Severe neonatal renal failure after maternal use of angiotensin II type I receptor antagonists.

Sartans are selective type 1 angiotensin II receptor antagonists that are used for treatment of arterial hypertension. We report a case of severe renal failure required dialysis after the use of olmesartan in the last month of pregnancy. Exposure to sartans during the last period of gestation seems to be associated with high risk of congenital malformations. It is important to stress that the use of these drugs during pregnancy must be avoided, especially in the third trimester.

A randomised, double blind, placebo controlled trial of the effect of theophylline in prevention of vasomotor nephropathy in very preterm neonates with respiratory distress syndrome.

BACKGROUND: Vasomotor nephropathy is a common renal dysfunction in very preterm neonates. OBJECTIVE: To determine whether theophylline could prevent vasomotor nephropathy in very preterm infants with respiratory distress syndrome. METHODS: A randomised, double blind, placebo controlled trial of 50 preterm infants of gestational age < or = 32 weeks needing assisted ventilation. Infants received an intravenous dose of theophylline (1 mg/kg) or placebo for three days. The 24 hour urine volume was measured daily. On days 2, 5, and 11, blood samples and 12 hour urine collections were analysed for electrolytes, creatinine, and urea. RESULTS: On day 1, urine output was significantly higher in the theophylline (2.4 (0.9) ml/kg/h) than the placebo (1.6 (1.0) ml/kg/h; p = 0.023) group (values are mean (SD)). The incidence of oligoanuria was significantly lower in the theophylline treated (5%) than the placebo (33%) group. Twenty four hours after the first administration of theophylline/placebo, serum creatinine concentration was significantly lower in the theophylline (0.76 (0.23) mg/dl) than the placebo (1.0 (0.41) mg/dl; p = 0.025) group. On day 5 an increase in serum creatinine was observed in both groups. On day 11 a significant reduction in serum creatinine was observed, compared with day 5, with no difference between the two groups. CONCLUSION: The results suggest that, in very preterm infants with respiratory distress syndrome, early theophylline administration improves renal function during the first two days of life.

[Pneumothorax during nasal-CPAP: a predictable complication?]. / Pneumotorace in corso di CPAP nasale. E una complicanza prevedibile?

OBJECTIVE: Pneumothorax (PNX) is a relatively common complication of nasal-CPAP (N-CPAP). Aim of the study was to identify prognostic factors of its onset. METHODS: Seventy-seven newborns, admitted from January to December 2002 to the Neonatal Intensive Care Unit of Brescia, who were treated with N-CPAP with Infant Flow System as first intention, were included. Gestational age and birth weight were (mean +/- SD) 33.7 +/- 3.02 weeks and 2.047 +/- 684 grams, respectively. Infants were put on N-CPAP at 2.7 +/- 4.1 hours of life. The duration of treatment was 27.7 +/- 27.7 hours. RESULTS: Fifty-one neonates improved and N-CPAP was discontinued, 26 worsened and required intubation and mechanical ventilation. Eight of them developed PNX (10,3%). No significant differences were found among the three groups (improved, worsened without PNX and worsened with PNX) concerning mode of delivery, gestational age, birth weight and blood gases. The patients with PNX needed a FiO2 28% higher than the initial value after 12 hours of treatment, and 46% higher at 24 hours (p = 0,017). At diagnosis, FiO2 was 53,5% higher than the initial value (p = 0,005). CONCLUSION: A 40% increase of FiO2, during the first 24 hours of N-CPAP may represent an useful marker to identify the infants at high risk of developing a pneumothorax.

Renal effects of antenatally or postnatally administered steroids.

