Barriers to medication adherence and its relationship with outcomes in pediatric dialysis patients.

BACKGROUND: Medication adherence is a major factor determining outcome in children with chronic disease. Children with end-stage renal disease are challenged with requirements for renal replacement therapy in addition to complicated medication regimens. METHODS: We assessed barriers to medication adherence in 22 pediatric patients receiving chronic dialysis [63.6 % hemodialysis (HD), 36.4 % peritoneal dialysis (PD); age 15.9 ± 0.7 years, dialysis vintage 31.6 ± 6.5 months]. Adherence was assessed by a 16-question survey with a maximum score (difficulty) of 64. RESULTS: The overall mean adherence score was 30.9 ± 2.4 (range 16-49; median 27.5). There was a trend for lower adherence scores in patients on HD (27.5 ± 2.9) compared to those on PD (36.8 ± 3.7) (p = 0.06). Compared to HD patients, the mean score/question was significantly higher in PD patients (1.7 ± 0.2 vs. 2.4 ± 0.2, respectively; p = 0.006). Of the 16 questions, HD and PD patients gave a mean response of ≤1.2 for five and zero questions, respectively. Neither gender, age nor dialysis vintage was related to adherence scores. There was also a trend for adherence scores to be higher in females (35.6 ± 3.7) than in males (27.5 ± 2.9) (p = 0.1), but this difference did not reach statistical significance. Markers of mineral bone disease were similar in HD and PD patients. Among all targets in HD and PD patients combined, there was no relationship between adherence scores and number of targets reached (r = -0.09, p = 0.7). CONCLUSION: There are many barriers to medication adherence in pediatric patients receiving dialysis. In our patient group the difficulties were more evident in patients receiving PD than in those receiving HD.

Cause and outcome of central venous catheter infections in paediatric haemodialysis patients.

BACKGROUND: Paediatric patients with end-stage renal disease often receive haemodialysis (HD) via a central venous catheter (CVC). The most common problem with CVC is infection. METHODS: We assessed infection rates and subsequent outcome in paediatric chronic HD patients receiving dialysis via a CVC. RESULTS: Over a 3-year period, there were 28 episodes of infection in 17 patients. The overall rate of infection was 13.7 infections/100 catheter months. Among all catheters, catheter survival was 4.5 ± 0.8 months and similar in infected versus uninfected catheters. Among the 28 infections, there were 43 organisms captured. The most common organisms were Gram-positive, comprising 79% of all species. Among Gram-positive organisms, all coagulase-negative and -positive organisms were sensitive to vancomycin while all enterococci were sensitive to vancomycin. The majority of Gram-negative organisms were sensitive to aminoglycosides or cephalosporins. Among infected catheters, the rate of thrombosis was 1 event/1.7 catheter months; in uninfected catheters, the overall prevalence and rate of thrombosis was similar (1 event/1.6 catheter months). Thirty-nine percent of infections resulted in catheter loss within the subsequent 2 months, the most common reason being catheter occlusion. Multiple organisms/episode were more common in patients who required catheter replacement (46%) than in those who had salvage of the catheter (25%). CONCLUSIONS: In summary, HD catheter infection rates are high, while thrombosis rates are similar in infected and uninfected catheters. Infection with Gram-positive organisms was most common. The vast majority of CVC infections are cleared by antibiotics, although catheter loss is not uncommon even after clearance of the organism.

Assessment of relationship between nutrition and growth in pediatric hemodialysis patients.

OBJECTIVE: Nutrition and growth are important outcome indicators in pediatric (Ped) hemodialysis (HD) patients. We hypothesized that there is a discrepancy among traditional measures of nutrition, and that adequate nutrition may not reliably predict growth. METHODS: We assessed longitudinal nutrition and growth parameters in 14 Ped HD patients over 1 year. Their age at the end of the study was 15.9 +/- 0.6 years, SEM. RESULTS: For the entire cohort over 1 year, serum albumin (Alb) was 4.3 +/- 0.0 g/dL, and the normalized protein catabolic rate (nPCR) was 1.0 +/- 0.0 (correlation, 0.33; P < .0001). The relationship between Alb and nPCR was significant in only 4/14 (29%). The mean standard deviation and variance were higher for Alb (0.27 +/- 0.03) compared with nPCR (0.18 +/- 0.02). The body mass index percentile (BMI%) was 35.5 +/- 2.9, the percent ideal body weight (%IBW) was 96.2 +/- 1.5, the height-SDS, or standard deviation score (Ht-SDS) was -1.30 +/- 0.11, and the percent weight change (PWC) was +4.9% +/- 1.9%. The highest incidence of reaching our targets for growth was seen for the BMI% (64% of patients) and PWC (79% of patients). The target for Ht-SDS was attained in only 21%. There was a significant negative relationship between Alb and nPCR with BMI%, %IBW, and Ht-SDS, and a significant positive relationship between Alb and nPCR with PWC. CONCLUSION: We conclude that the relationship between Alb and nPCR is weak in individual patients, and that adequate nutrition does not reliably predict growth in Ped HD patients.

Cinacalcet is efficacious in pediatric dialysis patients.

Secondary hyperparathyroidism (high-turnover bone disease, or HTBD) is manifested by elevated parathyroid hormone (PTH) levels. Control of HTBD may be achieved by maintaining low serum phosphorous levels and administering vitamin D therapy, although some patients continue to exhibit high PTH levels. We report the results of the efficacy of the calcimimetic cinacalcet in six hemodialysis (HD) and three peritoneal dialysis (PD) pediatric patients with HTBD, age 14.5 +/- 1.0 (range 7.5-17.5) years. Six patients received 30 mg/day, one required 60 mg/day, and two received 120 mg/day. Treatment with cinacalcet resulted in a 61% decline in intact PTH (iPTH) levels (1,070 +/- 171.5 pretreatment to 417.6 +/- 97.8 posttreatment pg/ml, p = 0.005). Serum alkaline phosphatase also declined (561.8 +/- 169.6 U/L pretreatment to 390.3 +/- 110.3 U/L posttreatment pg/ml). During therapy, serum calcium (p = 0.9) and phosphorous (p = 0.9) levels, calcium-phosphorous product (p = 0.8), systolic blood pressure (BP) (p = 1.0), diastolic BP (p = 0.8), and hemoglobin (p = 0.9) remained unchanged. The dose of oral calcitriol for the three patients on PD while receiving cinacalcet trended downward (0.8 +/- 0.2 pretreatment vs. 0.5 +/- 0.0 microg/day posttreatment pg/ml), as did the dose of paracalcitol for those receiving HD (6.6 +/- 2.3 pretreatment vs. 4.3 +/- 1.7 micrograms/day posttreatment pg/ml). We conclude that short-term treatment with the calcimimetic cinacalcet is efficacious in adolescent dialysis patients.