The bone and mineral disorder of children undergoing chronic peritoneal dialysis.

The mineral and bone disorder of chronic kidney disease remains a challenging complication in pediatric end-stage renal disease. Here, we assessed symptoms, risk factors and management of this disorder in 890 children and adolescents from 24 countries reported to the International Pediatric Peritoneal Dialysis Network Registry. Signs of this disease were most common in North American patients. The prevalence of hyperphosphatemia increased with age from 6% in young infants to 81% in adolescents. Serum parathyroid hormone (PTH) was outside the guideline targets in the majority of patients and associated with low calcium, high phosphorus, acidosis, dialysis vintage and female gender. Serum calcium was associated with dialytic calcium exposure, serum phosphorus with low residual renal function and pubertal status. PTH levels were highest in Latin America and lowest in Europe. Vitamin D and its active analogs were most frequently administered in Europe; calcium-free phosphate binders and cinacalcet in North America. Clinical and radiological symptoms markedly increased when PTH exceeded 300 pg/ml, the risk of hypercalcemia increased with levels below 100 pg/ml, and time-averaged PTH concentrations above 500 pg/ml were associated with impaired longitudinal growth. Hence, the symptoms and management of the mineral and bone disorder of chronic kidney disease in children on peritoneal dialysis showed substantial regional variation. Our findings support a PTH target range of 100-300 pg/ml in the pediatric age group.

[Simvastatin therapy and effect on hiperlipidemia and vascular status in nephrotic children with sustained dyslipidemia]. / Wplyw simwastatyny na zaburzenia profilu lipidowego i stan naczyn tetniczych u dzieci z idiopatycznym zespolem nerczycowym.

UNLABELLED: Dyslipidemia is common in nephrotic children and persistent lipid abnormalities are risk factor of late vascular complications. The aim of the study was evaluation of efficacy and safety of 12-months simvastatin therapy in nephrotic children with lipid profile abnormalities present despite clinical remission lasting for at least 8 weeks, including ultrasonographic assessment of carotid and femoral arteries. MATERIAL AND METHODS: Overall 52 children (40 steroid-dependent and 12 steroid-resistant) were initially introduced to the study and 29 of them were treated with simvastatin. Normalisation of lipid profile was achieved in 19/29 (65.5%) and improvement in 9/29 (31%). Significant reduction in total cholesterol (p < 0.00001), LDL-C (p < 0.000003), VLDL- (p < 0.0123), oxy-LDL-C fractions (p < 0.0002) and triglycerides (TG) (p < 0.0005) serum concentration was achieved in non-proteinuric patients. RESULTS: Analysis of the intima-media thickness (IMT) of the common carotid (c) and superficial femoral (f) arteries values revealed positive correlation between baseline cIMT and VLDL-C (p = 0.038) and TG concentration (p = 0.008), as well as positive correlation between fIMT and baseline creatinine (p = 0.04) and LDL-C serum concentration (p = 0.032) after simvastatine treatment. Number of children with significant vessels pathology (Z-score > 2.0) was small. Increased cIMT was seen at baseline in 4 patients and in 5 after simvastatin treatment, however average and Z-score values in children under simvastatin treatment have decreased. Increased fIMT values were seen at baseline in 2 and in one case after simvastatin treatment. Tolerance of simvastation was very good in all cases but one. CONCLUSION: Simvastatin therapy was effective and safe in nephrotic non-proteinuric children with abnormal lipid profile. Fair estimation of impact of the 12-months simvastatin therapy on vascular status was not available due to limited number of children with significantly increased IMT at baseline.

Application of novel dual wave meal bolus and its impact on glycated hemoglobin A1c level in children with type 1 diabetes.

BACKGROUND: An insulin pump is an advanced technology offering new options of bolus - normal (N), dual wave (D-W) or square wave (S-W) bolus to deliver mealtime insulin. OBJECTIVES: To assess the impact of D-W/S-W boluses on metabolic control (glycated haemoglobin A1c, HbA1c) and to estimate the paediatric patients compliance with implementation of this system in daily practice. METHODS: The cross-sectional study included 499 records of patients aged 0-18 yr. Data from the insulin pump memory provided information on the number of D-W/S-W boluses during a 2-wk period, the insulin requirement (U/kg/d) and the percentage of basal insulin. The HbA1c value (%) and the patient's weight were determined during medical examinations. Mealtime dose of insulin in D-W/S-W bolus was calculated based on the amount of carbohydrate and fat/protein products. RESULTS: The number of applied D-W/S-W boluses was 16.6 +/- 0.77/14 d (ranged 0-95), while 18.8% of patients did not program D-W/S-W boluses. The lowest HbA1c value was found in the group using two and/or more D-W/S-W boluses per day (p = 0.001) compared with the group administrating less than one D-W/S-W bolus/d. Patients with HbA1c level <7.5% had a statistically higher relevant number of D-W/S-W boluses, 19.55 (95% CI: 17.44-21.65) vs. 12.42 (95% CI: 10.22-14.61) (p < 0.001), while there was no correlation between the number of boluses and HbA1c in patients in the remission phase (<0.5 IU/kg/d) (r = 0.012, p = 0.930). CONCLUSIONS: Patients using at least one D-W/S-W bolus per day achieved a recommended level of HbA1c. Paediatric patients with type 1 diabetes mellitus were found to be able to apply D-W/S-W boluses in daily self-treatment process based on food counting.

