Peter Nourse

Peritoneal Dialysis for Acute Kidney Injury

Renal Unit,1 Greys Hospital, Pietermaritzburg, South Africa; Renal and Intensive Care Units,2 Royal Devon and Exeter Hospital, Exeter, United Kingdom; Pediatric Nephrology Unit,3 Soba University Hospital, University of Khartoum, Sudan; Pondicherry Institute of Medical Sciences and Madras Medical Mission,4 Chennai, India; Department of Medicine,5 Botucatu School of Medicine, Sao Paulo, Brazil; Division of Nephrology-Hypertension,6 University of California, San Diego, USA; Division of Pediatric Nephrology,7 Shaare Zedek Medical Center, Jerusalem, Israel; Pediatric Nephrology Unit,8 Instituto da Criança of the Hospital das Clinicas of the University of Sao Paulo Medical School, Sao Paulo, Brazil; Pediatric Nephrology Department,9 Red Cross War Memorial Children’s Hospital, University of Cape Town, Cape Town, South Africa; Department of Surgery,10 Red Cross War Memorial Children’s Hospital, University of Cape Town, Cape Town, South Africa; School of Medicine,11 Pontificia Universidade Catolica do Parana, Curitiba, Brazil; Division of Pediatric Nephrology,12 University of Missouri-Kansas City School of Medicine, Kansas City, USA; Division of Nephrology,13 Queen’s University, Kingston, Canada; and Yale University,14 New Haven, USA ispd guidelines/ReCOMMendATiOns

Continuous flow peritoneal dialysis: first experience in children with acute renal failure

BACKGROUND AND OBJECTIVES Acute renal failure can be treated with different dialysis modalities, depending on patient characteristics and hospital resources. Peritoneal dialysis (PD) can be first choice in situations like hypotension, disturbed coagulation, or difficult venous access. The main disadvantage of PD is the relatively limited efficacy. The aim of this study was to investigate whether continuous flow peritoneal dialysis (CFPD) is a more effective treatment than conventional PD in acute renal failure. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS A pilot study was performed at The Red Cross University Hospital in Cape Town in six patients. Patients were treated with both CFPD and conventional PD for 8 to 16 hours. CFPD was performed with two bedside-placed catheters. After initial filling, dialysate flow rate (100 ml/1.73 m2 per minute) was maintained with an adapted continuous venovenous hemofiltration machine. Ultrafiltration flow rate was set at 2.5 ml/1.73 m2 per minute. RESULTS Mean ultrafiltration was 0.20 ml/1.73 m2 per minute with conventional PD versus 1.8 ml/1.73 m2 per minute with CFPD. Mean clearances of urea and creatinine were 5.0 and 7.6 ml/1.73 m2 per minute with conventional PD versus 15.0 and 28.8 ml/1.73 m2 per minute with CFPD, respectively. No complications occurred. CONCLUSIONS In this first report of CFPD in six pediatric patients with acute renal failure, CFPD was on average three to five times more effective for urea and creatinine clearance and ultrafiltration than conventional PD, without any complications observed. CFPD has the ability to improve therapy for acute renal failure.

Renal manifestations in children co-infected with HIV and disseminated tuberculosis

Many children in Cape Town are co-infected with human immunodeficiency virus (HIV) and tuberculosis (TB). Granulomatous TB interstitial nephritis is a recognized entity. Our objective was to establish if TB plays a role in renal disease in HIV-infected children. We identified children co-infected with TB and HIV from our database and reviewed their biopsies and clinical notes. Since 2002, 12 renal biopsies or postmortem examinations were performed on HIV-infected children at our institution. The clinical scenario and renal biopsies in four cases (median age 73 months, range 24–108 months) were consistent with TB involvement. The mean CD4 count and percentage of these four patients were 508 cells/µl and 23%, respectively. All four patients presented with culture-proven disseminated TB (not yet on treatment) and had nephrotic range proteinuria and hypoalbuminemia. Three of these patients had renal impairment. The prominent features of the renal biopsies were a severe interstitial inflammatory infiltrate and mild to moderate mesangial proliferation. An interstitial granuloma was seen in one patient. With treatment for the TB, the proteinuria resolved and renal function improved in all four patients. Based on these results, we conclude that TB contributes to proteinuric renal disease in HIV-infected children and that the renal disease improves following TB treatment.

