Growth, development and nutritional status in Japanese children under 2 years on continuous ambulatory peritoneal dialysis

Elective Cesarean Section during Preterm Prevents Pulmonary Hypoplasia Development in Potter Sequence

Potter syndrome, first reported in 1946 by Edith Potter, refers to fatal cases of bilateral renal aplasia with pulmonary hypoplasia, peculiar facial features, and limb deformities. Presently, patients with oligohydramnios showing similar pathological manifestations due to oligohydramnios caused by conditions other than bilateral renal aplasia have been reported, and are known as the Potter sequence. There are limited studies and unclear guidelines on the safest delivery time and detailed postpartum management for patients with the Potter sequence. We experienced a case of Potter sequence, in which the patient was born by elective cesarean section at gestational age (GA) of 34 weeks. Fetal ultrasound at GA of 26 weeks 4 days showed oligohydramnios, multilocular cystic lesions in the left kidney, and an absent right kidney. Prenatal fetal MRI at GA of 33 weeks and 3 days showed pulmonary hypoplasia, and the ratio of fetal lung volume (FLV) to fetal body weight (FBW) was 0.0135 ml/g. We suspected that the fetal lung could not grow because of persistent oligohydramnios, which leads to a further decline in the ratio of FLV to FBW during pregnancy. We performed a cesarean section at GA of 34 weeks to prevent the exacerbation of the imbalance between lung volume and physique. We struggled to keep her condition stabilized with strict management of her respiratory condition, dialysis, and nutrition. She was discharged from the hospital at 169 days of age. Elective caesarean section in the term of premature birth prevented the progression of pulmonary hypoplasia and made it possible to save her life. Potter sequence is still relatively unknown, and it is necessary for more studies to be conducted in the future.

Overview of Albumin Physiology and its Role in Pediatric Diseases

PURPOSE OF REVIEW

Albumin plays a critical role in a wide range of disease processes; however, the role of albumin in pediatric patients has not been well described. This article aims to review albumin physiology and kinetics in children, albumin's impact on pediatric diseases, and the utility of albumin as a predictor of clinical outcome.

RECENT FINDINGS

Hypoalbuminemia is seen in a wide range of conditions, including protein-losing enteropathy, hepatic synthetic failure, malnutrition, inflammatory states, and renal disease. While the impact of hypoalbuminemia has been more extensively studied in adult patients, there is a relative paucity of literature in the pediatric population. Hypoalbuminemia is a marker of poor outcome in critically ill children and those undergoing a wide range of medical interventions. Albumin infusions may be an effective therapy for fluid resuscitation and for patients with severe hypoalbuminemia.

Malnutrition Essentials for Neurologists and Neurosurgeons: A Review of the Literature

Malnutrition still causes deaths in the world today and protein energy malnutrition (PEM) is characterized by increased oxidative stress, immune deficiency, and development of various infections. Even today, however, it is an underrecognized and undertreated entity in neurology and neurosurgery. In this article, we therefore seek to review the available literature regarding various factors affecting surgical outcome of children with malnutrition undergoing some neurosurgical interventions including shunt surgery and traumatic brain injury in intensive care unit, in addition to its effects upon oxidative stress status and immunity. Furthermore, we attempt to provide essential knowledge of malnutrition affecting surgical outcome of patients with PEM. Based on available evidence in the published literature, it is concluded that it is a serious public health problem characterized by increased oxidative stress, immune deficiency, and development of various infections.

Peritoneal Dialysis in Children under 5 Years of Age

Objective

We report our experience with maintenance peritoneal dialysis (PD) in small children.

Design

This is a retrospective analysis of the patient records of all children under the age of 5 years treated with continuous peritoneal dialysis (CPD) between 1986 and 1994 in Finland.

Setting

Treatment was started and the patients were seen at the outpatient clinic at the Hospital for Children and Adolescents, University of Helsinki, every 3 months. Between these visits, they had controls at their local hospital every 2 -4 weeks.

Patients

The most common primary renal disease in these 34 patients was congenital nephrotic syndrome of the Finnish type (27 patients). Others were: congenital nephrotic syndrome (3 patients), polycystic kidney disease (1), urethral valve (1), neuroblastoma (1), and renal dysplasia (1).