Insulin requirement in preschoolers treated with insulin pumps at the onset of type 1 diabetes mellitus.

THE AIM: The aim of this study is to analyze changes in the basal insulin requirement in preschoolers treated with insulin pump at the onset of T1DM, using system to calculate meal time insulin. METHODS: 58 children (31 girls) under 6 years (mean age 3.3 +/- 1.5 years) initiated on insulin pump therapy within 2 months after recognition of T1DM and treated at least for 1 year were analyzed during a follow-up period of 165 patient-years. Data was collected every 6 months: HbA1c, BMI SDS, diabetic ketoacidosis, severe hypoglycaemia, total daily insulin dose (TDD) and basal insulin. RESULTS: Basal insulin rose from 10% in the third month and did not exceed 30% of TDD after 12 months (p<0.0001). In the third month, 46% of children were without basal insulin; this group included significantly older children (3.7 +/- 1.4 vs. 2.8 +/- 1.4 years; p = 0.01), which had lower TDD (0.33 +/- 0.18 vs. 0.54 +/- 0.23 u/kg/d; p = 0.0007) than children with basal insulin. HbA1c persisted < or =7.3%. CONCLUSION: In preschool children initiated on CSII therapy at the time of T1DM diagnosis the first year of treatment is critical for altering the basal insulin dose. Preschoolers with TDD lower than 0.5 U/kg/d may not require basal insulin. Moreover, basal insulin did not exceed 30% of TDD in the first years after T1DM onset.

Age-dependent basal insulin patterns in children with type 1 diabetes treated with continuous subcutaneous insulin infusion.

AIMS: Identifying age-dependent basal rates in type 1 diabetic children treated with continuous subcutaneous insulin infusion (CSII). METHODS: CSII-treated children with type 1 diabetes exhibiting insulin requirement > 0.5 U/kg and glycated haemoglobin (HbA1c) < 8%. The study population was composed of 198 Caucasian children (111 girls) with mean age of 9.8 +/- 3.8 years, mean duration of diabetes of 4.3 +/- 3.1 years and mean HbA1c value of 6.7 +/- 0.7%. Data were evaluated for four age groups (0-6; 6-9; 9-12, 12-18 years). Basal rates records were downloaded from pump memory. HbA1c, weight, height were measured at scheduled visits. RESULTS: Significant differences in the average hourly basal rate between groups were observed: I gr. 0.14 versus II gr. 0.24 versus III gr. 0.39 versus IV gr. 0.72 units/h; p < 0.0001. The average hourly basal rate correlated with age, body weight, BMI, diabetes duration and total insulin daily dose. Insulin peaks were observed for: I gr. - before midnight, II gr. - before midnight and in the early morning, gr. III and IV - in the early morning. CONCLUSION: Basal insulin infusion rate profiles in well-controlled paediatric patients on CSII reflect the age-dependent amount of basal insulin (20-40%) and affect circadian distribution of insulin needs.

Basal insulin and total daily insulin dose in children with type 1 diabetes using insulin pumps.