Steroids administrated antenatally to the mothers improve postnatal outcomes of the newborns with pleiotropic effects. Furthermore steroids have been used in preterm infants to prevent or treat chronic lung disease. Synthetical glucocorticoids readily cross placental barrier and reach significant pharmacologic levels in the fetus: besides their well known pulmonary effects they have a concomitant maturational effect of postnatal renal function in preterm infants both with a direct and indirect effect. Endogenous and exogenous glucocorticoids play a role in the maintenance of glomerular filtration (GFR). The antenatal administration of steroids increases the GFR, in association to the maturation of the tubular function. According to different studies the improvement of renal function, expressed by the increase of GFR, is only partially referable to the increase of MAP and the improvement of the cardiovascular status, while it was imputable to a direct renal effect of the steroids, especially on the renal blood flow, on functional glomerular surface area available for filtration and on the glomerular filtrate of the single cortical nephron. However debate remains about the mechanism through which steroids would act on the renal vascular smooth muscolature. The increase the GFR observed after the antenatal administration of glucocorticoids in premature fetuses is also accompanied by an increase of urinary flow and of fractional excretion of sodium. Glucocorticoids would increase the proximal reabsorption of sodium increasing directly the function and the expression of the sodium transporters and both indirectly and directly increasing the activity of Na-K-ATPase. In extremely low weight antenatal administration of betamethasone or dexamethasone was associated with lower estimated insensible water loss, secondary to a direct maturational effect in the skin epithelial barrier, as well as an increased reabsorption of the fetal lung fluid. Moreover antenatal glucocorticoid administration was associated, at birth, to a significant suppression of plasma renin activity and angiotensin II in comparison to the controls. Despite the wide use of the steroidal therapy in the prevention of the bronchopulmonary dysplasia, only few articles, in literature, analyse the effects of glucocorticoids on postnatal renal function, such as the increase in urinary flow. The authors think that steroids contribute in a meaningful way to the clinical improvement observed in children with BPD through the maturative action on the premature kidney with effect both at glomerular and tubular level.

Complications linked to chronic peritoneal dialysis in children after kidney transplantation: experience of the Italian Registry of Pediatric Chronic Peritoneal Dialysis.

Our objective was to evaluate the infectious complications of the post-transplant period attributable to the persistence of catheter and other complications when chronic peritoneal dialysis (CPD) was performed post-transplantation. The design was a retrospective study, and the setting was an Italian registry of pediatric chronic peritoneal dialysis. There were 86 pediatric renal transplants (9/86 from living related donors, 2/86 simultaneous liver and kidney transplantation for oxalosis). Six of 86 transplants were lost at follow-up. Mean age of the children (n = 80) at transplantation was 9.3 years (range: 1.7-21 years). They had been on CPD for a mean period of 1.7 years (range: 0.2-4.6 years). During CPD, 67 peritonitis episodes (80% related to exit-site and/or tunnel infections) were observed, with an incidence of peritonitis of one episode per 16 months CPD. The mean safe interval of peritonitis and/or exit-site or tunnel infection was 208 days (range: 36-1897 days). The mean time of catheter removal was 80.3 days (range: 0-216 days) post-transplantation. During the first month post-transplantation, one episode of peritonitis secondary to a sepsis occurred in one child. No other episodes of peritonitis or exit-site and/or tunnel infections were observed. Two of 80 children returned to CPD (at four and at 12 months, respectively) because of persistent allograft failure. Furthermore, 12 patients were on CPD because of temporary graft failure. In all these patients the pretransplant peritoneal dialysis (PD) catheter was utilized, with no complications. These data show that the persistence of the PD catheter after kidney transplantation has produced no infections or other complications. What is more, the catheter was safely utilized during acute rejection or primary allograft nonfunction.

Comparison of patient hospitalization in chronic peritoneal dialysis and hemodialysis: a pediatric multicenter study.

Patient hospitalization was compared in 207 pediatric patients (age < or = 15 years at the start of dialysis) on chronic peritoneal dialysis (CPD) (127 patients) or center hemodialysis (HD) (80 patients), treated in 17 dialysis centers during the period 1989 to 1994, and followed up for at least three months. The hospitalization rate was expressed as hospital days per patient-month, and was calculated on the overall period of treatment and separately for the first and second year. Since the age at start of dialysis markedly differed between CPD (8.2 +/- 4.7 years) and HD (11.2 +/- 2.9 years) patients (with no HD patient younger than five years), results are separately presented in three patient groups: CPD patients aged < 5 years (A); CPD patients aged five to 15 years (B); HD patients (C). The duration of hospitalization was subdivided according to the following different causes: routine (monitoring of dialysis adequacy), complications of the modality, patient primary renal disease, and other causes. The results are presented in Table 1. A statistically significant difference in total days hospitalized was found between each of the two groups of CPD patients and the HD patients; the results for hospitalization for dialysis-related complications were higher in the group of younger children on CPD, while the difference between the two age-matched groups of patients on CPD and HD was not significant.

Clinical experience in the treatment of infants with chronic peritoneal dialysis.

