Lars Pape

Management of Anemia in Children Receiving Chronic Peritoneal Dialysis

Little information exists regarding the efficacy, modifiers, and outcomes of anemia management in children with CKD or ESRD. We assessed practices, effectors, and outcomes of anemia management in 1394 pediatric patients undergoing peritoneal dialysis (PD) who were prospectively followed in 30 countries. We noted that 25% of patients had hemoglobin levels below target (<10 g/dl or <9.5 g/dl in children older or younger than 2 years, respectively), with significant regional variation; levels were highest in North America and Europe and lowest in Asia and Turkey. Low hemoglobin levels were associated with low urine output, low serum albumin, high parathyroid hormone, high ferritin, and the use of bioincompatible PD fluid. Erythropoiesis-stimulating agents (ESAs) were prescribed to 92% of patients, and neither the type of ESA nor the dosing interval appeared to affect efficacy. The weekly ESA dose inversely correlated with age when scaled to weight but did not correlate with age when normalized to body surface area. ESA sensitivity was positively associated with residual diuresis and serum albumin and inversely associated with serum parathyroid hormone and ferritin. The prevalence of hypertension and left ventricular hypertrophy increased with the degree of anemia. Patient survival was positively associated with achieved hemoglobin and serum albumin and was inversely associated with ESA dose. In conclusion, control of anemia in children receiving long-term PD varies by region. ESA requirements are independent of age when dose is scaled to body surface area, and ESA resistance is associated with inflammation, fluid retention, and hyperparathyroidism. Anemia and high ESA dose requirements independently predict mortality.

Alterations of cyclosporin A metabolism induced by mycophenolate mofetil

Unexpectedly lower CsA 2‐h levels were found in patients who received additional immunosuppression by MMF in our center. The aim of this study is to prove whether there are differences in CsA metabolization when MMF is added to treatment. In 33 children who received an immunosuppression of prednisolone and CsA as well as in 15 children who were treated with additional MMF, C2 and C0 were taken. In 11 children, full AUC of CsA were obtained. C2 levelsdiffered significantly (p < 0.05) between patients treated with (617 ± 230 ng/mL) and without MMF (750 ± 271 ng/mL) but with similar CsA dosages. C2 correlated better with the AUC than CsA levels at other time points with r = 0.95. The equation AUC = 139 + 6.17 × C2 was calculated to match best in a C2‐limited sampling strategy. This formula proved to be safer than equations that had been published before. According to our findings, we suspect that MMF alters the CsA metabolism. When MMF is used in pediatric transplant recipients, either target values of CsA have to be changed or patients may require higher doses of CsA.

A single center clinical experience in intensive care management of 104 pediatric renal transplantations between 1998 and 2002

Abstract:  Only a few publications about the treatment in the intensive care unit (ICU) after pediatric renal transplantation have been published yet. As there are no guidelines, we hereby describe the results and recommendations of our transplant unit. A total of 104 renal transplantations have been performed in 96 children at our center since 1998. The age of the children has ranged from 6 months to 18 yr and their body weight from 6 kg to 110 kg. A special fluid management was performed in order to avoid hypotension and hypoperfusion of the graft. Systolic arterial pressure was kept at elevated levels above 100 mmHg during the first day after transplantation. The children remained on the respirator for 4–8 h after transplantation. Anticoagulation was performed using low dose heparin because of the size mismatch of the anastomosed vessels. The mean time in the ICU for the pediatric patients aged <3 yr was 2 days and for children older than 3 yr was 1 day. The main complications after renal transplantation in the ICU were disorders of electrolytes, acute renal failure because of a non‐functioning graft (12%), bleeding from the anastomoses (4%), arterial or venous thrombosis (1%), arterial hypertension and pulmonary edema, defined as radiographic evidence (1%). In case of non‐function peritoneal‐ or hemodialysis were performed in the ICU. Young children were more frequently affected than older children. From 1998–2002 one patient died during the ICU time. The 3 yr graft survival rate was 90%. To sum up, children undergoing renal transplantation should be treated in a specialized unit postoperatively to avoid early non‐functioning of the graft and extrarenal complications. General guidelines for postoperative care should be established.

Algorithmen zur Nierentransplantation

Diagnostische und therapeutische Algorithmen zur Nierentransplantation werden in diesem Kapitel dargestellt.

Immunsuppressive Behandlung des nephrotischen Syndroms im Kindesalter – Was kommt nach der Steroidtherapie?

Die Behandlung des idiopathischen nephrotischen Syndroms (NS) im Kindesalter erfordert bei Steroidtoxizitat oder fehlender Remission weitere immunsuppressive Masnahmen, vorausgesetzt dass keine nachgewiesene Mutation im Podocin, Nephrin oder α-Actinin vorliegt und die Nephrose nicht durch eine syndromale Erkrankung verursacht wird. Die klare Zuordnung des Verlaufes unter/nach Steroidtherapie in haufig rezidivierend – steroidabhangig – steroidresistent entscheidet uber das therapeutische Vorgehen. Bei haufig rezidivierenden und steroidabhangigen Patienten kommen Monotherapien mit Levamisol, Cyclophosphamid oder Cyclosporin A zum Einsatz. Beim steroidresistenten nephrotischen Syndrom im Rahmen einer glomerularen Minimallasion oder fokal-segmentalen Glomerusklerose sollten Kombinationstherapien mit intravenosen Prednisolonpulsen und Cyclosporin A oder Cyclophosphamid, Tacrolimus und Mycophenolsaure zum Erzielen einer kompletten Remission eingesetzt werden. Eine enge Zusammenarbeit zwischen Eltern, Kinderarzt und Kindernephrologen ist Voraussetzung fur anhaltende Remissionen und niedrige Medikamententoxizitat.