided by transplant teams, more and more outpatient care will eventually be performed at the patient's local community. Medical care from general pediatricians is particularly important, especially for children who are residing far from transplant centers. As these children require prolong immunosuppressive therapies and are susceptible to various specific clinical problems, it is imperative for their primary care providers and pediatricians to be knowledgeable about their specific needs and be competent in providing care. This article highlights the roles and common practice related issues that pertain to general pediatricians in the care of pediatric renal allograft recipients.

Thrombotic thrombocytopenic purpura in pediatric patients.

Although thrombotic thrombocytopenic purpura (TTP) is rarely seen in pediatric patients, failure to recognize this condition often leads to severe consequences and poor outcomes. Classic features of TTP include thrombocytopenia, microangiopathic hemolytic anemia, acute kidney injury, fever, and central nervous system involvement. However, patients suffering from this condition may not present with all of the symptoms simultaneously. Therefore, it is of utmost importance for healthcare providers to have a high index of suspicion. Laboratory investigations may reveal the presence of schistocytes on peripheral blood smear, negative Coombs test, high lactate dehydrogenase levels and severely low platelet counts. The etiology of TTP is mainly due to insufficient cleavage of the large multimers of von Willebrand factor (vWF) secondary to decreased activity of ADAMTS13 (a disintegrin and metalloprotease with Thrombospondin type 1 repeats, member 13). TTP can be broadly classified into familial TTP (Upshaw Schulman syndrome) and non-familial TTP. Familial TTP is due to a congenital deficiency of ADAMTS13. Its mainstay of therapy is initiation of plasmapheresis during the acute phase, followed by regular fresh frozen plasma (FFP) infusions. Alternatively, non-familial TTP is due to a decrease in ADAMTS13 activity secondary to the presence of anti-ADAMTS13 antibodies. Once again, the primary treatment is plasmapheresis; however, recent anecdotal data also supports the use of rituximab in select cases.

Pediatric en bloc kidney transplantation into pediatric recipients.

As a result of the ongoing shortage in organ supply, en bloc renal transplantation from small donors has become more common for adult recipients with ESRD. However, because of concern for higher complication rates and sub-optimal outcomes, it is not being performed in every center, and data describing its use in pediatric recipients are even more limited. We retrospectively studied three patients who have undergone en bloc renal transplantation at our center. Median age at transplantation was 16.7 yr with a median follow-up of 1.2 yr. Donor age ranged from nine to 49 months with weight ranging from 10 to 22 kg. There were no post-operative thrombotic complications. All grafts showed increased renal size at follow-up by ultrasound. There was no clinical or histological rejection at last follow-up. To the best of our knowledge, this is the first report on the outcomes of en bloc kidney transplantation from pediatric donors into pediatric recipients. Based on our experience, albeit very limited, we feel that en bloc renal transplantation from young donors is an acceptable and safe procedure with low complication rates in pediatric recipients and should be given consideration to minimize wait times on the wait list and to improve quality of life.

Extended experience with a steroid minimization immunosuppression protocol in pediatric renal transplant recipients.

PURPOSE: To determine the safety and efficacy of a novel steroid minimization protocol after renal transplantation at a single Northern California center. INTRODUCTION: We have previously reported our experience on the short-term outcomes in eight children using our steroid minimization protocol. Herein, we present our ongoing experience in using this regimen in 20 children. METHODS: Children receiving immunosuppression with a steroid minimization protocol at our center from 1/04-12/08 (Group 2) were retrospectively compared with 20 controls (Group 1). RESULTS: At one-month follow-up, Group 2 was observed to have lower eGFR, hemoglobin, white cell count, and cholesterol. The incidence of adverse events during the first yr was comparable. Three patients in Group 1 displayed histological evidence of acute rejection, one patient in Group 2 developed humoral rejection; another patient in Group 2 had sub-clinical rejection. Surgical complications were observed in 20% of patients in both groups. While 10% of patients in Group 1 developed diabetes mellitus, none was observed in Group 2. Thirty and 40% of patients in Groups 1 and 2, respectively, suffered from infectious complications during the first yr. CONCLUSIONS: Our novel steroid minimization immunosuppression is safe in children and associated with no increased risk of rejection and infection.