OBJECTIVE: To assess the contribution of basal insulin to the total daily dose (CBITDD) and to identify the determinant factors in children with type 1 diabetes mellitus. STUDY DESIGN: Cross-sectional study in which the basal insulin requirement was established based on a memory read-out of insulin delivery from pumps. Factors such as glycated haemoglobin A1c (HbA1c), fasting C-peptide, standard deviation score of body mass index (sdsBMI) and demographic data were determined during routine hospital visits. Study group included a total of 90 well-controlled diabetic children with the mean HbA1c 6.6 +/- 0.7 (5.2-7.9), age 10.4 +/- 4.4 yr (1.1-17.9 yr), diabetes duration 3.0 +/- 2.6 yr (0.3-10.9 yr) and sdsBMI 0.08 (-2.27 to 1.79), excluding patients with ketoacidosis or infectious diseases. RESULTS: Correlations between CBITDD and age (r = 0.39 and p < 0.005) and diabetes duration (r = 0.61 and p < 0.0001) and an inverse correlation with C-peptide (r = -0.41 and p = 0.0001) were found. C-peptide-positive patients had a significantly lower percentage of basal insulin compared with C-peptide-negative patients (20.6 +/- 11 vs. 31.6 +/- 11.0%, respectively; p = 0.0004); yet, no significant difference in total insulin daily dose (0.65 +/- 0.3 vs. 0.78 +/- 0.2 U/kg/d, respectively) was observed. CONCLUSIONS: The percentage of basal insulin in diabetic children is below 50% and in well-controlled diabetic children is related to the fasting C-peptide level, age of patient and diabetes duration but not to HbA1c and sdsBMI.

Sustained metabolic control and low rates of severe hypoglycaemic episodes in preschool diabetic children treated with continuous subcutaneous insulin infusion.

AIM: To evaluate the safety and efficacy of continuous subcutaneous insulin infusion (CSII) in children under 7 years of age. METHODS: One hundred and ten children, aged 0.9-7 years, who had received CSII therapy for at least 6 months, were studied for 237 patient-years by a retrospective chart review. Charts were reviewed for glycosylated hemoglobin (HbA1c), severe hypoglycaemia (SH), ketoacidosis (DKA), height, weight and insulin requirement. In 69 cases (children aged 1.6-7 years) CSII was administered after at least 3 months of insulin therapy with pens. In this group, data from the year from before CSII administration were compared with values recorded during 1 year of CSII treatment. RESULTS: Mean HbA1c decreased from 7.8 +/- 0.9 before CSII to 7.5 +/- 1.0 after 6 and 12 months of pump therapy (p = 0.04). In the whole group, the mean HbA1c after 6 months of CSII was 7.5 +/- 1.0 and remained unchanged for up to 4 years of follow-up. Some episodes of SH--4.2 per 100 patient-years, and DKA--5.7 per 100 patient-years were recorded. No increase in BMI z-score occurred. CONCLUSIONS: In the youngest children, CSII therapy lowers HbA1c values and provides sustained metabolic control without increases in hypoglycaemia or ketoacidosis episodes.

[The evolution of insulin therapy and new insight into nutrition recommendations for individuals with diabetes]. / Postep w insulinoterapii i nowe spojrzenie na zywienie w cukrzycy.

The dietary guideline has undergone change during the last decades. It has been done by the introduction of new insulin therapy methods, also by the numerous epidemiological studies which have documented the influence of eating habits on macro-vascular diseases, obesity and type 2 diabetes. The Glycemic Index (GI) and Glycemic Load (GL) play a pivotal role in carbohydrate classification and for food choice by diabetic patients. Post-prandial glycemia response and insulinemia strongly relate to value of GI and GL. Intensive insulin therapy as a multiple daily injection or pump therapy has brought a liberalization in diabetic regime and diet. It gives possibility to introduce modern dietary guidelines including healthy eating advice with respect for traditional eating habits.

[Evaluation of arterial intima-media thickness (IMT) in children with idiopathic nephrotic syndrome--preliminary report]. / Ocena grubosci kompleksu blona wewnetrzna-blona srodkowa naczyn tetniczych u dzieci z idiopatycznym zespolem nerczycowym--doniesienie wstepne.

UNLABELLED: One the complications of idiopathic nephrotic syndrome (i.n.s.) is long-lasting lipid unfavourable lipid profile, a risk factor of early atherosclerosis. Aim of the study was evaluation of the incidence of early signs of atheromathosis in children with INS expressed as the increased IMT in the (elastic) common carotid (cIMT) and (muscular) superficial femoral ((fIMT) arteries. The study included 50 children (34 boys and 16 girls) aged from 5.83 to 16.58 y (mean 10,8) with INS Overall duration of the disease ranged from 2.58 to 13.83 y (mean 7.81) [in 23 (46%) children < 10 yrs mean 6.21 yrs; in 16 (32%) from 10 to 14 yrs mean 11.93 yrs and in 11 (22%) >14 yrs mean 4.27 yrs]. 16 children were treated with prednisone, 32 with cyclosporine A (CsA) and 2 mycophenolate mofetil (MMF). The renal function in 49 children was normal and decreased in 1 case. Children treated with CsA and MMF received renoprotection with enalapril or enalapril/losartan. USG technique was used to evaluate cIMT and fIMT. In 39 (78%) pts, 26/34 (76.47%) > and 13/16 (81.25%) + cIMT was increased. fIMT was increased in 13 (26%) pts, including 12/34 (35.29%) > and 1/16 (6.25%) +. Among pts <10y. of age cIMT was increased in 19/23 (82.6%) and fIMT in 5/23 (21.73%). Among pts between 10-14 yrs cIMT was increased in 13/16 (81.25%), and fIMT in 4/16 (25%). Among pts >14 yrs cIMT was increased in 7/11 (63.63%), and fIMT in 4 (36,36%) cases. CONCLUSION: Increased intima-media thickness in (elastic) carotid artery was shown in vast majority of children with nephrotic syndrome.

