Antihypertensive treatment prescription in pediatric dialysis patients in Poland: A comparison between two nationwide studies 2003/2004-2013.

BACKGROUND: Blood pressure in pediatric dialyzed patients is under poor control. OBJECTIVES: The aim of the study was to assess the strategy and efficacy of antihypertensive drugs used for the treatment of hypertension in pediatric dialyzed patients in 2013 in comparison with the data collected in 2003/2004. The results have been viewed against present strategies of antihypertensive treatment in children. There is still limited data concerning the treatment of hypertension in dialyzed pediatric patients. MATERIAL AND METHODS: The study embraced 10 of 12 pediatric dialysis units in Poland treating 59 pediatric patients (mean age - 132 months). Collected information included present antihypertensive treatment with regard to drug classes and the dose of antihypertensive agent. The treatment was regarded as effective if both systolic and diastolic values of blood pressure were below 1.64 SDS. The results from 2013 were juxtaposed with previously analyzed data from a similar study on hypertension in dialyzed children conducted in 2003/2004. RESULTS: Forty subjects have been provided with antihypertensive treatment. In monotherapy and polytherapy 50% of the subjects were treated with ACEI (enalapril and ramipril), 67.5% with amlodipine, 50% with beta-blockers. Only 10% of the subjects were treated with angiotensin II receptor blocker (losartan). Thirty percent of the subjects received furosemide, whereas 5% were given doxazosin. Antihypertensive drugs regarded as the 2nd and 3rd choice in treating high blood pressure (doxazosin, beta-blockers and furosemide) were applied as monotherapy in 46% of the patients. Satisfactory control of treated blood pressure was reached in 45% of them. CONCLUSIONS: Antihypertensive treatment in dialyzed children did not change significantly during the last decade with regard to the groups of drugs being used. Despite a wider feasibility of antihypertensive substances, the effectiveness of this therapy was still unsatisfactory.

What has changed in the prevalence of hypertension in dialyzed children during the last decade?

BACKGROUND: Hypertension very often accompanies progression of chronic kidney disease (CKD) in children. A cross-sectional analysis of hypertension prevalence in dialyzed children in Poland was designed with a comparison with the data previously recorded 10 years earlier. METHODS: Two cohorts of children were analyzed: 59 subjects dialyzed in 2013, and 134 children from the previous study performed in 2003 that were reevaluated according to the current methodology. The incidence of hypertension (defined by SDS of sBP or dBP >1.64), clinical data, medical history, dialysis modalities and selected biochemical parameters of dialysis adequacy were analyzed. RESULTS: The prevalence of hypertension increased from 64% in 2003 to 78% in 2013. The efficacy of antihypertensive treatment remained unsatisfactory (61% proper BP control). Preservation of residual urine output and strict fluid balance may prevent development of hypertension in children on dialysis. CONCLUSIONS: Despite the higher awareness of hypertension and its complications in dialyzed children, the incidence of this entity has increased during the last decade, with the percentage of undertreated patients comparable to that observed 10 years ago. Thus, more attention should be paid to therapy efficacy in this population to prevent further damage to the cardiovascular system and to decrease morbidity.

Growth and nutritional status in children with chronic kidney disease on maintenance dialysis in Poland.

PURPOSE: Despite vast availability of modern methods of treatment of chronic kidney disease and its complications, the short stature still is a major point of concern in adolescents with chronic kidney disease. The aim of the study was to assess changes in growth and nutritional status of Polish children on renal replacement therapy in the decade, 2004-2013. MATERIAL AND METHODS: The study was designed as a cross-sectional analysis of anthropometric values and selected indices of growth status amongst children receiving dialysis in Poland between the years 2004 and 2013. Data were acquired during two different multicentre studies on hypertension in dialyzed children in Poland. Basic anthropometric parameters (body weight, body height/length, body mass index - BMI), dialysis adequacy and duration of RRT were assessed. RESULTS: The study showed that anthropometric parameters of children undergoing renal replacement therapy had not significantly changed in the last 10 years of observation. Children on RRT were still of short stature despite availability of modern methods of hormonal therapy and nutrition. Median of height z-score was -2.10 in 2004 and -2.19 in 2013. Expected clinical improvement in these measures was not proven. CONCLUSIONS: The cause of chronic kidney disease, method of dialysis, time on dialysis or dialysis adequacy did not influence the anthropometric parameters significantly in dialyzed children in Poland.

