Amrish Jain

Prediction of Primary vs Secondary Hypertension in Children

J Clin Hypertens (Greenwich). 2012; 14:316–321. ©2012 Wiley Periodicals, Inc.

Two-dose daclizumab induction in pediatric renal transplantation.

Abstract:  DCZ, an IL‐2 receptor antagonist, has been widely used for induction therapy in pediatric and adult solid organ transplantation. Originally, it was recommended as a five‐dose regimen; however, fewer doses may be efficacious and less costly for prevention of rejection. There is limited experience with the use of fewer doses in pediatric renal transplantation. We retrospectively reviewed the outcomes of 26 primary pediatric renal transplants performed at a single center between June 2004 and May 2007 receiving induction therapy with two‐dose DCZ (1.5 mg/kg preoperatively and day seven post‐transplant). Maintenance immunosuppression included tacrolimus, MMF, and prednisone in all patients. Forty‐six percent were African American and 92% were deceased‐donor transplants. After a mean follow‐up of 17.8 ± 7.5 months, acute rejection was noted in 11.5% and graft survival was 92.3%. CMV infection occurred in 11.5%, but no case of BK nephropathy or post‐transplant lymphoproliferative disorder was observed. Our preliminary results suggest that induction therapy with two‐dose DCZ was convenient, economical, and effective in preventing rejection episodes without an increase in adverse events or hospital stay. Larger randomized clinical trials with longer duration of follow‐up are needed to more fully validate the use of this regimen in pediatric renal transplantation.

Pharmacologic Treatment of Pediatric Hypertension

Prevalence of hypertension is increasing in children and adolescents. Uncontrolled hypertension in children not only causes end organ damage but also increases the risk of adult hypertension and cardiovascular disease. Clinical trials have proven efficacy of antihypertensive medications in children. These medications are well tolerated by children with acceptable safety profile. The choice of agent is usually driven by underlying etiology of hypertension, profile of its side effects, and clinician’s preference. This article will review currently available pediatric data on mechanism of action, common adverse effects, pediatric indication, recent clinical trial, and newer drugs in the common classes of antihypertensive medications.

Treatment of Hypertension in Children With Catecholamine-Secreting Tumors: A Systematic Approach

Management of blood pressure in children with pheochromocytoma and other catecholamine‐secreting tumors (CSTs) is unique and challenging. The authors report a single‐center experience using sequential α‐adrenergic blockade (phenoxybenzamine), increased fluid intake, and β‐blockade for presurgical management of 10 CSTs in children. In this retrospective review, mean duration for blood pressure control in preparation for surgery was 4.5±2.6 weeks. Intraoperative hypertension was noted transiently (<2 hours) in eight patients (80%) and was treated with continuous infusion of short‐acting antihypertensive agents. Two (20%) patients required vasopressor medication infusion to manage intraoperative hypotension. Only two (20%) patients developed postoperative hypotension and required vasopressor medication infusion for <24 hours. All antihypertensive medications were discontinued in the immediate (≤4 days) postoperative period in 80% of patients. In conclusion, a systematic and multidisciplinary approach utilizing adrenergic blockade is effective in treating children with CSTs.

Body fluid composition.

UNLABELLED Body fluid composition is maintained in a normal physiologic range by regulatory mechanisms that control sodium and water metabolism. A detailed knowledge of the homeostatic mechanisms will help in understanding the pathogenesis and management of disorders of sodium and water balance. OBJECTIVES After completing this article, readers should be able to: 1. Understand the distribution of fluid and solute in different body compartments. 2. Demonstrate the homeostatic mechanisms involved in maintaining sodium and water metabolism. 3. Calculate osmolality and recognize the clinical importance of maintaining osmotic equilibrium. 4. Recognize common disorders of hypernatremia or hyperosmolality and evaluate and understand the role of calculating free water deficit in the treatment of these disorders. 5. Recognize common disorders of hyponatremia or hypo-osmolality, appreciate the role of urine sodium and urine osmolality in evaluation,and understand the importance of slow correction of these disorders.