[Guidelines concerning insulin dosage in children and adolescents with type 1 diabetes on continuous subcutaneous insulin infusion]. / Zasady dawkowania insuliny w terapii z zastosowaniem osobistej pompy insulinowej u dzieci i mlodziezy chorujacych na cukrzyce typu 1.

The treatment of diabetes mellitus with a continuous subcutaneous insulin infusion (CSII) has become very popular and is well accepted by diabetic patients. Pump therapy mimics the physiological insulin secretion and has been shown to be a safe and effective method of insulin administration alternative to the method of multiple injections. Continuous insulin infusion provides greater flexibility in the timing of meals and snacks with higher treatment satisfaction. Programmed basal rates improve nocturnal glycemic control and help to minimize a pre-breakfast increase of blood glucose level (the dawn phenomenon). Moreover, CSII can reduce exercise-induced and nocturnal hypoglycemia. Insulin pump therapy is effective in lowering glycated hemoglobin levels without higher risk of severe hypoglycaemia and ketoacidosis. To achieve a proper metabolic control with this method of treatment, the patient and his family requires appropriate education including knowledge of diet management, insulin therapy and manual competence of pump device. Here we present general guidelines for patients education concerning insulin dosage, programming of basal insulin rates and meal boluses based on carbohydrates and protein-fat exchanges.

[The role of 2,3-DPG in nerve conduction of children with type 1 diabetes]. / Udzial 2,3 DPG w zaburzeniach przewodzenia w nerwach obwodowych u dzieci z cukrzyca typu 1.

BACKGROUND: Neuropathy is one of the chronic complications of diabetes, and it is uncommon in children and adolescents. It can be recognized in a short period after the onset of diabetes and not always is connected with poor metabolic control. Hypoxia is considered as one from greatest factors diabetic neuropathy and oxygen transport to tissue partially depends on the diphosphoglycerate (2,3 DPG) concentration. As showed recent clinical studies, its concentration in children with diabetes can be abnormal. OBJECTIVES: To assess the role of 2,3 DPG in nerve conduction velocity, as well as qualification of risk factors. MATERIAL AND METHODS: To study were included randomly selected 37 patients with diabetes type 1, average age 15.5+/-2.25 years, with a duration of diabetes of more than 5 years (av 9.64+/-1.95 years), treated with intensive insulin therapy (MDI and CSII), without metabolic acidosis pH - 7.35. The nerve conduction velocity was measured in the sensor and motor nerves. HbA1c and 2,3 DPG were assessed additionally. RESULTS: Changes in motor nerve conduction velocity were observed at 22 patients. Average value of HbA1c in the studied group was 8.22+/-1.2%, Average concentration of 2,3 DPG was 6.15+/-1.67 mmol/l (3.84-11 mmol/l), in group with nerve dysfunction was lower - 5.86+/-1.69 mmol/l vs. 6.38+/-1.67, but this difference was not statistically significant. The lower value of 2,3 DPG significantly correlated with abnormal results of electroneurography test, especially with motor and sensor nerve latency (r=-0.34, p=0.038; r=-0.4, p=0.013) but not correlated with HbA1c (r= -0,19;p= 0,25), age of patients (r=0.008; p=0.96) and diabetes duration (r=-0.16; p=0.31). CONCLUSIONS: Nerve dysfunction is common in children with type 1 diabetes despite metabolic control and duration of diabetes. 2,3 DPG can be an independent factor of diabetes neuropathy correlated with abnormal value of the nerve conduction test.

Memory of insulin pumps and their record as a source of information about insulin therapy in children and adolescents with type 1 diabetes.