Do children with end-stage renal disease live shorter? Analysis of mortality on the basis of data from the Polish Registry of Renal Replacement Therapy in Children.

PURPOSE: The mortality of patients with end-stage renal disease (ESRD) is much higher than that of the general population. To date no data has been published on the mortality of children with ESRD in Poland. The aim of this study was to compare the risk of death for pediatric patients on renal replacement therapy (RRT) with that of the general pediatric population and to identify the risk factors of death. MATERIAL/METHODS: Data of 779 children with ESRD registered in the Polish Registry of Children on RRT was analyzed. The relative risk of death was calculated as the ratio of the mortality rate in ESRD patients to the mortality rate in age-adjusted general population. RESULTS: The mortality rate of children with ESRD was 74-fold higher than that of the age- and gender-adjusted general pediatric population (4.05 vs. 0.05/100 person-years). The highest mortality rate (4.53/100 patient-years) was found in the youngest age group. Younger age and duration of dialysis therapy were identified as mortality risk factors. The major causes of death in ESRD patients were infections and cardiovascular complications, whereas deaths in general child population were mainly due to accidents or congenital defects. CONCLUSIONS: The mortality in Polish children with ESRD is 74-fold higher than that of the general pediatric population. Infections, followed by cardiovascular complications, constitute the main causes of mortality in children subjected to RRT. The risk of death is the highest among children who started RRT at a younger age and in those subjected to long-term dialysis treatment.

Anaemia treatment in chronically dialysed children: a multicentre nationwide observational study.

OBJECTIVE: Erythropoiesis-stimulating agents (ESAs) are applied as a standard therapy in children with anaemia in chronic kidney disease. The aim of this study was to describe the efficacy and details of ESA treatment in a population of dialysed children in Poland. MATERIAL AND METHODS: The study had a prospective observational design and was performed in 12 dialysis centres. The study group comprised 117 dialysed children with a mean age at enrolment of 165.33 (97.18-196.45) months. RESULTS: Dialysed children were treated mostly with epoietin beta and darbepoietin. The mean dose of ESA was 99 (68-147) U/kg/week with a significant difference between patients on peritoneal dialysis [83 (54-115)] and haemodialysis [134 (103-186)] (p < 0.0001). The mean haemoglobin of all the time-point tests during 6 months was 10.91 ± 1.18 g/dl. The efficacy of anaemia treatment was unsatisfactory in 52% of subjects. In multivariate analysis, initial haemoglobin level <10 g/l, any infection, younger age at first dialysis, malnutrition and inadequate ESA dosage remained significant predictors of anaemia. CONCLUSIONS: The study revealed that anaemia treatment in Polish children is unsatisfactory. Late commencement of the treatment, inadequate dosing, malnutrition and infections could constitute risk factors for therapy failure.

Successes and pitfalls of chronic peritoneal dialysis in infants - a Polish nationwide outcome study.

INTRODUCTION: Peritoneal dialysis (PD) is a preferred method of renal replacement therapy for end-stage renal disease in children. Recent advances have allowed chronic PD to be provided to children of all ages and sizes. MATERIAL AND METHODS: The study was designed as a national (10 dialysis centres), multicentre retrospective analysis of the medical history of 33 children who started chronic peritoneal dialysis in their infancy between 1993 and 2005, with a follow-up period of at least 24 months. RESULTS: The nutritional status of the infants was unsatisfactory. The mean SDS of body weight at the start was -2.0, at 1 year of age -1.7. Only 40% of infants were adequately nourished at 1 year of age. Long-term follow-up analysis showed that 12 children received a kidney transplant, 13 were still on dialysis (4 changed method) and 6 died (mortality rate in the first year of life of 9%). In 2 children we observed an improvement of renal function. We observed a relatively high (1/8.8 patient-months) peritonitis rate in the analysed children when compared to 1 : 22 patient-months in all children undergoing PD in Poland. CONCLUSIONS: The results of our survey have shown that the management of dialysed infants is still a challenge for the medical team and families, but long-term results of the therapy are encouraging.

[Congenital and genetic related causes of end-stage renal disease--data from Polish Registry of Renal Rreplacement Therapy in Children 2000-2004]. / Genetycznie uwarunkowane i wrodzone choroby nerek prowadzace do schylkowej niewydolnosci nerek--dane z polskiego rejestru dzieci leczonych nerkozastepczo (2000-2004).

