Are we late for the diagnosis of acute kidney injury in the intensive care units in pediatric patients? A preliminary, retrospective observational study among 66 patients.

BACKGROUND: The purposes of this study were to emphasize the importance of Risk, Injury, Failure, Loss, and End-Stage (RIFLE) classification in early diagnose and prognosis of acute kidney injury (AKI), and to evaluate the practicability of the RIFLE criteria in intensive care units. METHODS: Sixty-six patients applied acute peritoneal dialysis were included into the study. Patients having acute peritoneal dialysis within the first 24 hours of intensive care unit admission were named group 1, between 24-48 hours group 2, and those who had acute peritoneal dialysis 48 hours or more after admission to the intensive care unit were named group 3. Retrospectively, we evaluated patients by RIFLE criteria at the consultation time, and patients who had been just in AKI were called late referral patients. The mean interval time between the onset of AKI and the consultation time was defined as delay time in late referral patients. RESULTS: There were 20 patients in group 1, 15 were in group 2 and 31 in group 3. In total there were 18/66 patients in risk, 13/66 in injury while 35/66 in failure. There was statistically difference between delay times of in risk and failure class in group 3 (P<0.05). Also delayed patient numbers of both risk and failure class were found statistically highly significant (P<0.001). CONCLUSIONS: Most of the patients were in failure class at the time of consultation. We guess that if they would have been diagnosed earlier, prognosis might have been better. Therefore early diagnosis of AKI with RIFLE criteria and early initiation of acute peritoneal dialysis would probably improve prognosis.

Impact of peritoneal transport characteristics on cardiac function in paediatric peritoneal dialysis patients: a Turkish Pediatric Peritoneal Dialysis Study Group (TUPEPD) report.

BACKGROUND: The peritoneal equilibration test (PET) is recommended in paediatric peritoneal dialysis (PD) patients to assist prescription management. Despite contradictory reports, high transporter status is associated with reduced survival rate in adults. Since cardiac disease is one of the main causes of mortality in paediatric PD patients, we aimed to evaluate whether transport features have any effect on biochemical data and cardiac function in this group. METHODS: One hundred and ten PD patients (13 +/- 5 years, PD vintage: 31 +/- 27 months) were enrolled into the study. Four-hour dialysate/plasma creatinine ratio was used for differentiating PET groups. Thirty-eight patients were high transporters, 29 were high-average transporters and 43 were low-average/low transporters. Echocardiography was performed in all subjects. RESULTS: Age, PD vintage, dialysate glucose concentration, ultrafiltration volume, urine volume and blood pressure levels were similar in all PET groups. No biochemical or echocardiographic data (ejection fraction, fractional shortening, left ventricular mass index, myocardial performance index, power Doppler E/tissue Doppler E ratio reflecting diastolic function) were different among PET groups except lower albumin (P = 0.025) levels in high transporters and higher high-sensitivity C-reactive protein (P = 0.026) levels in high and high-average transporters compared to other transport groups. CONCLUSIONS: Cardiac structural and functional abnormalities are highly prevalent among paediatric PD patients. Transport rates did not have a significant effect on biochemical parameters or cardiac structural/functional parameters. It might be suggested that being a high transporter does not provide a disadvantage in terms of atherogenic tendency and cardiac disease in paediatric PD patients. Oligoanuria, anaemia and hypertension were independent predictors of cardiac disease.

Does endoluminal brushing eliminate the need for catheter removal in peritoneal dialysis patients with persistent peritonitis?

Recurrent and persistent peritonitis episodes are exhausting problems in children on chronic peritoneal dialysis (PD) and can lead to discontinuation of treatment. In the present report, we describe our clinical experience with endoluminal brushing (EB) in 3 pediatric patients with refractory peritonitis episodes maintained on chronic PD. The EB was performed on 4 occasions in 3 patients. Peritonitis resolved in 2 of the patients. The remaining patient required removal of the PD catheter. No adverse events have since been observed. Endoluminal brushing should be considered an option for the management of persistent peritonitis before catheter removal.

Postnatal assessment of growth, nutrition, and urinary tract infections of infants with antenatally detected hydronephrosis.

The widespread utilization of prenatal ultrasonography and the detection of antenatal hydronephrosis (AH) have raised the importance of postnatal follow-up of these infants. In this study, we aimed to determine the importance of an early diagnosis for the treatment of urinary tract malformations (UTM) as well as the postnatal evaluation of growth and nutrition status and the frequency of urinary tract infection (UTI) in infants with AH. We evaluated 246 infants (183 boys, 63 girls) whose routine antenatal scans showed an anterior-posterior pelvic diameter (APPD) ≥5 mm. Of the 246 patients, 175 (71.1%) were found to be pathological and 71 were evaluated as normal after the follow-up period. The median follow-up periods of normal and abnormal cases were 45.7 and 43.4 months, respectively. All cases with or without UTM were evaluated in terms of UTI, scars on DMSA, growth [Height Z score (HZ), Weight Z score (WZ)] and nutrition [Weight height index (WHI)] status. The annual UTI frequency was higher in cases with UTM (1.32 ± 1.66 episode/year) than in cases without abnormality (0.27 ± 0.67 episode/year) (P < 0.001). The postnatal evaluation of growth and nutritional status in children with UTM (mean WHI, HZ, and WZ scores: 96.82 ± 10.21, 0.03 ± 0.54 and 0.04 ± 0.61, respectively) was found to be significantly worse than in cases without abnormality (102.25 ± 9.84, 0.14 ± 0.64 and 0.24 ± 0.76, respectively), (P < 0.05). In abnormal patients, the mean WHI, HZ, and WZ were significantly improved to 101.63 ± 9.75, 0.26 ± 1.07, and 0.28 ± 0.98, respectively, and HZ or WZ scores were found to be similar when compared to normals. In conclusion, postnatal early management of infants with AH seems to prevent frequent UTIs and nutritional disturbances enabling normal growth.