Chronic peritoneal dialysis (CPD) is the first treatment modality for most infants with end-stage renal failure; this group of patients shows peculiar clinical and technical problems. We present the data from a National Registry on 22 children starting CPD under one year of age, representing 11.6% of the total population of the Registry (189 patients). Mean weight at start of CPD was 6.1 +/- 1.8 kg and duration of dialysis was 22.1 +/- 15.5 months. During the follow-up period, 9 patients were transplanted, 1 was shifted to hemodialysis, and 4 died. Patient survival was 89.1% and 82.2% at 1 and 2 years (97.9% and 96.5% in the group of 167 older children); technique survival results were 89.1% at 1 year and 77.1% at 2 years (vs 92.5% and 85.7%, respectively). The incidence of peritonitis was 1 episode every 15.6 CPD-months (1:16.1 in the older children). Catheter-related complications occurred more frequently in infants (1:11.8 vs 1:17 episode:CPD-months), even if this difference was not statistically significant. Statural growth was on average -0.29 +/- 0.66 SD/year with a significant improvement between the first (-0.50 +/- 0.79) and the second (+0.23 +/- 0.77) year of CPD. Our data confirm that infants represent a higher risk group and that they can be treated satisfactorily with CPD while awaiting renal transplantation.

Cardiovascular function in a chronic peritoneal dialysis pediatric population on recombinant human erythropoietin treatment.

Anemia, through a hyperkinetic state, is an important contributor to myocardial function impairment. To determine the cardiovascular effects of recombinant human erythropoietin (rHuEPO) therapy, 10 chronic peritoneal dialysis (CPD)-treated anemic children were studied before and during 18 months of treatment. The following parameters were recorded: hemoglobin (Hb) [percent of target level (TL) = x-2 standard deviations of normal Hb values for age and sex], heart rate (HR, beats/minute), mean arterial pressure (MAP, mmHg), end-diastolic left ventricular diameter (EDLVD, mm/sm BSA), shortening fraction (SF, percent), and interventricular septal thickness (IVS, mm/sm BSA). Student's t-test for paired data showed (vs time before treatment, T0) a progressive increase in Hb, a progressive decrease in HR, and a progressive increase in MAP. EDLVD progressively decreased, while SF and IVS remained unchanged throughout the study. Regression analysis showed a close correlation between anemia correction and decrease of HR (p < 0.01), while no correlation was found between Hb and EDLVD or SF, IVS, or MAP. Our data indicate that anemia correction in these patients is mainly associated with a decrease in hyperkinetic state (HR reduction with SF unvaried), while left ventricular function and dimensions remain normal, despite an increase in MAP.

Adequacy of solute and water removal in children treated with nightly intermittent peritoneal dialysis.

Nightly intermittent peritoneal dialysis (NIPD) is an automated form of intermittent peritoneal dialysis which has potential medical and psychosocial advantages in comparison with CAPD/CCPD due to the lack of daytime exchanges. Data on solute/water removal in children on NIPD are nevertheless scarce, so that no clear indications for NIPD can yet be formulated in pediatric age. For this reason, 12 patients, mean age 10.49 +/- 5.81, mean body weight 23.73 +/- 10.92, with a residual creatinine clearance 1.70 +/- 2.30 ml/min/1.73 sqm, on NIPD for 14.7 +/- 5.4 months, underwent clearance studies over 3 days. Mean dialysis infusion volume was 460.08 +/- 196.30 ml/kg/day, with 10.33 +/- 1.22 h dialysis time. Peritoneal creatinine and urea clearances were 6.36 +/- 2.96 and 8.49 +/- 3.35 1/day/1.73 sqm, respectively. Combined creatinine and urea clearances averaged 6.12 +/- 2.21 and 6.96 +/- 2.16 ml/min/1.73 sqm, resulting in serum creatinine and urea values of 7.78 +/- 1.90 and 115.58 +/- 29.93 mg/dl, respectively. Ultrafiltration rate was 16.94 +/- 16.34 ml/g glucose absorbed. NIPD provided similar or improved solute and water clearances compared with those reported in children and adults on CAPD/CCPD, without inconvenient long periods in bed. These data indicate that NIPD is a suitable treatment in pediatric end-stage renal disease.

Changes in visual evoked potentials in children on chronic dialysis treatment.

Visual evoked potentials (VEP) were recorded in 20 children undergoing dialysis for chronic renal failure. VEP before treatment (72 h after last dialysis) were pathological in 17 patients (85%); responses obtained 3 h after treatment were abnormal in only 6 cases (30%). Furthermore, all patients improved after treatment, except two who were unchanged. However, VEP recorded immediately after dialysis were worse in 4 of 7 patients than before treatment, probably as an effect of the dysequilibrium syndrome; they improved spontaneously afterwards. The acute changes caused by dialysis seem to be more evident in children than in adults. No correlations have been found between blood chemistry indexes and VEP modifications. Finally, VEP have proved to be more sensitive than EEG in identifying a central nervous system (CNS) dysfunction in these uremic patients.