[Chronic renal failure, dialysis and transplant: multicentric study: 1996-2003]. / Enfermedad renal crónica, diálisis y trasplante: Estudio multicéntrico: 1996-2003.

OBJECTIVE: The multicentric study of chronic renal failure, dialysis and transplant started in 1996 by the Nephrology Committee of the Argentine Pediatrics Society with the aim of knowing the development characteristics of children with this pathology. POPULATION, MATERIAL AND METHODS: The study included children and adolescents on conservative treatment, dialysis or transplant who have registered any of the three modalities before being 19 year-old, since january 1996 to december 2003. The statistical analysis was made with the statistical software SAS; in order to calculate the survival curve, the method employed was Kaplan-Meier and the standardized height and weight z-scores were calculated. RESULTS: In this report, there is data related to 710 patients with chronic renal failure, under conservative treatment 34.2%, dialysis 57.6% and transplant 29.5%. The end-stage renal disease incidence was of 6.5/million inhabitants. The main etiologies were obstructive uropathy 18.3%, reflux nephropathy 15.1%, hemolytic uremic syndrome 14.4%, aplasia/dysplasia/hypoplasia 13.8%, and focal segmental glomerulosclerosis 8.9%. From the patients on dialysis treatment, 62.3% were under hemodialysis, and only 37.7% on peritoneal dialysis. Live-donor sources accounted for 46.2 % of the transplants, with a 1-year patient's survival of 98.7% and a 1-year graft survival of 96.4 %, similar with both donors. CONCLUSION: The results obtained, even though they do not correspond to the total population affected and the monitoring is still insufficient, allowed us to have a profile of the chronic renal failure in our country.

Peritonitis in children who receive long-term peritoneal dialysis: a prospective evaluation of therapeutic guidelines.

In children who are on chronic peritoneal dialysis, peritonitis is the primary complication compromising technique survival, and the optimal therapy of peritonitis remains uncertain. An Internet-based International Pediatric Peritonitis Registry was established in 47 pediatric centers from 14 countries to evaluate the efficacy and safety of largely opinion-based peritonitis treatment guidelines in which empiric antibiotic therapy was stratified by disease severity. Among a total of 491 episodes of nonfungal peritonitis entered into the registry, Gram-positive organisms were cultured in 44%, Gram-negative organisms were cultured in 25%, and cultures remained negative in 31% of the episodes. In vitro evaluation revealed 69% sensitivity of Gram-positive organisms to a first-generation cephalosporin and 80% sensitivity of Gram-negative organisms to a third-generation cephalosporin. Neither the risk factors assumed by the guidelines nor the choice of empiric therapy was predictive of either the early treatment response or the final functional outcome of the peritonitis episodes. Overall, 89% of cases achieved full functional recovery, a portion after relapsing peritonitis (9%). These data serve as the basis for new evidence-based guidelines. Modification of empiric therapy to include aminoglycosides should be considered.

La amuchina en concentración al 3 por ciento es tan efectiva como al 50 por ciento en la prevención de infección del sitio de salida en niños en dialisis peritoneal continúa ambulatoria / Amuchin at a concentration of 30% is as effective as it is in a concentration of 50% for prevention of outlet site infection in children with ambulatory continuous peritoneal dialysis

En una comunicación previa, hemos demostrado que, la Amuchina (cloroxidante electrolítico en solución hipertónico de cloruro de sodio) al 50 por ciento en la prevención de infección del sitio de salida (ISS), en niños, es más efectiva que la lodopovidona solución al 10 por ciento y ta efectiva como el Gluconato de Clorexidina al 4 por ciento pero con menos efectos adversos. En el presente estudio, pudimos mostrar, que la Amuchina al 50 por ciento en la prevención de la ISS en niños en Diálisis Peritoneal Continúa Ambulatoria en Argentina. Se trata de un estudio abierto, unicentrico y prospectivo en 32 niños (por edad: 7.8 años; r 1.7 menos 17) que usaron Amuchina al 3 por ciento como agente desinfectante para el cuidado diario del sitio de salida sano. De los 32 niños, 14 cambiaron la Amuchina al 50 por ciento por Amuchina al 3 por ciento y 18 usaron Amuchina al 3 por ciento desde el comienzo del tratamiento. El grupo control estaba compuesto por 18 pacientes, quienes habían usado Amuchina al 50 por ciento, como agente desinfectante. Se utilizaron las recomendaciones de la Internacional Society for Peritoneal Dialysis, para cuidado del sitio de salida. No fueron observados efectos secundarios con el uso de Amuchina en cualquiera de las concentraciones. Los pacientes que usaron Amuchina al 3 por ciento presentaron un índice ISS similar que aquellos que utilizaron Amuchina al 50 por ciento. El costo de la Amuchina al 3 por ciento fue significativamente menor que la Amuchina al 50 por ciento, y aún menor que el costo de la lodopovidona al 10 por ciento o de la Clorexidina al 4 por ciento. Si bien son necesarios más estudios para asegurar la eficacia de la Amuchina al 3 por ciento, en nuestra opinión la Amuchina es un efectivo y económico agente desinfectante para el cuidado diario del sitio de salida sano en niños en Diálisis Peritoneal Continúa y Ambulatoria. Palabras Claves: Diálisis Peritoneal Continua Ambulatoria, infección del sitio de salida, Amuchina

