Coral Hanevold

Utility of citrate dialysate in management of acute kidney injury in children

Dialysis concentrate acidified with citrate as opposed to acetate has been reported to prevent clotting in hemodialysis circuits, and improve dialysis efficiency in adults. There is no information on its use in children. The purpose of the study was to evaluate the utility of citrate dialysate for renal replacement therapy in a pediatric population with acute kidney injury. We performed a retrospective review of our experience using Citrasate® concentrate from December 2007 to August 2009. All treatments were provided using the Fresenius 2008 dialysis machine. Citrasate® was utilized in 7 children aged 60.3±51.0 months (mean±SD), range 13 months to 12 years. The number of treatments varied from 4 to 31 (mean 12±8 treatments) for a total of 89 treatments. Rare sporadic mild hypocalcemia was noted but could not be definitively linked with the use of Citrasate®. Four children also required low‐dose heparin (3.6–15 U/kg/h) due to clotting. Activated clotting times (when checked) were not affected by this low‐dose heparin therapy. Some degree of clotting occurred in 21 of 89 (23.5%) treatments. Early termination of treatment due to thrombosis was required in 7 of 89 (7.8%) treatments. In summary, use of Citrasate® dialysis concentrate was well tolerated in critically ill children with acute kidney injury. Citrasate® reduced but did not completely eliminate the need for heparin in our population. Further study in a more diverse population would be helpful.

Diagnosis and management of white-coat hypertension in children and adolescents: A Midwest Pediatric Nephrology Consortium study

Although the definition of white‐coat hypertension (WCH) in children and adolescents is clearly defined, little is known about how this condition is actually approached clinically. To better understand the contemporary approach to the diagnosis and management of WCH in pediatric patients, the authors surveyed the membership of the Midwest Pediatric Nephrology Consortium. Seventy‐four faculty pediatric nephrologists responded to the survey. The survey results demonstrated uniformity in diagnosing WCH, including ambulatory blood pressure monitoring use in 93% of the respondents and a 75% adherence rate according to the 2014 American Heart Association scientific statement on pediatric ambulatory blood pressure monitoring. A total of 85% of respondents would not embark on further diagnostic evaluation once the WCH diagnosis was established, and none would initiate antihypertensive medications. There was a wide variety of practice habits in follow‐up of WCH including frequency of office and out‐of‐office follow‐up blood pressure measurements, the setting and timing of physician follow‐up, and the role of repeat ambulatory blood pressure monitoring. The results of this survey highlight the need for prospective studies aimed at establishing the optimal approach to pediatric patients with WCH.

Changing outpatient referral patterns in a small pediatric nephrology practice

BackgroundWe have noted a large number of referrals for abnormal kidney imaging and laboratory tests and postulated that such referrals have increased significantly over time. Understanding changes in referral patterns is helpful in tailoring education and communication between specialists and primary providers.MethodsWe performed a retrospective chart review of new patient referrals to Mary Bridge Children’s Nephrology clinic for early (2002 to 2004) and late (2011 to 2013) cohorts. The overall and individual frequencies of referrals for various indications were compared.ResultsThe overall number of new visits was similar for early (511) and late (509) cohorts. The frequency of referrals for solitary kidneys and multi-cystic dysplastic kidneys, microalbuminuria and abnormal laboratory results increased significantly (Odds Ratio (OR) and 95% Confidence Interval of OR: 1.920 [1.079, 3.390], 2.862 [1.023, 8.006], 2.006 [1.083, 3.716], respectively) over the time interval while the proportion of referrals for urinary tract infections (UTIs) and vesicoureteral reflux (VUR) decreased by half (OR: 0.472, 95% CI: 0.288, 0.633). Similarly, referrals for urinary tract dilation and hydronephrosis occurred significantly less often (8% versus 6%, OR: 0.737, 95% CI: 0.452, 1.204) with similar changes in referrals for voiding issues (OR: 0.281, 95% CI: 0.137, 0.575). However, these changes were not statistically significant. Frequencies for other indications showed little variation.ConclusionsChanges in indications for referral likely reflect evolution of practice in management of UTIs and VUR and increased use of imaging and laboratory testing by pediatric providers. These findings have relevance for ongoing education of pediatricians and support the need for collaboration between primary providers and nephrologists to assure the judicious use of resources.

American Society of Pediatric Nephrology Position Paper: Standard Resources Required for a Pediatric Nephrology Practice

From the Department of Pediatrics, University of Massachusetts Medical School, UMassMemorial Children’s Medical Center, Worcester, MA; Department of Pediatrics, Geisel School of Medicine at Dartmouth, Children’s Hospital at Dartmouth-Hitchcock, Lebanon, NH; and Department of Pediatrics, University of Washington School of Medicine, Seattle Children’s Hospital, Seattle, WA P ediatric nephrologists diagnose, treat, and manage congenital, hereditary, and acquired conditions of the kidney and urinary tract, as well as hypertension, in infants, children, and adolescents. They manage multisystem complications secondary to kidney dysfunction and provide specialized services, such as acute and chronic dialysis, continuous renal replacement therapy, kidney transplantation, kidney biopsy, and ambulatory blood pressure monitoring; in some programs, they oversee apheresis. Additionally, they provide consultation to families with antenatally suspected congenital kidney abnormalities. Pediatric nephrologists must provide consultation related to critical disorders of kidney function, fluid and electrolyte abnormalities, inborn errors of metabolism, intoxications, and acute kidney injury, which may require dialysis, as well as hypertension and abnormalities of the urine. Children with acute or chronic medical conditions, including those who are critically ill, often develop kidney disease as a consequence of their primary illness or their life-saving therapies (eg, nephrotoxic medications). Neonatology, critical care, perinatology, pediatric oncology and stem cell transplantation, cardiology and cardiothoracic surgery, solid organ transplant programs, urology, and other pediatric surgical services all depend on the expertise and therapies of a pediatric nephrology practice. A lack of pediatric nephrology support would make provision of these other specialty services difficult if not impossible. Many of these programs are net revenue generating. Therefore, pediatric nephrology divisions could also be considered an important part of a fiscally sustainable children’s medical center. A pediatric nephrology service allows a children’s medical center to maximize and optimize all medical and surgical services. The range of services provided by pediatric nephrology practices is summarized in Table I. There are also several pediatric clinical services that are mandated to have pediatric nephrology services. TheAmerican Academy of Pediatrics Section of Critical Care Medicine Guidelines lists a pediatric nephrologist as “essential” for a Level I pediatric intensive care unit and “desired” for a Level II pediatric intensive care unit. Hemodialysis, peritoneal dialysis and continuous renal replacement therapy are considered “essential” services for a Level I pediatric intensive care unit and “optional” for a Level II pediatric intensive care unit. The American College of Surgeons states, that “in Level I and II trauma centers, medical specialists on staff must include