Growth in very young children undergoing chronic peritoneal dialysis.

Very young children with chronic kidney disease often have difficulty maintaining adequate nutrition, which contributes to the high prevalence of short stature in this population. Characteristics of the dialysis prescription and supplemental feeding via a nasogastric (NG) tube or gastrostomy may improve growth, but this is not well understood. Here, we analyzed data from 153 children in 18 countries who commenced chronic peritoneal dialysis at <24 months of age. From diagnosis to last observation, 57 patients were fed on demand, 54 by NG tube, and 10 by gastrostomy; 26 switched from NG to gastrostomy; and 6 returned from NG to demand feeding. North American and European centers accounted for nearly all feeding by gastrostomy. Standardized body mass index (BMI) uniformly decreased during periods of demand feeding and increased during NG and gastrostomy feeding. Changes in BMI demonstrated significant regional variation: 26% of North American children were obese and 50% of Turkish children were malnourished at last observation (P < 0.005). Body length decreased sharply during the first 6 to 12 months of life and then tended to stabilize. Time fed by gastrostomy significantly associated with higher lengths over time (P < 0.001), but adjustment for baseline length attenuated this effect. In addition, the use of biocompatible peritoneal dialysate and administration of growth hormone independently associated with improved length, even after adjusting for regional factors. In summary, growth and nutritional status vary regionally in very young children treated with chronic peritoneal dialysis. The use of gastrostomy feeding, biocompatible dialysis fluid, and growth hormone therapy associate with improved linear growth.

The bone and mineral disorder of children undergoing chronic peritoneal dialysis.

The mineral and bone disorder of chronic kidney disease remains a challenging complication in pediatric end-stage renal disease. Here, we assessed symptoms, risk factors and management of this disorder in 890 children and adolescents from 24 countries reported to the International Pediatric Peritoneal Dialysis Network Registry. Signs of this disease were most common in North American patients. The prevalence of hyperphosphatemia increased with age from 6% in young infants to 81% in adolescents. Serum parathyroid hormone (PTH) was outside the guideline targets in the majority of patients and associated with low calcium, high phosphorus, acidosis, dialysis vintage and female gender. Serum calcium was associated with dialytic calcium exposure, serum phosphorus with low residual renal function and pubertal status. PTH levels were highest in Latin America and lowest in Europe. Vitamin D and its active analogs were most frequently administered in Europe; calcium-free phosphate binders and cinacalcet in North America. Clinical and radiological symptoms markedly increased when PTH exceeded 300 pg/ml, the risk of hypercalcemia increased with levels below 100 pg/ml, and time-averaged PTH concentrations above 500 pg/ml were associated with impaired longitudinal growth. Hence, the symptoms and management of the mineral and bone disorder of chronic kidney disease in children on peritoneal dialysis showed substantial regional variation. Our findings support a PTH target range of 100-300 pg/ml in the pediatric age group.

Dialytic phosphate removal: a modifiable measure of dialysis efficacy in automated peritoneal dialysis.

BACKGROUND: Although hyperphosphatemia is one of the few established risk factors for cardiovascular mortality in patients on dialysis, the relationship between peritoneal dialysis (PD) prescription and dialytic phosphate removal is largely unexplored. METHODS AND PATIENTS: We analyzed 24-hour clearances (n = 60) together with peritoneal equilibration tests (PETs) (n = 52) performed in children and adolescents (n = 35) on automated PD. RESULTS: Dialytic phosphate clearance was more closely correlated with 2-hour and 4-hour dialysate-to-plasma ratio (D/P) of phosphate in the PETs (r = 0.44 and r = 0.52, both p < 0.0001) than with 2-hour and 4-hour D/P creatinine (r = 0.26 and r = 0.27, both p < 0.05). Dialytic 24-hour phosphate clearance was independently predicted by total fluid turnover (partial R(2) = 0.48, p < 0.001), the number of cycles (r = 0.52, p < 0.001), 2-hour D/P phosphate (partial R(2) = 0.07, p = 0.001), dwell time (partial R(2) = 0.05, p = 0.01), and achieved ultrafiltration (partial R(2) = 0.05, p = 0.005). 4-hour D/P phosphate and 24-hour phosphate clearance were significantly lower in hyperphosphatemic children (3.38 +/- 1.17 vs 4.56 +/- 1.99 L/1.73 m(2)/day, p < 0.05), whereas creatinine equilibration and clearance rates were not distinctive. CONCLUSION: Dialytic phosphate removal is an important modifiable determinant of phosphate control in automated PD. It strongly depends on total dialysate turnover and the prescribed number of cycles and is more adequately predicted by phosphate than by creatinine equilibration characteristics. Due to the deleterious effects of hyperphosphatemia, dialytic phosphate removal should be monitored routinely.