La amuchina en concentración al 3 por ciento es tan efectiva como al 50 por ciento en la prevención de infección del sitio de salida en niños en dialisis peritoneal continúa ambulatoria / Amuchin at a concentration of 30% is as effective as it is in a concentration of 50% for prevention of outlet site infection in children with ambulatory continuous peritoneal dialysis

En una comunicación previa, hemos demostrado que, la Amuchina (cloroxidante electrolítico en solución hipertónico de cloruro de sodio) al 50 por ciento en la prevención de infección del sitio de salida (ISS), en niños, es más efectiva que la lodopovidona solución al 10 por ciento y ta efectiva como el Gluconato de Clorexidina al 4 por ciento pero con menos efectos adversos. En el presente estudio, pudimos mostrar, que la Amuchina al 50 por ciento en la prevención de la ISS en niños en Diálisis Peritoneal Continúa Ambulatoria en Argentina. Se trata de un estudio abierto, unicentrico y prospectivo en 32 niños (por edad: 7.8 años; r 1.7 menos 17) que usaron Amuchina al 3 por ciento como agente desinfectante para el cuidado diario del sitio de salida sano. De los 32 niños, 14 cambiaron la Amuchina al 50 por ciento por Amuchina al 3 por ciento y 18 usaron Amuchina al 3 por ciento desde el comienzo del tratamiento. El grupo control estaba compuesto por 18 pacientes, quienes habían usado Amuchina al 50 por ciento, como agente desinfectante. Se utilizaron las recomendaciones de la Internacional Society for Peritoneal Dialysis, para cuidado del sitio de salida. No fueron observados efectos secundarios con el uso de Amuchina en cualquiera de las concentraciones. Los pacientes que usaron Amuchina al 3 por ciento presentaron un índice ISS similar que aquellos que utilizaron Amuchina al 50 por ciento. El costo de la Amuchina al 3 por ciento fue significativamente menor que la Amuchina al 50 por ciento, y aún menor que el costo de la lodopovidona al 10 por ciento o de la Clorexidina al 4 por ciento. Si bien son necesarios más estudios para asegurar la eficacia de la Amuchina al 3 por ciento, en nuestra opinión la Amuchina es un efectivo y económico agente desinfectante para el cuidado diario del sitio de salida sano en niños en Diálisis Peritoneal Continúa y Ambulatoria. Palabras Claves: Diálisis Peritoneal Continua Ambulatoria, infección del sitio de salida, Amuchina

Improved long-term allograft function in pediatric renal transplantation with mycophenolate mofetil.