BACKGROUND: This study was designed to provide information regarding basal and bolus insulin dosage in children and adolescents using continuous subcutaneous insulin infusion (CSII) and to evaluate the safety and efficacy of the CSII method in youths. PATIENTS AND METHODS: Data from 100 patients (1.6-18 years old) were collected during scheduled visits in an outpatient clinic. The mean duration of diabetes was 4.57 years (range 0.6-16 years), and mean duration of CSII therapy was 1.75 years (range 0.5-3.0 years). Each child had his or her insulin doses reviewed using the Medtronic MiniMed (Northridge, CA) Pumps&Meters software program. At each visit glycosylated hemoglobin (HbA1c) values and growth parameters (weight and height) were assessed, and episodes of severe hypoglycemia and ketoacidosis were recorded. RESULTS: The mean HbA1c value in our study group was 7.63 +/- 0.09% (range, 5.15-12.5%). Statistically significant better metabolic control was found in children under 10 years of age, in children with lower body mass index (r = 0.33), in patients with a lower contribution of basal insulin to the total daily dose (r = 0.35; P < 0.05), and in boys. Ten percent of participants skipped mealtime boluses, which correlated with their glycemic control; in those children HbA1c was 8.67 +/- 0.57% (r = 0.34; P < 0.05). The mean total daily insulin was 0.79 +/- 0.02 U/kg/day (range, 0.3-2.0 U/kg/day). Basal insulin constituted on average 35.6 +/- 1.1% (5-70%) of the daily insulin dose. We found a statistically significant higher contribution of basal insulin dose in patients who missed mealtime boluses (r = 0.42; P < 0.05) and a significantly lower contribution in pre-pubertal children and in boys (P < 0.05). Around 7% of patients made mistakes in programming the basal insulin. CONCLUSIONS: CSII may be safely and efficiently used in children with type 1 diabetes in different age groups. This method of treatment requires regular visits to an outpatient clinic, proper education, and frequent revisions of the pump's memory.

[Metabolic control in young children with type 1 diabetes treated with continuous subcutaneous insulin infusion (insulin pump)]. / Wyrównanie metaboliczne u malych dzieci z cukrzyca typu 1 leczonych metoda ciaglego podskórnego wlewu insuliny (pompa insulinowa).

UNLABELLED: Intensive insulin therapy is a method of choice in the management of patients with type 1 diabetes. Its administration in the youngest children is limited by little or no acceptance of multiple injections and a typical fear of needles and syringes. In recent years more and more frequently the method of multiple daily injections (MDI) of insulin is being replaced by the method of continuous subcutaneous insulin infusion (CSII) even in the youngest children. OBJECTIVE: Evaluation of the safety and efficacy of CSII method in children at prepubertal age. MATERIAL AND METHODS: There were 61 children under 10 years of age with type 1 diabetes recruited for the study (33 boys, 28 girls). CSII method was implemented for the period of minimum 6 months. In the group of 21 children CSII method was the first method of their therapy (it was administered at the time of diagnosis). Mean duration of diabetes was 3.0 years +/-1.87 year, mean age at diagnosis was 3.82+/-2.19 years and mean duration of CSII treatment was 1.4 +/-0.75 year. The average HbA1c at the baseline for all children was 8.7+/-1.4%. RESULTS: In the group where CSII therapy was implemented as the first method of management, mean duration of treatment was 1.5 years, mean HbA1c decreased after first 3 months from 9.6+/-1.68% to 7.22+/-0.99% (p<0.05). After 12 and 24 months the value further decreased to 7.01+/-0.57%. In the group that was earlier treated with MDI method (n=40), mean value of HbA1c decreased after 3 months from 8.27+/-1.4% to 7.6 +/-0.86% (p<0.05), after 12 months it further decreased to 7.37+/-0.86%, after 24 months its mean value was 7.53%. The number of patients with HbA1c >8% decreased from 58.4% to 10%. Adverse events were observed only in the group that was earlier treated with the MDI method. There were 3 incidences of severe hypoglycaemia, 2 incidences of diabetic ketoacidosis, 2 incidences of infection at the needle site (in one case the surgical attention was necessary). After two years of the trial there was a statistically significant difference in the mean value of HbA1c between children that used CSII method from the moment of their diagnosis (HbA1c=7.01%) and those who were earlier treated with MDI method (HbA1c=7.53 +/-0.73%). In both groups the daily insulin requirement was similar (CSII method 0.69+/-0.2 unit/kg/day, MDI method 0.75+/-0.19 unit/kg/day). CONCLUSIONS: The method of continuous subcutaneous insulin infusion (CSII) provides good and sustained metabolic control in the youngest children with type 1 diabetes. Administering of that method from the very beginning of the diabetes treatment may decrease the risk of acute complications.