[Pre-emptive renal transplantation in a boy with obstructive uropathy following reconstruction procedures]. / Przeszczep nerki u pacjenta z zastawka cewki tylnej (ZCT) po zabiegach plastyki pecherza moczowego.

Patients with bladder dysfunction comprise over 30% of pediatric patients on renal replacement therapy. We report on a successful cadaveric pre-emptive renal transplantation performed in a boy born with posterior urethral valve. Following bilateral ureterocutaneostomies, left nephrectomy and valve resection, at 6 years of age a continent ileocolonocystoplasty was performed. The boy started intermittent daytime catheterization, passing urine both via urethra and fistula. At the age of 18 he received a renal transplant. Continuing the previous regime, at 1.5 years follow up his graft is well functioning (GFR >75 ml/min/1.73 m2) with sporadic episodes of urinary tract infection.

[Peritoneal transport properties for glucose and creatinine in Polish children and adolescents on chronic peritoneal dialysis]. / Ocena przepuszczalnosci otrzewnej dla kreatyniny i glukozy w polskiej populacji dzieci i mlodziezy dializowanych otrzewnowo.

INTRODUCTION: The mode of PD treatment is dependent on the individual transport properties of the peritoneal membrane. Two multicentre trials performed in the U.S. (PPDSC) and Europe (MEPPS) have established reference curves for solute equilibration in children performed with the use of 1100 ml/m2 fill volume in the former and 1000 ml/m2 in the latter study. AIM OF THE STUDY: Assessment of basal peritoneal membrane equilibration based on PET tests in polish children and adolescents treated with chronic peritoneal dialysis. MATERIAL AND METHODS: 58 PET tests from patients treated at 8 Polish PD centres were analysed. The mean time of performing PET test was 6,5 months after the start of PD therapy. All of the patients had been peritonitis free from onset. The mean fill volume was 1021 (906-1170) ml/m2. RESULTS: Based on the results of creatinine and glucose equilibration we established basal peritoneal solute transport curves for polish PD children using an average fill volume of 1020 ml/m2. The following values were obtained at 4hrs of dwell time for 2.27% glucose solution: D/P for creatinine = 0.68 +/- 0.15 and D/Do for glucose = 0.39 +/- 0.12. CONCLUSIONS: The DIP creatinine equilibration curves were similar to the previously published reference curves for children, whereas those for glucose was significantly lower. Using a fill volume scaled to body surface area of 1020 ml/m2 equilibration curves for glucose and creatinine are similar in children over 1 year of age and adults.

[Left ventricular hypertrophy in paediatric predialysis children and treatment--induced regression of left ventricular mass]. / Przerost lewej komory serca u dzieci z przewlekla niewydolnoscia nerek w okresie przeddializacyjnym oraz wplyw leczenia hipotensyjnego na regresje zmian sercowych.