Pathogenesis of Henoch-Schönlein purpura nephritis.

The severity of renal involvement is the major factor determining the long-term outcome of children with Henoch-Schönlein purpura (HSP) nephritis (HSPN). Approximately 40% children with HSP develop nephritis, usually within 4 to 6 weeks after the initial onset of the typical purpuric rashes. Although the pathogenetic mechanisms are still not fully delineated, several studies suggest that galactose-deficient IgA1 (Gd-IgA1) is recognized by anti-glycan antibodies, leading to the formation of the circulating immune complexes and their mesangial deposition that induce renal injury in HSPN.

Financial implications of pediatric outpatient renal biopsies: a single-center experience.

BACKGROUND: With improvements in technology, renal biopsies have become safer and could potentially be effectively carried out in the outpatient setting. The purpose of our study is to compare the safety and cost of performing outpatient versus inpatient renal biopsies at a single Northern California pediatric hospital. METHODS: We retrospectively studied the records of patients who underwent renal biopsy at our hospital during the period June 2001 to June 2006. Patients who were admitted to the hospital were compared with those who underwent biopsy as outpatients and were observed postprocedure for 4 hours for complications. RESULTS: 54 patients underwent 60 biopsies as inpatients and 58 patients underwent 78 biopsies as outpatients. Two inpatients required intervention for bleeding. One patient in the outpatient group was readmitted for persistent gross hematuria that subsided without intervention, and another patient had an inadequate sample obtained. Considering physician, nursing and ancillary hospital charges for the inpatient stay, the difference in cost was US $4,133 per procedure. CONCLUSIONS: Our study suggests that discharging patients after a 4-hour monitoring period is a safe practice in a select group of patients. This practice has profound financial advantages by reducing health care costs and potentially improves patient satisfaction.

Control of aquaporin 2 expression in collecting ducts of quail kidneys.

Birds and mammals are the only vertebrates that can concentrate urine. Avian kidneys contain structurally primitive loopless nephrons and also more advanced looped nephrons, in the cortical and medullary regions, respectively. We have identified the gene sequence of an aquaporin 2 (AQP2)-homologue water channel in collecting ducts of kidneys from adult quail, Coturnix japonica. Although immunoreactive quail AQP2 (qAQP2) was found in both types of nephrons, the expression is enhanced more clearly in the medullary regions after water deprivation. We therefore hypothesized that regulation of qAQP2 expression in quail kidneys via antidiuretic hormone (ADH) may require more advanced nephron structure. In this study, we determined the expression of qAQP2 mRNA in tissues isolated from the cortical and medullary regions before and after water deprivation, by conventional reverse transcriptase-polymerase chain reaction (RT-PCR) and quantitative real-time PCR. In both normally hydrated and water-deprived groups, qAQP2 mRNA levels in the medullary regions were significantly higher (P<0.01) than in the cortical regions. In medullary areas, qAQP2 mRNA levels (real-time PCR normalized with 18S) were significantly higher (P<0.01, ANOVA) after water deprivation (1.09+/-0.10) than in normally hydrated controls (0.46+/-0.08). In cortical areas, qAQP2 mRNA levels were also higher after water deprivation (0.37+/-0.05) than in controls (0.11+/-0.02). qAQP2 mRNA signals determined by in situ hybridization of digoxigenin-labeled riboprobe were also enhanced after water deprivation in both cortical and medullary collecting ducts. The results suggest that, contrary to our hypothesis, the endogenous production of ADH by water deprivation stimulates qAQP2 mRNA in both loopless and looped nephrons.

Induction therapy for pediatric focal proliferative lupus nephritis: cyclophosphamide versus mycophenolate mofetil.