Results

Mean age at onset was 1.6 years and median treatment time 9.3 months. Time spent in hospital decreased from 270 days/year in the 1980s to 150 days/year in the 1990s. Two children died (5.9%). The peritonitis rate on continuous cyclic peritoneal dialysis was 1:11.5 patient-months. Hernias were diagnosed in 29% of the patients. After 3 months half of the patients were on antihypertensive medication. Pulmonary edema was diagnosed once in 12 patients and twice in 2 patients. During the first 6 months on PD the mean height standard deviation score (hSDS) increased from -2.13 to -1.66 (p < 0.0001). The 6-month change in hSDS before initiation and 6 months after the start of CPD increased from -0.12 ± 0.68 to +0.59 ± 0.64 (p = 0.0008).

Conclusions

Our results indicate that peritoneal dialysis is feasible and safe in small children. Mortality was low and growth was good. The major challenges presented by CPD therapy were maintenance of optimal nutrition, avoidance of peritonitis, and control of volemia.

Efficacy of Gastrostomy Feeding in Infants and Older Children Receiving Chronic Peritoneal Dialysis

Objective

To assess the efficacy of supplemental gastrostomy tube (g-tube) feeding in infants and children receiving chronic peritoneal dialysis (CPD).

Design

Retrospective observational study.

Setting

Pediatric nephrology division of tertiary care center.

Patients

Fifteen patients undergoing g-tube insertion while receiving CPD were included in the study, and were subdivided, on the basis of age, into the following groups: infants (≤ 2.5 years, n = 8); older children (> 2.5 years, n = 7).

Main Outcome Measures

Assessment of the effect of CPD and g-tube feeding on statural growth assessed by height standard deviation score (SDS) and percentage weight-for-height, and measured anthropometric variables including triceps skinfold thickness (TSF), midarm muscle circumference (MAMC), and midarm mean circumference (MAC). Assessment of the effects of CPD and g-tube feeding on measured biochemical variables including total protein, albumin, cholesterol, triglycerides, and high density lipoprotein.

Results

No significant change in height SDS was observed; however, the reported continuing decline in height SDS in infants was arrested. Percentage weight-for-height increased significantly in infants at 6 months ( p = 0.008) and 12 months ( p = 0.006) following initiation of g-tube feeding. An increase was also observed in the older child group, being significant at 12 months ( p = 0.031) following g-tube insertion. Increases in all anthropometric variables occurred in the infant group during CPD and post g-tube insertion, significant only for MAMC at 12 months ( p = 0.037) post g-tube insertion. In older children little change occurred during CPD, with all variables increasing post g-tube insertion, significant only for MAMC at 6 months ( p = 0.02) and 12 months ( p = 0.02). An increase in total protein and albumin was noted; however, no significant changes in any biochemical parameters were observed.

Conclusions

Supplemental g-tube feeding facilitates weight gain in infants and older children receiving CPD and arrests the decline in height SDS traditionally observed in infants with end-stage renal disease. No significant alteration was observed in measured biochemical variables, although an increase in total protein and albumin was noted.

Low Body Mass Index and Low Intelligence Quotient Are Infection Risk Factors in Vagus Nerve Stimulation

BACKGROUND

Risk factors for infection after vagus nerve stimulation (VNS) device implantation represent an important issue but remain unclear. We hypothesized that specific risk factors for infection would be associated with VNS device implantation. This study reviewed patients with epilepsy who underwent VNS device implantation and undertook a statistical analysis of risk factors for surgical site infection (SSI).

METHODS

We reviewed all medical records for patients who underwent VNS therapy in our facility between August 2011 and May 2018. Age, sex, height, body weight, body mass index (BMI), intelligence quotient (IQ), surgical incision opening time, blood loss, epilepsy classification, activities of daily living, and generator replacement were statistically compared between cases with and without SSI.

RESULTS

We performed 208 VNS device implantation surgeries at our facility during the study period. Among these, 150 patients underwent initial implantation, 56 patients underwent first generator replacement, and 2 patients underwent second replacement. Six patients (2.7%) with initial implantation and 3 patients (5.4%) with first replacement showed SSI. Low BMI was a risk factor for infection at initial implantation (P < 0.0012) using a BMI within 1.78 kg/m2 of the cutoff for being underweight (100% sensitivity, 25% specificity). Low IQ (P = 0.0015) was also a risk factor for SSI.

CONCLUSIONS

This study identified low BMI and low IQ at initial implantation as risk factors for infection.