UNLABELLED: Cardiovascular disease remains the leading cause of morbidity and mortality in the chronic renal failure adult population. Recently it has been shown that also paediatric CRF patients are at high risk of cardiovascular complications. Recent research programs are looking into the initial stages of chronic renal insufficiency to assess the early predictors of cardiac or cardiovascular disease. In the present study we analyzed the prevalence of left ventricular hypertrophy (LVH) in predialysis paediatric population and the potential value of efficient antihypertensive treatment on regression of left ventricular mass. Forty-nine chronic renal failure patients, aged 2-19 years, had two echocardiographic evaluations: at the time of establishing CRF diagnosis and after 30 months of antihypertensive treatment. In this study LVH was defined as left ventricular mass index (LVMI) greater than 51 g/m2.7. At the baseline assessment LVH was found in 18 out of 49 children (63.2%). In the second echocardiographic study LVH was present in 7 (14.2%) children. CONCLUSIONS: 1. Left ventricular hypertrophy is common in young CRF patients. 2. The reduction of left ventricular mass is possible, and may be determined by the effectiveness of antihypertensive treatment.

Cardiac geometry in children receiving chronic peritoneal dialysis: findings from the International Pediatric Peritoneal Dialysis Network (IPPN) registry.

BACKGROUND AND OBJECTIVES: Left ventricular hypertrophy (LVH) is an independent risk factor and an intermediate end point of dialysis-associated cardiovascular comorbidity. We utilized a global pediatric registry to assess the prevalence, incidence, and predictors of LVH as well as its evolution in the longitudinal follow-up in dialyzed children. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Cross-sectional echocardiographic, clinical, and biochemical data were evaluated in 507 children on peritoneal dialysis (PD), and longitudinal data were evaluated in 128 patients. The 95(th) percentile of LV mass index relative to height age was used to define LVH. RESULTS: The overall LVH prevalence was 48.1%. In the prospective analysis, the incidence of LVH developing de novo in patients with normal baseline LV mass was 29%, and the incidence of regression from LVH to normal LV mass 40% per year on PD. Transformation to and regression from concentric LV geometry occurred in 36% and 28% of the patients, respectively. Hypertension, high body mass index, use of continuous ambulatory peritoneal dialysis, renal disease other than hypo/dysplasia, and hyperparathyroidism were identified as independent predictors of LVH. The use of renin-angiotensin system (RAS) antagonists and high total fluid output (sum of urine and ultrafiltration) were protective from concentric geometry. The risk of LVH at 1 year was increased by higher systolic BP standard deviation score and reduced in children with renal hypo/dysplasia. CONCLUSIONS: Using height-adjusted left ventricular mass index reference data, LVH is highly prevalent but less common than previously diagnosed in children on PD. Renal hypo/dysplasia is protective from LVH, likely because of lower BP and polyuria. Hypertension, fluid overload, and hyperparathyroidism are modifiable determinants of LVH.

Defining left ventricular hypertrophy in children on peritoneal dialysis.

BACKGROUND AND OBJECTIVES: Left ventricular hypertrophy (LVH) is an important end point of dialysis-associated cardiovascular disease. The objective of this study was to evaluate the effect of different pediatric reference systems on the estimated prevalence of LVH in children on chronic peritoneal dialysis (CPD). DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Echocardiographic studies in 507 pediatric CPD patients from neonatal age to 19 years were collected in 55 pediatric dialysis units around the globe. We compared the prevalence of LVH on the basis of the traditional cutoff of left ventricular mass (LVM) index (>38.5 g/m(2.7)) with three novel definitions of LVH that were recently established in healthy pediatric cohorts. RESULTS: Application of the new reference systems eliminated the apparently increased prevalence of LVH in young children obtained by the traditional fixed LVM index cutoff currently still recommended by consensus guidelines. However, substantial differences of LVM distribution between the new reference charts resulted in a marked discrepancy in estimated LVH prevalence ranging between 27.4% and 51.7%. CONCLUSIONS: Although our understanding of the anthropometric determinants of heart size during childhood is improving, more consistent normative echocardiographic data from large populations of healthy children are required for cardiovascular diagnostics and research.

Dialysate leakage into pericardium in an infant on long-term peritoneal dialysis.

We report on a 2-year-old boy on automated peritoneal dialysis (PD) with a history of multiple hernias and dialysate leaks who developed pericardial effusion. Magnetic resonance imaging (MRI) demonstrated a peritoneo-pericardial fistula. Dialysis had to be discontinued, since head-down tilt reproducibly induced significant hypotension. In PD patients with pericardial effusion a peritoneo-pericardial leak should be considered.