UNLABELLED: One of the objectives of Polish Registry of Renal Replacement Therapy in Children established on 31st Dec. 2000 was to collect complete data on etiology of end stage renal disease (ESRD) in polish children. MATERIAL AND METHODS: Data on 469 patients (251 boys, 218 girls) aged 0-22 years treated with renal replacement therapy (RRT) at 13 pediatric dialysis units in Poland from 2000 to 2004 were analyzed. The mean age at start of dialysis was 10 years and 3 months. Renal diseases were defined according to EDTA coding system. Data is presented for the whole group, in 5-year age groups and separately for both sexes. RESULTS: Congenital and genetic renal diseases were the cause of ESRF in 56% of the polish population of children and adolescents on RRT. 39% of causes were acquired diseases, 5% remained unidentified. Congenital and genetic causes dominated in children < 5 years of age (71%). They accounted for 49%, 61% and 45% of causes in the consecutive 5-year age groups. The most numerous group of congenital diseases leading to ESRF were uropathies 37% and 25% of causes in the consecutive age groups. In boys the most frequent uropathy was obstructive uropathy (25%), the majority caused by posterior urethral valves. In girls the most frequent uropathies were reflux nephropathy (10%) and nephropathy secondary to neurogenic bladder (9%). Uropathies were followed by renal hypo-dysplasia without urinary tract anomalies (11%) and cystic diseases (10%). CONCLUSIONS: Congenital kidney anomalies and genetic diseases are the leading cause of end-stage renal disease in children up to 15 years of age.

[Chronic peritoneal dialysis in infants--preliminary results of the multicenter survey]. / Przewlekla dializa otrzewnowa u niemowlat--wstepna analiza ankiety wieloosrodkowej.

We retrospectively analysed peritoneal dialysis treatment in 29 infants dialysed in 9 paediatric centres in Poland in the years 1993-2004. The mean age at the start of dialysis was 4.9 +/- 3.5 months (range 2 days to 11 months), mean body mass 5.6 +/- 2.5 kg (range 2.5 to 11 kg). The mean duration of PD was 6.8 +/- 3.9 in the first year of life and total duration of the therapy 34 +/- 27 months. Of the 29 infants 4 died (2 in infancy), 11 underwent renal transplantation, in 2 children PD was stopped (they received a conventional treatment) and 12 were still dialysed at the date of data collection. The peritonitis rate was 1/9.5 patient-month and exit site infection rate 1/16 patient-month up to 1 year of life. 9 children (31%) required hernia repairs and in 9 catheters were replaced. Chronic peritoneal dialysis in infants is associated with high risk of infections and surgical complications and remains a challenge for paediatric nephrologists.

Hypertension in dialysed children: the prevalence and therapeutic approach in Poland--a nationwide survey.

BACKGROUND: The aim of this nationwide analysis was to assess the incidence and current treatment profile of arterial hypertension in children undergoing chronic haemodialysis or peritoneal dialysis and attitudes of paediatric nephrologists towards the choice of antihypertensive drugs in their patients. METHODS: The study group consisted of 134 children (89 males, 45 females, mean age 10.7+/-5 years) from all 13 paediatric dialysis centres in Poland. The data were gathered through a questionnaire for each patient dialysed in November 2004. RESULTS: The overall incidence of hypertension in the study group was 55% (74 of 134 patients; 47 males, 27 females). The incidence rate was similar in boys and girls (53 vs 60%) and in those on haemodialysis and peritoneal dialysis (56 vs 54%). Chronic glomerulonephritis as an underlying renal disease was significantly more frequent in the hypertensive than in the normotensive subjects (37 vs 10%, P = 0.004). Residual urine output was higher in normotensives (41 vs 10 ml/kg body weight; P < 0.001). Among those treated with antihypertensives: 32% were treated by monotherapy, 36% received two drugs, 22% received three drugs, while 7% received > or = 4 drugs. The therapy was effective in only 57% of subjects. We observed no differences in biochemical and clinical parameters between those who responded to the therapy and those who failed to do so. Calcium channel blockers constituted the most frequently administered class of drugs [73% of children; in 43 out of 48 (90%) combined with other drugs, but in 11 out of 24 (46%) as a monotherapy]. In monotherapy, angiotensin-converting enzyme inhibitors and calcium channel blockers were administered most frequently. CONCLUSION: We conclude that the incidence of hypertension in dialysis children in Poland is high (55%). The effectiveness of antihypertensive treatment is rather low (58%) and the choice of drugs is limited.