Individual and community level factors with a significant role in determining child height-for-age Z score in East Gojjam Zone, Amhara Regional State, Ethiopia: a multilevel analysis

Background

In Ethiopia, child undernutrition remains to be a major public health challenge and a contributing factor for child mortality and morbidity. To reduce the problem, it is apparent to identify determinants of child undernutrition in specific contexts to deliver appropriately, targeted, effective and sustainable interventions.

Methods

An agroecosystem linked cross-sectional survey was conducted in 3108 children aged 6–59 months. Multistage cluster sampling technique was used to select study participants. Data were collected on socio-demographic characteristics, child anthropometry and on potential immediate, underlying and basic individual and community level determinants of child undernutrition using the UNICEF conceptual framework. Analysis was done using STATA 13 after checking for basic assumptions of linear regression. Important variables were selected and individual and community level determinants of child height-for-age Z score were identified. P values less than 0.05 were considered the statistical level of significance.

Results

In the intercept only model and full models, 3.8% (p < 0.001) and 1.4% (p < 0.001) of the variability were due to cluster level variability. From individual level factors, child age in months, child sex, number of under five children, immunization status, breast feeding initiation time, mother nutritional status, diarrheal morbidity, household level water treatment and household dietary diversity were significant determinants of child height for age Z score. Also from community level determinants, agroecosystem type, liquid waste disposal practice and latrine utilization were significantly associated with child height-for-age Z score.

Conclusion

In this study, a statistical significant heterogeneity of child height-for-age Z score was observed among clusters even after controlling for potential confounders. Both individual and community level factors, including the agroecosystem characteristics had a significant role in determining child height-for-age Z score in the study area. In addition to the existing efforts at the individual levels to improve child nutritional status, agroecosystem and community WASH related interventions should get more attention to improve child nutritional status in the study area.

Long-term neurocognitive outcomes of patients with end-stage renal disease during infancy

BACKGROUND

End-stage renal disease (ESRD) during infancy has been associated with poor short-term neurocognitive outcomes. Limited information exists regarding long-term outcomes.

METHODS

Neurocognitive outcomes for 12 patients diagnosed with ESRD during the first 16 months of life were assessed. Nine patients (mean age: 11 years) were compared to their healthy siblings (mean age: 10 years) on measures of intellectual and executive functioning, memory, and academic achievement using paired-samples t tests.

RESULTS

Patients' Full Scale IQ (FSIQ) scores (M = 78, SD = 16.1) were significantly lower than sibling controls (M = 94, SD = 18.9; p < 0.03). For patients, FSIQ negatively correlated with total months on dialysis (r = -0.6, p < 0.04), as did WISC-IV Processing Speed (r = -0.6, p < 0.05). Patients' scores on the Metacognition Index of the BRIEF (M = 61.4, SD = 16.3) were significantly higher (indicating greater risk for dysfunction) than siblings (M = 46.7, SD = 6.4; p < 0.04). Patients' scores (M = 84, SD = 19) on the WIAT-II-A Total Achievement were significantly lower than siblings (M = 103, SD = 20, p < 0.01). Younger age at transplant was associated with higher scores on measures of Processing Speed (r = -0.7, p < 0.05), as well as higher scores on measures of executive functioning, memory, and academic achievement.

CONCLUSIONS

In summary, patients diagnosed with ESRD as infants had intellectual and metacognitive functioning significantly lower than sibling controls. Fewer months on dialysis and younger age at transplant were associated with better outcomes.

Neurological development in 21 children on peritoneal dialysis in infancy

Few studies have focused on the neurodevelopment of infants on peritoneal dialysis (PD). Infants are the most demanding patient group on PD and thus are vulnerable to neurological sequelae. We studied 21 patients <2 years of age (mean 0.59 years) at onset of PD. They were evaluated by a neurologist, otologist, physiotherapist, and occupational therapist during PD. Neuropsychological tests were collected from all patients at least 5 years old, and the brain images were reviewed. Eleven patients (52%) had a pre- or neonatal problem or comorbidity as risk factor for their development at onset of PD. All infants tolerated PD well. At the end of the study, 71% had some neurological abnormality, 29% a major impairment (all with predialysis risk factors), and 43%  a minor one. Brain infarcts were detected in four patients (19%) and other ischemic lesions in three (14%). Three patients (14%) developed hearing defect. Mortality rate was 5%. PD is a safe treatment modality for end-stage renal failure in infants. Some patients had risk factors for development, but their neurological problems did not progress during PD. Patients without risk factors tolerated PD well without major neurological sequelae.

