Vimal Chadha

Consensus Guidelines for the Prevention and Treatment of Catheter-related Infections and Peritonitis in Pediatric Patients Receiving Peritoneal Dialysis: 2012 Update

Infectious complications remain the most significant cause for morbidity in pediatric patients receiving chronic peritoneal dialysis (PD). Although prophylactic measures have led to improved results in some centers, the frequency of peritonitis in children on PD continues to exceed that seen in adults, and peritonitis remains the most common reason for changing dialysis modality in children (1,2). The serious nature of this infection led to the creation and publication in 2000 of the Consensus Guidelines for the Treatment of Peritonitis in Pediatric Patients Receiving Peritoneal Dialysis (3), under the auspices of the International Society for Peritoneal Dialysis (ISPD). Those largely opinion-based guidelines were composed by an international committee of experts in the field of pediatric dialysis and served as the first such set of recommendations specific to the pediatric PD population. After the publication of those guidelines, the International Pediatric Peritoneal Dialysis Registry (IPPR) was established to support evaluations of the impact of implementing the guidelines on a global basis and to collect data to serve as evidence upon which future guidelines could be based. Data generated from 501 episodes of peritonitis were collected by the IPPR and serve as a foundation for many of the recommendations made in the present publication (4,5). As with the earlier publication, an international group of experts consisting of pediatric nephrologists, a pediatric dialysis nurse, and a pediatric infectious disease specialist collaborated in the effort. Committee discussions took place face-to-face, during conference calls, and by e-mail. The strength of each guideline statement is graded as Level 1 or 2, or Not Graded, and the quality of the supporting evidence as A, B, C, or D in accordance with the rating scheme used in the KDIGO (Kidney Disease: Improving Global Outcomes) Clinical Practice Guideline for the Care of the Kidney Transplant Recipient (6). Table 1 describes the scheme. TABLE 1 Guideline Rating Scheme Finally, wherever possible, efforts were made to achieve harmonization between the recently published adult treatment recommendations and those designed for children (7). In addition, supporting information (for example, reporting of peritonitis rates, definitions) that is included in the publication pertaining to adults and that is equally applicable to pediatric populations was included in the present publication.

Bilateral nephrectomy reverses hypothyroidism in congenital nephrotic syndrome

Abstract A state of biochemical hypothyroidism is commonly seen in infants with congenital nephrotic syndrome (NS) and therefore the current recommendation is to place all patients with congenital NS on supplemental thyroid preparations. We report our experience in five children with congenital NS in whom thyroid supplementation was discontinued following bilateral nephrectomy and initiation of renal replacement therapy. Immediately after nephrectomy, thyroid function tests normalized, except serum thyroid-stimulating hormone (TSH) concentration, which initially rose, but normalized later. This observation supports the hypothesis that hypothyroidism in these patients is secondary to the chronic massive proteinuria and is not the result of a defect intrinsic to the thyroid gland itself. Abatement of massive proteinuria enables discontinuation of thyroid supplementation, and a transient rise in TSH in the early post-nephrectomy stage should be potentially expected.

Donor selection in pediatric kidney transplantation using DR and DQ eplet mismatching: A new histocompatibility paradigm.

It is now appreciated that more HLA‐DR mismatching at the time of the first renal transplant is associated with higher degrees of sensitization, lower rates and longer times to retransplantation, and worse graft outcomes in children who are subsequently retransplanted. As such, our pediatric renal transplant program preferentially uses 0 or 1 HLA‐DR–mismatched kidneys and reserves 2 DR‐mismatched kidneys for recipients with an eminent need for a kidney. Based on a new HLA class II epitope matching strategy that is designed to minimize dnDSA production to DR and DQ antigens, we evaluated the prevalence of DR and DQ eplet mismatching for dd offers made to our pediatric wait‐listed candidates. Each candidate/dd pair were HLA‐DR (β1 and β3 and/or β5) and DQ (α1 and β1) allele typed by rSSO and were then evaluated for eplet mismatches by the HLAMatchmaker program. We evaluated 78 offers made to 16 children on our UNOS waiting list from 27 consecutive dd from 4/14/14 to 3/23/15. The data show that 40% (8/20) of the 1 DR‐mismatched dd offers and 64% (37/58) of the 2 DR‐mismatched offers were in the high‐risk category for both DR and DQ dnDSA development. Whereas only 15% (3/20) of the 1 DR‐mismatched offers and 5% (3/58) of the 2 DR‐mismatched offers were in the low‐risk category for both DR and DQ dnDSA development, 55% and 33% of the 1 DR‐ and 2 DR‐mismatched offers, respectively, had a favorable DQ eplet mismatch threshold. In summary, HLA class II eplet mismatching is common in potential pediatric transplant recipient/donor pairs. Additional study will be necessary to validate the DR and DQ eplet threshold levels in children and to determine whether eplet mismatching strategies in donor selection result in improved transplant outcome and decreased dnDSA production.

Sieving coefficient inaccuracies during hemodiafiltration in patients with hyperbilirubinemia

Abstract Hemodiafiltration has assumed an important role in the supportive therapy of critically ill patients. The viability of the filter used for hemodiafiltration can be monitored by estimating the sieving coefficient of small molecules such as creatinine and/or urea. We report on three patients with severe hyperbilirubinemia whose creatinine sieving coefficient was spuriously elevated as a result of discordance in the accuracy of creatinine measurement in plasma and ultrafiltrate respectively. This discordance was a consequence of lack of bilirubin clearance during hemodiafiltration. As a result, while the plasma creatinine determination by the kinetic Jaffe method was negatively influenced by the hyperbilirubinemia, the ultrafiltrate creatinine was not. This report is the first to document the lack of bilirubin clearance during hemodiafiltration and its impact on the calculation of sieving coefficient based on creatinine. The use of urea as the solute for determining the sieving coefficient allows for an accurate estimate and provides a valid means of monitoring this parameter in the setting of hyperbilirubinemia.

Extracorporeal Therapy for Drug Overdose and Poisoning

Poisoning continues to be a significant cause of morbidity and mortality. The 2008 Annual Report of the American Association of Poison Control Centers (AAPCC) published information on 2,491,049 human exposure cases of poisoning, half of them being children younger than 6 years [1]. Prescription drugs, over the counter medications, illicit drugs, and common household substances can all be responsible for poisoning. As per the 2008 Annual Report, the top four most frequently involved substances in all human exposures were analgesics (13.3%), cosmetics/personal care products (9.0%), household cleaning substances (8.6%), and sedatives/hypnotics/antipsychotics (6.6%). Most (82.8%) poison exposures were unintentional, and suicidal intent was suspected in 8.7% of cases. In 10.6% of exposures (263,942 cases), poisoning resulted due to therapeutic errors such as inadvertent double-dosing, incorrect dosing, wrong medication taken or given, and inadvertent exposure to someone else’s medication.