[Assessment of fructose-1,6-biphosphatase in urine of children with acute pyelonephritis]. / Ocena aktywnosci fruktozo-1,6 dwufosfatazy w moczu dzieci chorych na ostre odmiedniczkowe zapalenie nerek.

UNLABELLED: We assessed the excretion of fructose-1,6-bisphosphatase (FBP) and N-acetyl-beta-D-glucosaminidase (NAG) in 52 children (aged 4.1 +/- 2.3): group I--26 children with acute pyelonephritis (APN), in whom the examination were carried out twice: A--before treatment, B--after 14-21 days of antibacterial treatment, group II--21 healthy children. Activity of FBP in urine was found in 80% children from group I and II, and activity of NAG was found in all children from both groups. In examination A mean excretion of FBP and NAG was higher than in healthy children (p < 0.05). After antibacterial treatment excretion of both enzymes decreased to values, which did not differ from control group (p > 0.05). High correlation between FBP and NAG (r = 0.9355; p = 0.00001) was shown only in 14 children, in whom the course of acute pyelonephritis was serious (CRP > 20 mg%, leucocytosis > 10 x 10(9), and renal swelling in ultrasonography). CONCLUSION: Increased excretion of FBP in urine is found mainly in children with severe course of acute pyelonephritis, in whom the correlation between NAG and FBP is observed.

[Assessment of transforming growth factor-beta1 in serum of children with idiopathic nephrotic syndrome depending on the way of treatment]. / Stezenie transformujacego czynnika wzrostowego beta 1 w surowicy u dzieci z idiopatycznym zespolem nerczycowym w zaleznosci od sposobu leczenia.

UNLABELLED: The concentration of transforming growth factor-beta 1 (TGF-beta 1) in serum was performed by immunoenzymatic method in serum of children with nephrotic syndrome in following groups: group I--9 children (5-15 years) with focal segmental glomerulosclerosis (FSG), before Cyclosporine A treatment (CyA) (examination A) and after 3-6 months of Cyclosporine A treatment during remission (examination B), group II--13 children (5-14 years) with minimal change nephrotic syndrome (MCNS) during relapse (examination A) and after 7-20 days of prednisone (Encorton) treatment in dose 60 mg/m2, without the proteinuria (examination B), group III--15 healthy children (5-15 years). The aim of the work was to demonstrate any differences in concentration of TGF-beta 1 in serum of examined children and to show the influence of prednisone and Cyclosporine A on the concentration of TGF-beta 1. The results showed that before treatment increased concentration of TGF-beta 1 was shown only in children with MCSN (p < 0.05) and it was reverse proportional to albuminemia. However in children without proteinuria (B), the concentration of cytokines decreased in children with MCSN and increased in children with FSG treated with Cyclosporine A. CONCLUSION: The concentration of TGF-beta 1 in serum increases in children with nephrotic syndrome during gross proteinuria and hypoalbuminemia and after Cyclosporine A treatment.

[Reference values of arterial pressure depending on age, assessed by 24-hour ambulatory monitoring]. / Wartosci referencyjne cisnienia tetniczego w zaleznosci od wieku oceniane metoda calodobowego ambulatoryjnego monitorowania.

UNLABELLED: 24-hour blood pressure monitoring has been ever more widely used in children. However, percentile ranks for healthy children have not been prepared yet. The aim of the study was to define percentile ranks of blood pressure measured by ambulatory blood pressure monitoring in healthy children aged 7-17 years depending on sex in children from the Province of Podlasie. The examinations were carried out in a group of 540 children: group I-girls--265, group II boys--275, who were divided into subgroups according to age. Blood pressure was measured by ambulatory blood pressure monitors: BR-102 f. Schiller, Poland LTD and Quiet Tycos, USA according to the principles in force. The results showed that mean systolic blood pressure (RRs) increased with age from 103.2 to 117.7 mm Hg in girls and from 98.8 to 125.6 mm Hg in boys. The differences were statistically significant (p > 0.05). Diastolic blood pressure (RRr) increased less (p > 0.05). Mean systolic blood pressure at night was 9-10% and diastolic pressure 10-11% lower, irrespective of sex. The range of normal blood pressure values (5-95 centile) was established. In group I in the youngest girls the range of RRs was 89-110 mmHg, that of RRr was from 51 to 75 mm Hg while in group II in the youngest boys RRs range was from 95 to 108 mm Hg and RRr--from 52 to 73 mm Hg. In group I and II in the oldest girls and boys the values were higher. The percentile ranks (5-95) were prepared for systolic and diastolic blood pressure based on blood pressure monitoring during 24-hours and separately during activity (day) and resting time (night). CONCLUSIONS: 1. Systolic blood pressure in children aged 7-17 years increases with age more than diastolic blood pressure. 2. Percentile ranks for healthy children aged 7-17 years depending on age, sex and daily time period were established.