Peritoneal dialysis in infants: the experience of the Italian Registry of Paediatric Chronic Dialysis

BACKGROUND

Although chronic peritoneal dialysis (CPD) is considered the replacement therapy of choice for infants with end-stage renal failure, many questions persist about treatment risks and outcomes.

METHODS

We present data on 84 infants who started CPD at <1 year of age; these patients represent 12% of the total population of the Italian Registry of Paediatric Chronic Dialysis. We analysed patient records from all children consecutively treated with CPD between 1995 and 2007 in Italy. Growth data analysis was performed only in infants with complete auxological parameters at 0, 6 and 12 months of follow-up.

RESULTS

Median age at the start of CPD was 6.9 months, weight was 6.1 kg and length 63.6 cm. In one-half of the study population diagnosis leading to renal failure was congenital nephrouropathy. Twenty-eight per cent of the children had at least one pre-existing comorbidity. The mean height standard deviation score was -1.65 at the start of CPD, -1.82 after 12 months and -1.53 after 24 months. Catch-up growth was documented in 50% of patients during dialysis. A positive correlation was observed between longitudinal growth and both exchange volume (R(2) = 0.36) and dialysis session length (R(2) = 0.35), while a negative association was found with the number of peritonitis cases (P = 0.003). Peritonitis incidence was 1:20.7 episode:CPD-months (1:28.3 in the older children from the same registry) and was significantly higher in children with oligoanuria (1:15.5 episode:CPD-months) compared to infants with residual renal function (1:37.4 episode:CPD-months). Catheter survival rate was 70% at 12 months and 51% at 24 months. Catheter-related complications were similar in infants and older children (1:20.5 versus 1:19.8 episode:CPD-months), while clinical complications were more frequent in children under 1 year of age (1:18.3 versus 1:25.2 episode:CPD-months; P < 0.05). During the follow-up period, 33 patients were transplanted (39.3%), 18 were shifted to haemodialysis (21.4%) and 8 died (9.5%). The mortality rate was 4-fold greater than in older children (2.3%).

CONCLUSIONS

Our data confirm that infants on CPD represent a high-risk group; however, our experience demonstrated that growth was acceptable and a large portion was successfully transplanted. Increased efforts should be aimed at optimizing dialysis efficiency and preventing peritonitis. The higher mortality rate in infants was largely caused by comorbidities.

2009 Japanese Society for Dialysis Therapy guidelines for peritoneal dialysis

The guidelines for peritoneal dialysis (PD) of the Japanese Society for Dialysis Treatment were prepared at 2009. Upon presenting a concrete frame of PD practiced in Japan, it aims to promote PD as a standardized therapy in Japan. Notably, the guidelines recommended combination therapy of PD and hemodialysis as a part of integrated renal replacement therapy for end-stage renal disease, as well as timely PD withdrawal by peritoneal degeneration in order to prevent progression of encapsulating peritoneal sclerosis.

Current advances in chronic kidney disease in children: growth, cardiovascular, and neurocognitive risk factors

Linear growth and neurocognitive development are two of the most important differences between adults and children, in terms of clinical issues that must be addressed in patients with chronic kidney disease (CKD). Correction of metabolic acidosis, nutritional deficiency, and renal osteodystrophy improve linear growth, but many children require administration of growth hormone to achieve normal growth. A variety of neurocognitive deficits occur in children with CKD, although there has been an improvement in outcome via improved dialysis, correction of malnutrition, and decreased aluminum exposure. Although growth and neurocognitive development are delayed, cardiovascular complications are accelerated in children with CKD, and are reflected in a dramatic increase in cardiovascular mortality compared with healthy children. Other early cardiovascular complications in children with CKD include left ventricular hypertrophy, cardiac dysfunction, and vascular calcifications.

Nutrition in children with CRF and on dialysis

The objectives of this study are: (1) to understand the importance of nutrition in normal growth; (2) to review the methods of assessing nutritional status; (3) to review the dietary requirements of normal children throughout childhood, including protein, energy, vitamins and minerals; (4) to review recommendations for the nutritional requirements of children with chronic renal failure (CRF) and on dialysis; (5) to review reports of spontaneous nutritional intake in children with CRF and on dialysis; (6) to review the epidemiology of nutritional disturbances in renal disease, including height, weight and body composition; (7) to review the pathological mechanisms underlying poor appetite, abnormal metabolic rate and endocrine disturbances in renal disease; (8) to review the evidence for the benefit of dietetic input, dietary supplementation, nasogastric and gastrostomy feeds and intradialytic nutrition; (9) to review the effect of dialysis adequacy on nutrition; (10) to review the effect of nutrition on outcome.