Serum Osmolal Gap in Patients With Idiopathic Nephrotic Syndrome and Severe Edema

Pseudohyponatremia in idiopathic nephrotic syndrome with severe edema is attributed to hyperlipidemia that results in displacement of a portion of water phase of plasma. Current methods of measurement of serum electrolytes are unaffected by hyperlipidemia. In this report we demonstrate that patients with idiopathic nephrotic syndrome with severe edema and true hyponatremia may have an increased rather than normal osmolal gap. We believe that this could be secondary to non-Na+ and non-K+ osmoles in response to plasma-volume contraction secondary to hypoalbuminemia. This observation has implications for management of severe edema in such patients, because fluid restriction could increase their risk for pre–renal failure.

Barriers to live donor kidney transplants in the pediatric population: A single-center experience

A decrease in live donor pediatric kidney transplants has occurred in the United States. This study investigates barriers that may influence access to live donor kidney transplants in children. Retrospective chart review was conducted for 91 children (69% male, mean age 11.9 years) who underwent pretransplant workup from 2005 to 2015 at an urban pediatric hospital. Fifty‐four percent were African American, 32% Caucasian, 8% Arabic, 3% Hispanic, and 3% Others. Government‐sponsored insurance (Medicaid/Medicare) was utilized by 73%, and 54% had dual caregivers. Only nine of 68 kidney transplants were live donor transplants. Live donor transplants (11%) were significantly (P=.008) lower than deceased donor transplants (59%) in African Americans. Private insurance was reported by 56% of live donor recipients and 25% of deceased donor recipients. Among live donor recipients, 78% were from dual caregiver families. Caregiver, health‐related, financial, and religious/cultural barriers to live donor transplants were reported, several of which may be amenable to positive intervention.

Sweat chloride concentrations in children with Idiopathic Nephrotic Syndrome.

Idiopathic Nephrotic Syndrome (INS) has been believed to cause a false positive elevation of sweat chloride concentrations, as measured by the sweat test.

An adolescent on peritoneal dialysis with acute encephalopathy: Answers

Total parenteral nutrition (TPN) was started on hospital day 7 as the patient was still intubated and stuporous. Prior to initiation of TPN, serum thiamine and cobalamin levels were obtained given the patient’s history of malnutrition and chronic peritoneal dialysis (PD). On hospital day 11, the patient began to improve. She was extubated, able to respond to basic questions but remained withdrawn and taciturn and not back to baseline. A repeat echocardiogram showed resolution of abnormal left ventricular function. TPN was discontinued as the patient began to tolerate small amounts of food. The patient was then transferred back to the Nephrology service for further care. On the Nephrology service, she continued to act withdrawn and minimally responsive. On hospital day 15, results for serum thiamine levels came back as 28 nMol/l (reference range 70 – 180 nMol/l). Cobalamin levels were within normal limits. She was given a 25 mg bolus of intravenous (IV) thiamine. Within several hours after this bolus, the patient showed a dramatic improvement in her neurological status. She became more responsive and was able to sit up on a chair at the bedside, order a meal on her own from the hospital menu and text her mother. She was later seen to be ambulating with assistance and interacting with her family members. Thiamine was continued at a dose of 50 mg IV for 1 week, and then continued orally at the same dose. Repeat measurements of the thiamine level obtained after 4 days of thiamine replacement therapy was shown to be >2,000 mMol/l. The patient required physical and occupational therapy services for deconditioning. On hospital day 29, she was discharged home in a much improved condition. Since then the patient has been doing well with no permanent neurological deficit.

Erratum: Serum osmolal gap in patients with idiopathic nephrotic syndrome and severe edema (Pediatrics (2007) 119 (e1404-e1407))

An error occurred in the article by DuRant et al, titled “Firearm Ownership and Storage Patterns Among Families With Children Who Receive WellChild Care in Pediatric Offices,” published in the June 2007 issue of Pediatrics (doi:10.1542/peds.2006-1485). On page e1277, Acknowledgments section, lines 1–6, the authors wrote that the study was supported by the National Shooting Sports Foundation, among others. Funding for the study was not provided by the National Shooting Sports Foundation. This section should have read: “This study was supported by National Institute of Child Health and Human Development grant HD 42260, the Agency for Healthcare Research and Quality, the Robert Wood Johnson Generalist Faculty Scholars Program, the AAP’s Friends of Children Fund, and the Wachovia Foundation. In-kind support was provided through the US Department of Justice.”