Furosemide and albumin for the treatment of nephrotic edema: a systematic review.

BACKGROUND: Edema is one of the cardinal clinical features of nephrotic syndrome (NS). It may vary from mild periorbital edema to severe generalized edema (anasarca). In patients where edema does not improve with prednisone therapy, the most common supportive medications are diuretics and albumin. However, due to the complex pathophysiology of edema formation in NS patients resulting in intravascular normovolemia or hypovolemia, optimal therapy for edema is still debated. We conducted a systematic review with the objective of evaluating the change in urine volume and urine sodium excretion after treatment with furosemide only versus furosemide with albumin in edematous patients with NS. OBJECTIVES: (1) To evaluate efficacy of furosemide alone versus furosemide with albumin in the treatment of nephrotic edema in adults and children. (2) To compare the harms and benefits of different doses of furosemide for treating nephrotic edema. SEARCH METHODS: The search included all randomized or quasi-randomized controlled trials in English and French using MEDLINE, Embase, and CENTRAL Trials Registry of the Cochrane Collaboration using the Ovid interface. CLINICALTRIALS: gov and the International Clinical Trials Registry Platform were also searched. SELECTION CRITERIA: We included all RCTs and randomized cross-over studies in which furosemide and furosemide plus albumin are used in the treatment of children or adults with nephrotic edema. We excluded patients with hypoalbuminemia of non-renal origin and severe chronic kidney disease (CKD) with a glomerular filtration rate below 30 ml/min/1.74 m2 and patients with congenital NS. DATA COLLECTION AND ANALYSIS: All abstracts were independently assessed by at least two authors to determine which studies met the inclusion criteria. Information on study design, methodology, and outcome data (urine volume, urine sodium excretion, adverse effects) from each identified study was entered into a separate data sheet. The differences in outcomes between the types of therapy were expressed as standardized mean difference (SMD) with 95% confidence intervals (CI). RESULTS: The search yielded 525 records, and after screening, five studies were included in the systematic review and four of those studies in the meta-analysis. One study had high risk of bias and the remaining three studies were deemed to have some concerns. Urine excretion was greater after treatment with furosemide and albumin versus furosemide (SMD 0.85, 95% CI = 0.33 to 1.38). Results for sodium excretion were inconclusive (SMD 0.37, 95%CI = - 0.28 to 1.02). AUTHORS' CONCLUSIONS: The current evidence is not sufficient to make definitive conclusions about the role of albumin in treating nephrotic edema. High-quality randomized studies with adequate samples sizes are needed. Including an assessment of intravascular volume status may be helpful. TRIAL REGISTRATION: Prospero: CRD4201808979. https://www.crd.york.ac.uk/PROSPERO A higher resolution version of the Graphical abstract is available as Supplementary information.

Neonatal end of life care in a tertiary care centre in Canada: a brief report.

OBJECTIVE: To describe the processes followed by a neonatal team engaging parents with respect to end of life care of babies in whom long term survival was negligible or impossible; and to describe feedback from these parents after death of their child. METHODS: A retrospective review was conducted of health records of neonates who had died receiving palliative care over a period of 5 years at a tertiary neonatal centre. Specific inclusion criteria were determined in advance that identified care given by a dedicated group of caregivers. RESULTS: Thirty infants met eligibility criteria. After excluding one outlier an average of 4 discussions occurred with families before an end of life decision was arrived at. Switching from aggressive care to comfort care was a more common decision-making route than having palliative care from the outset. Ninety per cent of families indicated satisfaction with the decision making process at follow-up and more than half of them returned later to meet with the NICU team. Some concerns were expressed about the availability of neonatologists at weekends. CONCLUSIONS: A compassionate and humane approach to the family with honesty and empathy creates a positive environment for decision-making. An available, experienced team willing to engage families repeatedly is beneficial. Initiating intensive care with subsequent palliative care is acceptable to families and caregivers.

The Use of Indomethacin for Nocturnal Enuresis in Children With Nephrogenic Diabetes Insipidus: A Case Report and Review of the Literature.

Rationale: Nocturnal enuresis is a common symptom of nephrogenic diabetes insipidus (NDI) in children. Published reports on the treatment of nocturnal enuresis in this population are scarce. Presenting concern of the patient: 2 brothers, aged 8 and 9 years, presented for outpatient pediatric nephrology follow-up. Despite being medically stable on their current medication regimen, they both experienced significant distress due to primary nocturnal enuresis, including decreased self-esteem and social stress. Diagnoses: The brothers had primary nocturnal enuresis related to their high urine output from NDI. Interventions: we describe a case of 2 brothers with NDI in whom indomethacin was added to their pharmacologic treatment specifically to address enuresis. Outcome: Both brothers experienced a significant decrease in the frequency of nocturnal enuresis and improvement in their perceived quality of life. Teaching points: Nocturnal enuresis is a bothersome symptom of NDI with adverse psychological effects. Indomethacin can improve nocturnal enuresis in some patients. Treatment with nonsteroidal anti-inflammatory drugs carries a risk of gastrointestinal and kidney side effects. We advocate for a patient-centered approach to the treatment of NDI which includes optimizing both the medical and the psychological needs of the patient.

Justification: L'énurésie nocturne est un symptôme courant du diabète insipide néphrogénique (DIN) chez l'enfant. Les rapports publiés portant sur le traitement de l'énurésie nocturne dans cette population sont rares. Présentation du cas: Deux frères âgés de 8 et 9 ans se sont présentés pour un suivi de néphrologie pédiatrique en ambulatoire. La pharmacothérapie actuelle maintenait leur état de santé stable, mais les deux garçons éprouvaient une importante détresse psychologique, notamment du stress social et une diminution de l'estime de soi, liée à l'énurésie nocturne primaire. Diagnostic: Les deux frères souffraient d'énurésie nocturne primaire due à leur débit urinaire élevé découlant du DIN. Intervention: Nous décrivons le cas de deux frères atteints de DIN chez qui l'indométhacine a été ajoutée à la pharmacothérapie spécifiquement pour traiter l'énurésie. Résultats: Les deux enfants ont connu une diminution significative de la fréquence de l'énurésie nocturne et une amélioration de leur qualité de vie perçue. Enseignements tirés: L'énurésie nocturne est un symptôme incommodant du DIN qui entraîne des conséquences psychologiques néfastes. L'indométhacine peut réduire l'énurésie nocturne chez certains patients. Le traitement par anti-inflammatoires non stéroïdiens (AINS) comporte un risque d'effets secondaires gastro-intestinaux (GI) et rénaux. Pour le traitement du DIN, nous préconisons une approche centrée sur le patient englobant l'optimisation des besoins médicaux et psychologiques du patient.

Management of congenital cutaneous candidiasis in a healthy term baby: A case report.

The management of congenital cutaneous candidiasis in a healthy term neonate of normal birth weight is unclear. Often, healthy term neonates undergo extensive evaluation followed by systemic treatment, which may not be clinically warranted. Here, we present a case of a healthy term neonate with congenital cutaneous candidiasis, whose work-up was minimally invasive and was successfully treated with one oral dose of antifungals and topical antifungals, as well as a review of the literature.