Hypoalbuminemia and risk of death in pediatric patients with end-stage renal disease

BACKGROUND

Although serum albumin is a marker for malnutrition and associated with a higher mortality in adult patients with end-stage renal disease (ESRD), the risk of death associated with serum albumin is unknown in pediatric patients with ESRD. We evaluated the association between serum albumin and death among pediatric patients initiating dialysis.

METHODS

Data from the United States Renal Data System (USRDS) were used to identify all patients under the age of 18 who initiated dialysis between January 1, 1995 and December 31, 1998. Using the Cox proportional hazards models, the association between serum albumin obtained 45 days prior to dialysis initiation and death was estimated, controlling for demographic factors, dialysis modality, and anthropometric measures.

RESULTS

Of 1723 patients included in the analysis, there were 93 deaths over 2953 patient-years of observation. The multivariate analysis demonstrated that each -1 g/dL difference in serum albumin between patients was associated with a 54% higher risk of death [adjusted relative risk (aRR), 1.54; 95% confidence interval (CI), 1.15 to 1.85; P=0.002]. This was independent of glomerular causes for their ESRD and other potential confounding variables.

CONCLUSIONS

Pediatric patients initiating dialysis with hypoalbuminemia are at a higher risk for death. This finding persists after adjusting for glomerular causes for ESRD and other potential confounding variables. Low serum albumin at dialysis initiation is an important marker of mortality risk in pediatric ESRD patients.

Long-term outcome of peritoneal dialysis in infants

Debate continues concerning the treatment of infants with end-stage renal disease. We evaluated progress and outcome of 20 infants with a mean age of 0.34 year (range, 0.02-1 year) in a long-term peritoneal dialysis program at a single center. Mean weight at the start of dialysis was 4.8 kg (range, 1.7-11.4 kg), and the duration of dialysis was 17.3 months (range, 1-59 months). Eleven infants received renal transplants, 4 were switched to hemodialysis and then received transplants, 4 died, and 1 continues to receive peritoneal dialysis. There was significant co-morbidity in 6 infants who died or required hemodialysis. Catheter interventions were frequent, with 12 infants requiring at least one replacement. There were 1.1 episodes of peritonitis per patient-year; 70% of infants had 0 to 1 episode. Mean weight standard deviation score (SDS) was -1.6 at the start, -0.3 at 1 year (P =.0008), and 0.3 at 2 years (P =.0008). Height SDSs were -1.8 at the start, -1.1 at 1 year (P =.046), and -0. 8 at 2 years (P =.06). Head circumference SDSs were -1.9 at the start, -1.3 at 6 months (P =.003), and -0.9 at 1 year (P =.015). Fourteen of 16 survivors are achieving normal developmental milestones or attend mainstream school. Peritoneal dialysis in infancy is a demanding treatment, but outcome for growth, development, and transplantation justifies this intensive approach. When parents are counseled, the importance of non-renal co-morbidity must be emphasized.

Optimal care of the pediatric end-stage renal disease patient on dialysis

This manuscript is an effort on behalf of the American Society of Pediatric Nephrology to provide recommendations designed to optimize the clinical care of pediatric patients with end-stage renal disease (ESRD). Although many of the recommendations are evidenced-based with the supporting data being derived from a variety of sources, including patient registries, others are opinion-based and derived from the combined clinical experience of the authors. In all cases, it is recommended that the decision to initiate dialysis should be made only after an assessment of a combination of biochemical and clinical characteristics. Irrespective of the choice of dialysis modality (hemodialysis v peritoneal dialysis), dialysis efficacy should be measured regularly, and the dialysis prescription should be designed to achieve target clearances. Attention to dialysis adequacy, control of osteodystrophy, nutrition, and correction of anemia is mandatory, because all may influence patient outcome in terms of growth, cognitive development, and school performance. Finally, the availability of a multidisciplinary team of pediatric specialists is desirable to provide all facets of pediatric ESRD care, including renal transplantation, in an optimal manner. Future clinical research efforts intended to address topics such as dialysis adequacy, anemia management, and growth should be encouraged.