"Pedogeriatrics": a pediatric nephrologist's outlook on common challenges facing pediatric and geriatric nephrologists.

Dramatic demographic changes longevity and medical progress helped create a new population made up of the survivors of previously fatal diseases. These trends pose new major social and economic challenges that should be accounted for in health policy making. This paper discusses the similarities between the specialties of pediatrics and geriatrics, especially in the realm of patient care. Children and the elderly share a limited autonomy and dependence on the human environment (i.e., willing and able caregiving persons) due to age or disease. The long-term care of dependent patients (DP) requires caregiving persons who share with dependent persons the risk of losing autonomy, facing burnout, family disruption, and interference with work and educational activities. Families with DPs may face potential losses of income because both patients and caregivers are partially or completely unable to work, the former for medical reasons and the latter due to the new demands on their time and energy. Additionally, new expenses have to be met because while direct medical expenses might be covered by insurance or the State, other expenses have to be financed by the family, such as co-payments for medicines, new water or electricity home installations, and transport and eventual hotel costs if they have to stay overnight near a hospital outside of their town. The main objectives of long-term care should be to maximize patients' independence and prevent their physical and psychological deterioration while minimizing the social, economic and personal costs to caregivers. To achieve these goals, one needs a holistic approach, a multidisciplinary professional team (doctors, nurses, social workers, nutritionists and psychologists) and auxiliary staff (secretaries, electricians, administrators, messengers, cleaning staff, doormen, nursing aids and coordinators of medical appointments and medical procedures). Optimal management of DPs on chronic treatments such as chronic dialysis requires adequate communication skills, respectful attitudes toward patients and caregivers and effective use of communication and information technologies. Auxiliary personnel require specific training to contribute effectively to the DP attention processes. This paper postulates that pediatric and geriatric teams and their patients would benefit from closer training and sharing of experiences and systems.

Comparison of chronic peritoneal dialysis outcomes in children with and without spina bifida.

This study was designed to compare chronic peritoneal dialysis (CPD) long-term outcomes (patient and technique survival, incidence of peritonitis, and overall average death outcomes) between seven patients with lumbar spina bifida (SB) and 20 controls without SB. Both groups were matched for potentially outcome-confounding factors: gender, and socioeconomic status (SES). SES was established using modified Graffar's method. No significant differences were found in CPD outcomes. The incidence of peritonitis was one episode per 17.6 and 10.3 months in SB patients and controls, respectively (p = 0.5). Overall patient survival at 5 years was 86% and 73% in SB patients and controls, respectively (p = 0.55). Overall average death rate between SB and control patients was 47.6/1,000 and 79.4/1,000 patient years, respectively (p = 0.63). Overall technique survival at 5 years was 83% and 73% in SB patients and controls, respectively (p = 0.84). There were no cases of retrograde brain ventricular infection secondary to PD-related peritonitis. We conclude that SB is not a risk factor for CPD, and therefore, it is an effective renal replacement alternative in children with SB.

Hydrothorax due to ventriculopleural shunting in a child with spina bifida on chronic dialysis: third ventriculostomy as an alternative of cerebrospinal diversion.

The purpose of this paper is to describe the risks of ventriculopleural shunt in patients with spina bifida and end-stage-renal-diseases (ESRD), and to describe endoscopic third ventriculostomy as an alternative for the combination of cerebrospinal shunt and dialysis modality. We report a 16-year-old boy with spina bifida on chronic dialysis with a massive unilateral hydrothorax and respiratory distress complicating a ventriculopleural (VPL) shunt. Two thoracocenteses were performed, draining 3200 ml of a clear fluid. The VPL shunt was removed and revised successfully to a third ventriculostomy (TVE). Peritoneal dialysis (PD) was the initial dialysis modality. After 12 months on PD, the patient was transferred to hemodialysis (HD) because of refractory peritonitis. Hydrothorax developed while the patient was on PD, reaching its maximum 2 months after the transference to HD. To our knowledge there has been no other report of ventriculopleural (VPL) shunt failure, and endoscopic TVE, as a cerebrospinal fluid (CSF) diversion alternative in patients on chronic dialysis.

Twenty years' pediatric chronic peritoneal dialysis in Uruguay: patient and technique survival.