Expression of glucocorticoid receptors in mononuclear cells in nephrotic syndrome.

Coulter flow cytometry was used to determine glucocorticoid receptors (GCR) in the peripheral blood cells of patients with nephrotic syndrome. The expression of GCR in the lymphocytes (CD3/GCR) and monocytes (CD14/GCR) of peripheral blood of 23 (age 4.9+/-2.7 years) children with steroid-sensitive nephrotic syndrome was assessed before treatment (proteinuria >50 mg/kg per 24 h), after 4-6 weeks of prednisone treatment, without proteinuria, and in remission, without proteinuria and without any treatment. Before treatment the expression of CD3/GCR was 61.8+/-18.3% and CD14/GCR 43.6.8+/-20.3%; this did not differ from the results of the normal control group ( P>0.05). However, after treatment GCR expression in lymphocytes was 50% ( P<0.001) and in monocytes about 20% lower ( P<0.05). In remission, the GCR expression increased and did not differ from the results before treatment ( P>0.05). A positive correlation between the serum cortisol concentration and the expression of CD3/GCR was found ( r=0.504, P=0.02). In summary, we report that in children with steroid-sensitive nephrotic syndrome, prednisone treatment causes the temporary decrease of the expression of GCR in lymphocytes. A positive correlation between GCR expression and serum cortisol was found. A decrease in GCR expression in monocytes did not correlate with cortisol concentration.

[Vasculitis of cerebral vessels, probable cause of neurological complications in a child with Schonlein-Henoch purpura]. / Zapalenie naczyn mózgu prawdopodobna przyczyna powiklan neurologicznych u dziecka z choroba Schönleina-Henocha.

We report 6-years old boy with Schönlein-Henoch purpura who presented neurologic manifestations: depressed state generalised convulsions, and cortical blindness. Sequential magnetic resonance imaging showed bilateral cerebral ischemic lesions in the cortex and white matter of parieto-occipital lobes caused by vasculitis.

Evaluation of bladder instability in children with recurrent urinary tract infections.

BACKGROUND: Impairment in the functions of the lower urinary tract can be the cause of recurrent urinary tract infections (UTI) and vesicoureteral reflux (VUR) in children. The purpose of our research was to evaluate the frequency of occurrence of bladder instability in children with UTI. MATERIAL/METHODS: The research involved 114 children (21 boys, 93 girls), ranging in age from 5 to 16. Group I consisted of 61 children with a history of recurrent UTI, while Group II included 53 children with recurrent UTI and VUR. Urodynamic tests (uroflowmetry and cystometry) were done on all the children, while in selected cases profilometry was also performed, using a Duet apparatus (Dantec Medical A/S). RESULTS: Abnormal functioning of the lower urinary tract was found in 45 children (74%) from Group I and 44 children (84%) from Group II. The most common dysfunction was instability of the detrusor muscle, which was found in 52 children (45%), including 23 (38%) from Group I and 29 (55%) from Group II. In 19 children detrusor instability was accompanied by reduced bladder volume, and in 8 cases there was a lack of detrusor-sphincter coordination. In both groups ca. 20% of the children did not present with symptoms indicating urination dysfunctions. Ca. 80% reported various symptoms, of which the most common were nocturnal wetting and urinary urgency. In half of the children from Group I and one-fourth of the children from Group II there were several co-occurring symptoms: nocturnal and diurnal wetting, pollakiruria, and urinary urgency, or all three symptoms simultaneously. CONCLUSIONS: The most common disturbance of lower urinary tract functioning in these children with recurrent UTI was instability of the detrusor muscle, which occurred more often in children with VUR.