A "sweet" hydrothorax in a child on peritoneal dialysis.

Peritoneal dialysis (PD) is an established, effective long term renal replacement treatment modality for children with end stage renal disease (ESRD). A rarely reported complication of PD in children is the development of hydrothorax1. We report the case of an 8-year-old boy that developed a right-sided pleural effusion during automated PD (APD), in order to raise awareness amongst paediatricians; we also review the diversity of clinical presentation and the available diagnostic tools, discuss theories regarding aetiology and highlight the available treatment options.

Cyclosporine and its metabolites before and 2 h post-dose: comparative measurements of a monoclonal and a polyclonal immunoassay.

The aim of the study was to investigate the better accuracy of the 2-h post-dose (C2) levels of cyclosporine (CyA), compared with the pre-dose (C0) levels and to evaluate the results measured by a monoclonal or a polyclonal immunoassay. The parent compound of CyA in C2 (monoclonal2) was measured in 53 kidney transplant patients by the monoclonal fluorescence polarization method, as well as the parent compound plus metabolites (polyclonal2) by the polyclonal fluorescence polarization method. Also, the parent compound was measured in 21 of the patients for the C0 (monoclonal0), whereas the parent compound plus metabolites in 36, for the C0 (polyclonal0). As level of metabolites was considered the difference between polyclonal and monoclonal values (polyclonal-monoclonal), either in C0 (metabolites0) or in C2 (metabolites2). The ratio polyclonal2/monoclonal2 gave a mean value of 1.7+/-0.2 (mean+/-SD), whereas the mean value of the ratio polyclonal0/monoclonal0 was 2.3+/-0.6, with almost double variation. The mean value of the ratio metabolites2/monoclonal2 was 0.7+/-0.2 and of the ratio metabolites0/monoclonal0 was 1.3+/-0.6. The difference between the two ratios is very significant (p = 0.000001) and they are not correlated with each other (r = 0.18, p = 0.44). The measurements of monoclonal0 and polyclonal0 or monoclonal2 and polyclonal2 are very significantly correlated (r = 0.94, p = 0.000001 and r = 0.97, p = 0.000001, respectively). In C0 the proportion of metabolites is higher than in C2, with a double variation, as the degree of metabolism is diverse. Consecutively, in monoclonal methods, as cross-reactions occur with metabolites, it is more accurate to use the C2 measurement for the evaluation of CyA. The application of both methods, the polyclonal and the monoclonal, could be a useful tool as it gives an estimation of metabolites whose degree of contribution to the immunosuppressive result is difficult to ascertain. Finally, if for reasons of clinical experience, the polyclonal method is used, then the mean therapeutic levels of polyclonal2 are 1.5-1.7 compared with monoclonal2.

Acute renal failure--which treatment modality is the best?

Despite the progress in animal research concerning the pathophysiology and the progress in clinical practice regarding the methods of therapy, the incidence and mortality of acute renal failure remain high, especially when other organs are involved. New pharmacological interventions have led to the perspective that in the near future it may be possible to prevent and/or ameliorate this devastating syndrome. Continuous dialysis therapy and the selection of a biocompatible membrane may possibly help the critically ill patient especially when parenteral nutrition and correction of electrolyte and acid-base disturbances are important. Nevertheless, more solid data are needed and one should take into consideration that acute renal failure is a multifactorial syndrome. The type of dialysis itself is not the only matter which has to be evaluated since the mortality rate can be correlated with the number of involved organs before or after the initiation of acute renal failure and with the severity of the original disease. In clinical practice, a large number of prospective studies and more sophisticated statistical methodology are needed in order to evaluate the proper treatment modality.