Peter Beale

Hypertension as the major problem of idiopathic arterial calcification of infancy

We describe two infants with severe hypertension associated with idiopathic arterial calcification of infancy. In both children, blood pressure control was refractory to aggressive antihypertensive therapy. There was radiologic and laboratory evidence of renovascular disease requiring the use of specific renin antagonists and later nephrectomy, resulting in moderate improvement of hypertension. Although on occasion there is a familial incidence, in the vast majority of cases the diagnosis hinges on a high index of suspicion.

Management of severe hypertension in childhood Takayasu's arteritis

Six children presented with severe hypertension caused by Takayasus arteritis (TA), of whom four had bilateral renal artery narrowing and two coarctation syndrome. Two presented with hypertensive encephalopathy and four with congestive cardiac failure. All had a strongly positive skin reactions to purified protein derivative of mycobacterium tuberculosis. Bilateral renal arterial bypass grafts performed in two children resulted in prolonged normalization of their blood pressures, but the grafts clotted 12–18 months later. Primary renal autotransplantation was unsuccessful in two children, one with bilateral renal arterial narrowing and iliac vessel involvement and one with a long coarctation. Secondary renal autotransplantation was successful in a third child with localized aortitis. A successful aortic patch graft was performed in one child with coarctation of the aorta. Angiotensin-converting-enzyme inhibitors should be used with caution in treating the hypertension caused by TA, since bilateral renal arterial narrowing is common and their administration may result in renal insufficiency. The long-term prognosis is guarded in severely hypertensive children with extensive vascular disease due to TA.

Pediatric renal transplantation in a South African teaching hospital: A 20-year perspective

Abstract:  Introduction:  Renal transplantation is established as the standard of care for end‐stage renal failure (ESRF) in the developed world. In emerging nations, the appropriateness of such costly interventions has been questioned. We undertook an analysis of all renal transplants undertaken under the care of the pediatric nephrology service at the Johannesburg Hospital, South Africa, in order to establish the outcomes of a transplantation service in a resource‐constrained environment in a developing country.

Management of renal hypertension in children with Takayasu's arteritis using renal autografting or allograft transplantation in selected circumstances and total lymphoid irradiation

In a decade from 1980, 11 children aged 3 to 11 years presented with Takayasus arteritis (TA). All were severely hypertensive. Operative correction was offered to 10 of 11 children presenting with renovascular hypertension (RVH) including cardiac failure alone in 1 and both renal and cardiac failure in 8, a result of TA involving renal arteries by stenosis or occlusion. Nine patients had renal autotransplantation to an heterotopic site in the pelvis. Seven of 12 kidneys were salvaged by autotransplant with relief of RVH. Renal artery stenosis was successfully corrected by this procedure in 5 patients. Autotransplantation failed in 4 patients, 1 of whom subsequently had a successful allograft transplant. One patient was treated primarily by cadaver allograft transplantation. One patient whose autotransplant failed had a functioning contralateral kidney and is well with controlled RVH. One patient died prior to any treatment. Patient survival improved with the use of total lymphoid irradiation in the most recent 7 patients.

Laparoscopic Drainage of a Post-Traumatic Intramural Duodenal Hematoma in a Child

Duodenal intramural hematoma owing to blunt abdominal trauma is a relatively rare condition and is normally managed non-operatively. In this paper, we present the case of an 11-year-old boy with a post-traumatic duodenal hematoma, who after failing conservative management, underwent laparoscopic drainage. A four-port approach in a similar position to the laparoscopic cholecystectomy was used. After disentangling the inflammatory mass, the duodenal serosa was opened by simple hook diathermy and the hematoma evacuated. The child recovered uneventfully and was discharged home 48 hours later. To our knowledge, this is the first time that this condition has been successfully treated laparoscopically.

Esophegeal replacement in children with AIDS

We report 2 human immunodeficiency virus-positive patients with refractory esophageal strictures secondary to candidiasis. They presented with progressive dysphagia and had suffered from oropharyngeal and/or esophageal candidiasis within the preceding 3 months. Both failed conservative management of these strictures, including systemic antifungal therapy, administration of proton pump inhibitors, and numerous attempts at stricture dilation, ultimately progressing to open transhiatal esophagectomy. Although challenging in the immunocompromised host, successful treatment of these strictures by gastric interposition is achievable with minimal morbidity.