PURPOSE OF THE STUDY: Although cyclophosphamide has been used with success in children, mycophenolate may be a better alternative with less toxicity. The objective of this study is to determine the efficacy of mycophenolate compared with cyclophosphamide as induction therapy in children with class III lupus nephritis. METHODS: We retrospectively studied pediatric patients with class III lupus nephritis from two pediatric centers from January 1991 to December 2005 who were treated either with monthly cyclophosphamide or mycophenolate mofetil for the first 6 months. Thirteen patients were studied, with seven patients in the cyclophosphamide group and six patients in the mycophenolate group. RESULTS: At 6 months, in the cyclophosphamide group, no patient had achieved complete remission, while 57% were in partial remission. In the mycophenolate group, 66% had achieved complete remission, 17% were in partial remission, and 17% were not in remission. DISCUSSION: In a small group of children with class III lupus nephritis, we observed a trend of more patients in the mycophenolate group achieving remission at 6 months. However, the long-term benefit of using mycophenolate as an induction agent is still unclear.

Use of a "composite" vascular access graft in a young child on hemodialysis.

Although arterio-venous fistulae (AVF) are currently considered to be the first choice of permanent vascular access for hemodialysis, there are some patients who are not candidates for fistulae and synthetic grafts provide other options. The Thoratec (Vectra) polyurethane vascular access graft is a new prosthetic graft that may be cannulated within days of insertion due to "self-sealing" properties. However, a tendency for kinking at the suture site due to the strong elasticity of this graft, leading to undesirable complications such as thrombosis, have been reported. We describe a surgical modification of the anastomosis by interposing a segment of expanded polytetrafluoroethylene graft (ePTFE, Venaflo) between the native vessels and the polyurethane graft sections in a pediatric patient. This modification may overcome the kinking complication associated with use of the polyurethane graft and the resulting thrombosis.

Mitochondrial encephalopathy with lactic acidosis and stroke-like episodes syndrome with hypothyroidism and focal segmental glomerulosclerosis in a paediatric patient.

Herein, we report on a paediatric patient with mitochondrial encephalopathy, lactic acidosis and stroke-like episodes (MELAS) who was hospitalized for acute on chronic renal insufficiency, seizures and deterioration of the level of consciousness. She also had hypertension, hypothyroidism and nephrotic range proteinuria. Kidney biopsy revealed many sclerotic glomeruli and focal segmental glomerulosclerosis (FSGS). Glomerulopathy is rare in patients with MELAS, and FSGS has been reported only in a few patients. The histopathological features of the renal biopsy suggested that the aetiology of the FSGS may have been secondary to chronic renal injury rather than from a primary immunologic cause. Moreover, our case is unique in that, the coexistence of MELAS, hypothalamic hypothyroidism and FSGS has not been reported in the past. The purpose of this report is to increase the awareness of health-care professionals, especially in the fields of paediatrics, neurology, endocrinology and nephrology, regarding the manifestations and complications of MELAS.

Glomerulonephritis.

GN in the adolescent requires prompt diagnosis. When even mild degrees of renal insufficiency are documented, immediate referral to a nephrologist is necessary to ensure that serious conditions, such as RPGN, are correctly diagnosed and aggressively managed. In an adolescent with macroscopic hematuria, the demonstration of dysmorphic RBCs, RBC casts, and proteinuria indicates that the bleeding is of glomerular origin. Physicians caring for adolescents with chronic GN should have a basic understanding of the specific disorders. They may be involved in blood pressure monitoring and should be aware of the potential side effects of the antihypertensive and immunosuppressive medications used in patients with GN.

Chest wall abscesses due to continuous application of silicone gel sheets for keloid management.

A patient with three episodes of chest wall abscesses as a result of 6 years of round-the-clock, uninterrupted (except during bathing) application of silicone gel sheets to a chest wall keloid is described. Two of the episodes occurred during hot weather. It is suggested that, in the space beneath the silicone sheet, the higher humidity and temperature, both generated as a result of prolonged sheeting, especially during hot weather, might have caused the keloid and its neighbouring skin to become soggy. This sogginess might have facilitated bacterial invasion. It is suggested that some sheeting-free time during a 24 h period might be indicated so that a keloid and its adjacent skin have the time to recover from their sheeting-induced sogginess. A sheeting-free period might especially be needed in the face of sweat accumulation beneath the silicone sheet.