Microsporidiosis in pediatric renal transplant patients in Cape Town, South Africa: Two case reports

Microsporidia are an emerging group of pathogens associated with life‐threatening opportunistic infections in immunocompromised hosts, particularly human immunodeficiency virus (HIV)‐infected individuals. There have, however, been recent reports of infection in adult solid organ transplant recipients. We report two cases in children, to our knowledge the first in the paediatric literature. Two 13‐yr‐old, HIV‐seronegative females received deceased donor renal transplants from the same donor. Both patients suffered acute cell‐mediated rejection and CMV infection reactivation, managed with intensified immunosuppression and ganciclovir. Pyrexia of unknown origin and intermittent diarrhea in both prompted extensive investigations. In both patients, numerous spores of a microsporidial species were demonstrated in renal tissue on biopsy and in the urine, using modified trichrome and quick‐hot Gram‐chromotrope staining. Electron microscopy and PCR confirmed Encephalitozoon cuniculi infections. Both patients were successfully treated with 400 mg twice daily of albendazole, with sustained clinical improvement. We recommend that microsporidiosis be considered in the differential diagnosis of pyrexia of unknown origin in severely immunocompromised pediatric solid organ transplant recipients, particularly when associated with diarrhea.

Neonatal Urinary Ascites: A Report of Three Cases

Urinary ascites in neonates is not a common condition. Three cases of urinary ascites are presented and each of them has a different aetiology. Neonates with urinary ascites usually present as clinical emergency, requiring resuscitation, ventilator support, and subsequent drainage of urine. The ultimate management depends on the site of extravasation and the underlying cause.

Salvageability of renal function following renal revascularisation in children with Takayasu's arteritis-induced renal artery stenosis.

BACKGROUND Renal artery revascularisation procedures are usually carried out on children with renal artery stenosis from varied causes, including Takayasus arteritis. Reports on the outcome of such procedures in children usually refer to the improvement in blood pressure, with only minimal mention of effects on renal function. OBJECTIVE Salvageability of renal function in children who underwent renal revascularisation for Takayasus arteritis-induced renal artery stenosis (TARAS) was the focus of this study. METHODS We undertook a retrospective analysis of children aged ≤16 years with angiographically confirmed TARAS who underwent renal artery revascularisation procedures between 1990 and 2010. Outcomes of renal function were studied over a period of 2 years and were defined as: (i) improvement: >20% increase in estimated glomerular filtration rate (e-GFR) from presurgery value; (ii) stabilisation: e-GFR within 20% of presurgery value; and (iii) failure: >20% deterioration in e-GFR from presurgery value. The GFR was estimated using the Schwartz formula. RESULTS Twenty children (9 males and 11 females, age range 2 - 14 years) had 27 renal artery revascularisation procedures. Thirteen of the patients (65.0%) had bilateral renal artery stenosis. The baseline mean e-GFR was 88.6 (standard deviation (SD) 25.4) mL/min/1.73 m2 and the mean duration of follow-up was 28.80 (SD 25.62) months. All the patients had stable or improved renal function until the 2-year follow-up, when the proportion decreased to 92.3% (12/13), as failure was recorded in one child. Bilateral revascularisation was found to be significantly associated with improvement in renal function in the early postoperative period (p=0.04). CONCLUSION Renal artery revascularisation procedures are successful in salvaging renal function in children with TARAS.