In this study we analyze the impact of the patient's socioeconomic status (SES) and the distance from the patient's home to the dialysis center (DPH-DC), classified as < or =300 km or >300 km, on the patient and technique survival of 59 patients starting chronic peritoneal dialysis (CPD) between May 1983 and January 2004 at a single center in Uruguay. SES was established using Graffar's method. Mean duration of CPD was 38.1+/-26.0 months. Mean age at the start of CPD was 8.4+/-5.2 years. Overall patient and technique survival at 5 years were 86.4% and 77.9%, respectively. Twenty (33.8%) patients were transferred to hemodialysis. Eight (13.5%) patients died. The incidence of peritonitis was one episode every 9.1 months. There was no statistically significant difference in patient and technique survival between the patients in the low and high SES groups (p=0.72 and 0.99, respectively), and between those in the two DPH-DC groups, (p=0.22 and p=0.99, respectively). Logistic regression analysis confirmed low SES and DPH-DC >300 km are not predictors of patient death (p=0.79 and p=0.09, respectively) or technical failure (p=0.35 and p=0.15, respectively). No SES- and DPH-DC-related statistically significant differences were found in patient and technique survival.

Peritoneal dialysis in children with spina bifida and ventriculoperitoneal shunt: one center's experience and review of the literature.

OBJECTIVE: The goal of this paper was to review the viability of peritoneal dialysis (PD) in patients with spina bifida and/or ventriculoperitoneal shunt (VPS). SETTING: Pediatric dialysis unit in a tertiary-care hospital. DATA SOURCE: The course and outcome in 9 children, 5 from the authors' experience and 4 from reported experience, are analyzed. RESULTS: One patient died of a cause unrelated to PD or VPS, 2 were transferred to hemodialysis because of recurrent peritonitis, 1 discontinued PD transiently, 2 were transplanted, and 3 continue on PD. Six of these 9 children had a functioning VPS, and none presented evidence of ventriculitis or VPS dysfunction, even though 4 had PD-related peritonitis. One child presented with a massive PD-related hydrothorax. CONCLUSIONS: (1) Having a VPS is not an absolute contraindication to PD; the available data support the viability of PD in patients with spina bifida and/or a VPS. (2) If cerebrospinal fluid diversion is needed simultaneously or after starting PD, an extraperitoneal site should be a better choice than VPS. This should avoid the risk of intra- and postoperative infection in the PD catheter secondary to surgical intervention for VPS insertion. (3) Loss of peritoneal function is a potential late risk related to cerebrospinal fluid and PD. (4) Spina bifida patients on PD present specific diagnostic challenges due to overlapping symptoms (e.g., vomiting, abdominal tenderness, fever) secondary to PD- or VPS-related complications (e.g., peritonitis, visceral injury by devices) or primary disease (e.g., neurogenic bladder, pyelonephritis), with inherent risks of delaying adequate treatment. Cloudy peritoneal effluent is an early indication of peritonitis, although it is not specific. (5) Early evaluation by a pediatric surgeon and a neurosurgeon is required for effective management of complications and selection of more efficient individualized therapeutic alternatives. Prompt treatment of complications is crucial. A registry of children with spina bifida on PD and the accumulation of a large population followed up for longer periods will provide an objective assessment of their problems and management.

Recomendaciones para pacientes con vejiga neurógena / Recomentations for patients with neurogenic bladder

La difusión de medidas que permitan prevenir mayores complicaciones cuando ya está presente una patología, y la necesidad de facilitar una vida más adecuada a aquellos individuos afectados por una enfermedad, como es la vejiga neurogéna, es el objetivo que persigue este artículo dirigido a médicos y enfermeras, al entregar algunas indicaciones prácticas para que sean dadas a conocer al paciente y a sus familiares

Atención de niños con nefrosis en medios con reducida dotación tecnológica / Care of children with nephrosis in means of reduced technological equipment

La salud global es el objetivo de la atención de un paciente con nefrosis corticosensible (NCS); ésta, abarca en el niño todas las dimensiones de la salud, tomando en consideración la continuidad a través del tiempo, las interacciones con el entorno y el desarrollo, tanto en la enfermedad como en la salud (M. Manciaux). El desarrollo normal del niño está estrechamente relacionado a la salud, y constituye su mejor indicador positivo. No existe, por lo tanto, ni en la salud ni en la enfermedad de los niños, la posibilidad de disociar los aspectos físicos, sociales y psicológicos de un ser en crecimiento y desarrollo. Un niño portador de una enfermedad prolongada, con probabilidades de extenderse a la adolescencia y edad adulta, como la NCS, tiene riesgos de interferencia con el desarrollo normal. Estos riesgos derivan de la enfermedad, de la iatrogenia y del modelo de atención médica. El tratamiento de la nefrosis, sencillo y de bajo costo, es un aspecto básico, pero parcial de la atención del paciente. La atención del paciente incorpora al tratamiento componentes que son determinantes no biológicos de la salud global. Los componentes no somáticos de la atención tienen como características destacadas: a) no son ostensibles, salvo que se orienten las acciones especifícamente a su detección; b) no son estables; c) son determinantes básicos para lograr la salud global