MMF has been shown to decrease the incidence of acute rejection in children and adults at 1 and 3 yr. Other beneficial effects of MMF have been more difficult to demonstrate. Our open-labeled study presents a 5-yr data for patients and graft survival, allograft function, and growth in MMF-treated patients. The trial included 29 patients who were treated with MMF in combination with cyclosporine and methylprednisone. Patients were compared with a preceding group of 29 patients treated with AZA instead of MMF. Patient and graft survival rate 5 yr after transplantation were 97 and 90% in the MMF group vs. 93 and 83% in the AZA group (p: NS). Acute rejection was 20.6% in the MMF group vs. 58.6% in the AZA group (p < 0.01). Chronic rejection was 10.3% in the MMF group and 25% in the AZA group (p: NS). The changes in the creatinine clearance from baseline to 5 yr (Delta) were different between groups (-6.0 +/- 5.1 mL/min/1.73 m(2) in the MMF group vs. -22.2 +/- 7.6 mL/min/1.73 m(2) in the AZA group, p < 0.05). Also, the slope of 1/Scr showed a significant lower incidence of worsening renal function after the second year of renal transplantation (p < 0.0001) in the MMF group compared with the AZA group. Delta Height SDS in prepubertal patients was 0.3 +/- 0.4 SDS in the MMF group vs. -0.8 +/- 0.2 SDS in the AZA group (p < 0.05). This study shows that long-term MMF therapy has resulted in a decrease in acute rejection and was associated with a protection against renal function deterioration. The use of MMF enables a reduction in the dose of steroids and leads to a linear growth improvement of children after renal transplantation.

3% Amuchina is as effective as the 50% concentration in the prevention of exit-site infection in children on chronic peritoneal dialysis.

In a previous communication, we demonstrated that, in the prevention of exit-site infection (ESI) in children, the cleansing agent 50% Amuchina (electrolytic chloroxidizer. Amuchina SpA, Genoa, Italy) is more effective than 10% povidone iodine and as effective as 4% chlorhexidine, but with fewer adverse secondary effects. In the present study, we assessed, in an Argentine pediatric population, whether Amuchina 3% is as effective as Amuchina 50% in preventing ESI in children on chronic peritoneal dialysis. In an open-label, single-center prospective study, 27 children (mean age: 7.2 years; range: 1.7-17 years) used 3% Amuchina as a cleansing agent for the daily care of a healthy exit site. Of the 27 children, 14 were switched from 50% Amuchina to 3% Amuchina, and 13 were using the 3% Amuchina for the first time. The control group consisted of 18 patients who had previously used 50% Amuchina as a cleansing agent. We followed the recommendations of the International Society for Peritoneal Dialysis with regard to exit-site care, which include keeping the cleansing agent out of the sinus and rinsing the exit site with sterile water. Amuchina was used from the first post-implantation care of the exit site. No adverse secondary effects were seen with the use of Amuchina at either concentration. Patients using 3% Amuchina presented an ESI rate similar to that of patients using Amuchina 50%. The cost of 3% Amuchina was significantly lower than that of the 50% concentration, and it was even lower than the cost for 10% povidone iodine or 4% chlorhexidine. Although more research trials are needed to assess the efficacy of 3% Amuchina, we conclude that 3% Amuchina is the best and most cost-effective cleansing agent for the daily care of a healthy exit site in children on chronic peritoneal dialysis.

Fibrin glue is useful in preventing early dialysate leakage in children on chronic peritoneal dialysis.

OBJECTIVE: To assess if application of fibrin glue sealant to the peritoneal cuff suture is useful in the prevention of early dialysate leakage in children with end-stage renal disease on chronic peritoneal dialysis (CPD). DESIGN: Single-center, open-label, prospective randomized study. SETTING: University Pediatric Hospital. METHODS: 52 catheters were implanted in 45 children (mean age 6.2 +/- 4.5 years). Catheters were randomly assigned to either the control group or the sealant group. In the latter group, 1 mL of fibrin glue sealant was applied to the peritoneal cuff suture. 18 catheters were used for the first time within 5 days after implantation (early-used catheters). Leakage, exit-site or tunnel infection, peritonitis, and adverse secondary effects were evaluated during the initial 60 days after implantation. RESULTS: No adverse secondary effects were seen after the application of the fibrin glue sealant. The incidence of exit/tunnel infection and peritonitis was similar in the two groups. The incidence of leakage was significantly lower in the sealant group (p < 0.02). In the early-used catheters, leakage was detected in 9% of the catheters in the sealant group and in 57% of the control group (p < 0.05). CONCLUSIONS: The application of 1 mL of fibrin glue to the peritoneal cuff suture prevented early dialysate leakage without secondary adverse effects in children on CPD.

Shiga toxin-associated hemolytic uremic syndrome: absence of recurrence after renal transplantation.