Percutaneous nephrostomy in children: diagnostic and therapeutic importance.

The aim of this study was to evaluate the effectiveness and safety of percutaneous nephrostomy (PN) in terms of diagnostic and therapeutic approach in children with urological problems. PN was performed on 39 kidneys in 28 patients (12 girls, 16 boys) aged 4.5 months to 13 years (average 5.38+/-3.41 years) during the period from January 1996 to December 2003. Underlying abnormalities were ureteropelvic junction obstruction (UPJO) in 14 patients (17 kidneys), ureterovesical junction obstruction (UVJO) in six patients (eight kidneys), supravesical obstruction due to tumour or hydatid cyst or ureteral stone in three patients (five kidneys), and severe vesicoureteral reflux (VUR) with/without neurogenic bladder associated with pyonephrotic kidneys in five patients (nine kidneys). The duration of catheter insertion was between 2 and 160 days (average 80+/-65.01 days). The complications were haematuria (six cases), infection (five cases) and displacement of catheter (four cases). Radical surgical management was performed in 25 patients (33 kidneys): pyeloplasty in eight cases (ten kidneys), UVJO correction in six cases (eight kidneys), nephrectomy in five cases (five kidneys), ureteroneocystostomy in four cases (seven kidneys), hydatid cyst operation in one case (two kidneys) and stone extraction in one case (one kidney). PN is an easy, safe and efficient diagnostic and therapeutic procedure with few complications in childhood.

Postnatal management of infants with antenatally detected hydronephrosis.

With the increasing use of antenatal sonography, fetal hydronephrosis has been reported more frequently. Because of the lack of consensus regarding treatment of these infants, the postnatal approach toward fetal renal pelvis enlargement remains controversial. The aim of this prospective study is to demonstrate the postnatal investigation, treatment, and outcome of infants with prenatally diagnosed hydronephrosis. Infants whose antenatal ultrasound scan showed a fetal renal pelvis of 5 mm or greater were investigated postnatally using ultrasound (US) and voiding cystourethrography. When indicated, isotope studies and intravenous urograms were also performed. We followed prospectively neonates with antenatally diagnosed hydronephrosis and recommended management guidelines on the basis of our findings. In 156 neonates (193 kidney units) that were found to have hydronephrosis, the average gestational age at which the diagnosis was made was 32.94+/-5.10 weeks. The mean duration of postnatal follow-up was 26.3+/-13.56 months (range 3-60 months). The mean APPD of the fetal renal pelvis was 10.35+/-3.24 mm (5-9 mm in 84 kidneys, 10-14 mm in 96 kidneys and > or =15 mm in 13 kidneys). Of the 193 kidney units, 145 units were found to be pathological. The most common detected underlying abnormalities were ureteropelvic junction obstruction (in 91 kidneys; 62.7%) and vesicoureteral reflux (in 24 kidneys; 16.6%). Postnatally, 23 (45%) of 51 patients whose first US was normal were diagnosed postnatally as having urinary tract abnormality. There was a negative correlation between APPD and the rate of spontaneous resolution and positive correlation between APPD and the rate of surgery (P<0.01). In conclusion, because it is not possible to determine an upper limit of normal for the antenatal renal pelvis, any baby with AH should not be considered clinically insignificant. Infants with antenatal renal pelvis measurements > or =5 mm should be investigated postnatally. A normal postnatal ultrasound scan does not preclude the presence of urinary tract abnormality.

Chronic peritoneal dialysis in Turkish children: a multicenter study.

Chronic peritoneal dialysis (CPD) has been utilized in the treatment of children since 1989 in Turkey. The aims of this study were to summarize our experience with CPD in children and to establish a pediatric registry data system in Turkey. Standard questionnaires were sent to all pediatric CPD centers. 514 patients treated between 1989 and 2002 in 12 pediatric centers were enrolled in the study. Reflux nephropathy was the most common (18.1%) cause of renal failure. Mean age at dialysis initiation was 10.1+/-4.6 years. Mean duration of dialysis was 24.1+/-20.5 months. Continuous ambulatory peritoneal dialysis (CAPD) was the first CPD modality for 476 (92.6%) patients, 142 of whom switched to automated peritoneal dialysis (APD) during follow-up. Currently, 47.3% of the patients are still on CPD, 15.4% were transplanted, 13.2% switched to hemodialysis, 16.7% died. The patient and technique survivals were 90% and 95% at one year and 70% and 69% at five years, respectively. The survival was significantly shorter in the youngest age group (0-24 months) compared to those in older age groups (p=0.000). We herein report the first results of the TUPEPD study providing information on demographic data and survival of pediatric CPD patients. As opposed to clear recommendations in favor of APD, there is a clear preponderance of CAPD in our pediatric CPD population. That vesicoureteral reflux (VUR) is still the leading cause of renal failure is a distressing finding. Remarkably lower survival rates and transplantation ratios are as striking and distressing as the high incidence of VUR among the causes of ESRD. We conclude that we must make a great effort to achieve better results and to change these undesirable events.