Audit of Hemodialysis in Children Weighing Less than 20 kg in an African Pediatric Nephrology Unit: Chronic Dialysis in Young Children

Peritoneal dialysis and kidney transplantation remain the preferred choices for renal replacement therapy in young children. These options, however, are not always feasible, and hemodialysis (HD) is therefore an accepted alternative. In small children presenting with end‐stage renal disease, HD presents several challenges and is often unavailable in lower‐ and middle‐income countries. To assess these challenges and outcomes of maintenance HD in young children, we performed an audit of children below 20 kg with end‐stage renal disease, receiving HD for ≥4 weeks, from 1 January 2008 to 31 July 2016 at the Red Cross War Memorial Childrens Hospital. We identified 15 children weighing 6.8–18.5 kg (mean 12.9 kg ±3.5 SD) and aged 11.5–105 months (mean 52.2 months±4.2 SD) at HD initiation. Mean duration of HD was 11.8 months (range 1–61.5 months ± 16.9 SD). Seven children underwent successful transplantation, two patients died, and four currently still receive HD. Two patients, while on HD, relocated to other centers. An average of 2.6 (range 1–5) different vascular accesses was required per patient. Technical difficulties were the most common cause of central‐line removal (81%), while catheter‐associated bacteremia was 1.1/1000 catheter days. Frequent problems were intradialytic hypotension, growth stunting, and interdialytic hypertension. HD in lower‐ and middle‐income countries is feasible in small children but presents with certain challenges. Advocacy with lobbying for funding and development of “child‐friendly” dialysis equipment and specialized centers with highly skilled personnel are the cornerstones of successful pediatric HD programs in less‐resourced centers.

Urological complications following unstented pediatric renal transplantation

Urological complications which develop post‐renal transplantation can be associated with significant morbidity especially in children. We evaluated the occurrence and management of all urological complications in a series of unstented pediatric renal transplants in a tertiary pediatric hospital. We reviewed the medical records of children who underwent unstented renal transplant between January 1996 and December 2014. Postoperative urological complications and the outcomes of their management were analyzed. A total of 160 unstented renal transplants were performed, and 32 urological complications were noted in 29 transplants (18%). There were 20 boys and nine girls with an age range of 2.5 years to 18.4 years. Nine (31%) of these patients had LUTD. The most common complication was VUR occurring in 17 patients (10.6%). Urine leaks occurred in six patients (3.8%) and ureteric obstruction in six patients (3.8%), and three patients (1.9%) had unexplained hydronephrosis. Loss of graft occurred in three patients (1.9%), and one patient died from sepsis post‐uretero‐ureterostomy. Patients with LUTD had more urological complications (P = .037). Unstenting is feasible in most pediatric renal transplants. LUTD is associated with a higher incidence of urological complications, especially VUR.

Rapid Equilibration Rates in Most Small Babies on Acute Peritoneal Dialysis

Editor: Whereas the prescription in chronic peritoneal dialysis (PD) is based on body surface area (BSA) and the results of standardized peritoneal equilibration tests (PETs), in the acute setting there are very little data regarding the peritoneal transport characteristics of children. We report here the D:P creatinine ratios of 7 children undergoing PD for acute kidney injury (AKI) secondary to a variety of illnesses. Manual PD with dwell times of 1 hour and a fill volume of approximately 20mL/kg was used in all patients. After 1 hour, the dialysate was allowed to drain for 20 minutes, and urea, creatinine, and sodium levels were analyzed. This was not a formal PET but was done to get an idea of the peritoneal transport rates with a normal prescription. The D:P creatinine ratios were calculated using the following formula: dialysate creatinine divided by the 1.5-hour serum creatinine. Most patients (except 1) had more than 1 test performed on separate cycles, and the mean is given. The results for patients are shown in Table 1. Our patients were all less than 2 years old and therefore have been compared with PET curves for this age group (1). Five of the patients would be classified as high/high average transporters whereas 2 would be low/low average. The D:P ratios were calculated using a smaller volume than standard PET, which could account for the high values. Nevertheless,

Dialysis Modality Choice and Initiation: Global Preferences

In the developed world, renal replacement therapy for children is generally accepted as standard care. However, this is not the case in developing countries with lower per capita incomes. This chapter focuses on the issues that impact therapy for severe chronic kidney disease in the developing world, addressing diagnosis, management and outcomes. Although the discussion primarily looks at the care of children in India, China, and the African continent, the general principals apply to children in all underdeveloped countries. Because maintenance dialysis is only provided for a minority of patients, the discussion includes an outline of causes and strategies for prevention and management of acute kidney injury.