We evaluated the relationship between the acute phase and the development of end-stage renal disease (ESRD) and the outcome of renal transplant in patients with Shiga toxin-associated hemolytic uremic syndrome (Stx-HUS). A 20-year retrospective study was performed of 66 renal transplants in 62 patients with Stx-HUS compared with 189 renal allografts in 178 children with other diseases. Of 62 patients, 61 had >7 days of oliguria during the acute phase. Stx-HUS patient survival was not different from controls (92% vs. 83% 15 years after renal transplantation). In the cyclosporine (CsA) era, survival of grafts from living related (LRD) and cadaver (CD) donors in Stx-HUS and control patients was 83% versus 70% ( P<0.03) and 77% versus 49% ( P<0.05) at 10 years. Graft survival in Stx-HUS and dysplasia/obstructive uropathy patients was 79% versus 76% ( P=NS), but it was different from that of other diseases (79% vs. 58%, P<0.001). There was no clinical or histopathological evidence of Stx-HUS recurrence. In conclusion, in Stx-HUS patients the duration of the acute oliguric period was a good predictor for the progression to ESRD. Use of CsA and the absence of recurrence of the disease influenced the excellent prognosis in Stx-HUS patients after renal transplantation. The development of ESRD in Stx-HUS could be mediated by non-immunological factors.

Valoración de un nuevo esteroide (deflazacort) en el tratamiento inicial en niños con síndrome nefrótico idiopático / Evaluation of deflazacort, a new steroid, in the initial theraphy of children with idiopathic nephrotic syndrome

Evaluamos un nuevo derivado oxazolínico de la prednisona comparando su respuesta y efectos secundarios con los observados en el tratamiento clásico con prednisona, en un grupo de 24 niños durante el primer episodio de Síndrome Nefrótico Idiopático. Grupo A: 12 niños de edad media: 43 meses (r: 10 á 72 m) recibieron deflazacort en dosis de 1.8 á 2.2 mg/kg/día durante 30 días contínuos y 30 días alternos (serie completa). Grupo B: 12 niños, edad media: 37 meses (r: 29 á 70) recibieron metilprednisona a la dosis de 1.5 á 1.7 mg/kg/día con igual esquema que los del grupo A. En 6 pacientes del Grupo A la proteinuria desapareció entre los 7 y 26 días de tratamiento (x 13.8 d). Los otros 6 no negativizaron la proteinuria. En 7 niños del Grupo B la proteinuria remitió entre 5 y 15 días (x 10.5 d), los 5 restantes persistieron con proteinuria masiva hasta la finalización de la primera serie de tratamiento. Los parámetros bioquímicos pre y post tratamiento en los pacientes corticosensibles no mostraron diferencias significativas entre ambos grupos. Los valores de colesterol fueron menores en los que recibieron deflazacort aunque sin significancia estadística. Los efectos esteroides colaterales estuvieron presentes en la mayoría de los niños tratados con prednisona, y fueron significativamente menores en los que recibieron deflazacort (AU)

Valoración de un nuevo esteroide (deflazacort) en el tratamiento inicial en niños con síndrome nefrótico idiopático / Evaluation of deflazacort, a new steroid, in the initial theraphy of children with idiopathic nephrotic syndrome

Evaluamos un nuevo derivado oxazolínico de la prednisona comparando su respuesta y efectos secundarios con los observados en el tratamiento clásico con prednisona, en un grupo de 24 niños durante el primer episodio de Síndrome Nefrótico Idiopático. Grupo A: 12 niños de edad media: 43 meses (r: 10 á 72 m) recibieron deflazacort en dosis de 1.8 á 2.2 mg/kg/día durante 30 días contínuos y 30 días alternos (serie completa). Grupo B: 12 niños, edad media: 37 meses (r: 29 á 70) recibieron metilprednisona a la dosis de 1.5 á 1.7 mg/kg/día con igual esquema que los del grupo A. En 6 pacientes del Grupo A la proteinuria desapareció entre los 7 y 26 días de tratamiento (x 13.8 d). Los otros 6 no negativizaron la proteinuria. En 7 niños del Grupo B la proteinuria remitió entre 5 y 15 días (x 10.5 d), los 5 restantes persistieron con proteinuria masiva hasta la finalización de la primera serie de tratamiento. Los parámetros bioquímicos pre y post tratamiento en los pacientes corticosensibles no mostraron diferencias significativas entre ambos grupos. Los valores de colesterol fueron menores en los que recibieron deflazacort aunque sin significancia estadística. Los efectos esteroides colaterales estuvieron presentes en la mayoría de los niños tratados con prednisona, y fueron significativamente menores en los que recibieron deflazacort