An 11-month-old with anti-glomerular basement membrane disease.

Anti-glomerular basement membrane antibody disease is an autoimmune disease that has rarely been described in children, and no cases have previously been described in a patient younger than 2.5 years of age. We report an 11-month-old infant girl who developed anti-glomerular basement membrane disease and progressed to end-stage renal disease and eventual renal transplantation. Although it has been suggested that this disease does not occur in infants, the possibility of anti-glomerular basement membrane disease must be considered in the differential diagnosis of acute renal failure and glomerulonephritis in an infant. The characteristic linear pattern of immunofluorescent studies for Immunoglobulin (Ig) G is important in suggesting the diagnosis, which can be confirmed by serologic testing for antibody titers.

Use of a modified peritoneal equilibration test to optimize solute and water clearance.

The standard peritoneal equilibration test (PET) characterizes the peritoneal transport of fluid, creatinine and urea. However, the applicability of the standard PET may be limited in patients on cycling peritoneal dialysis due to the choice of 2- and 4-h sampling times which exceed the usual dwell time of most patients on cycling peritoneal dialysis. We have performed a modified PET on seven pediatric dialysis patients in an effort to optimize dwell time to achieve maximal clearance of solutes and fluid. When compared with the standard PET, values obtained for dialysate/plasma urea and dialysate/plasma creatinine with the modified PET are significantly different. This resulted in an increased estimated creatinine clearance in five of seven and increased estimated urea clearance in six of seven patients. The modified PET is a more appropriate method for evaluation of peritoneal clearances in children as well as older patients who may require cycling peritoneal dialysis.

Hematuria.

Hematuria occurs in approximately 1.5% of children. It is important in evaluating the patient who has hematuria to make sure that a positive dipstick test is accompanied by RBCs on the microscopic examination. Hematuria is defined by several parameters, the most common of which are 6 cells/cc of urine in a counting chamber or 2 cells per high-power field in a urinary sediment. Although the differential diagnosis for hematuria is extensive, the most important differentiating feature is the presence or absence of proteinuria. Those who have significant proteinuria deserve a rapid evaluation and early referral to a nephrologist. Those who do not have proteinuria should be followed and a step-wise evaluation performed. Finally, most patients who have asymptomatic microscopic hematuria do not have clinically significant glomerular pathology.

The outcome of renal transplantation in children without prolonged pre-transplant dialysis.

Controversy in the literature exists over whether or not it is beneficial to maintain a patient on dialysis for a prolonged time before transplantation. Because no data exist comparing children who have had prolonged dialysis before transplantation to those who have none, we reviewed the charts of all children transplanted at the Children's Hospital of the Cleveland Clinic Foundation. Of those, we selected three groups for analysis: group one (n = 12) consisted of patients who had had less than or equal to 10 weeks of dialysis before transplantation (6.8 +/- -2.2 weeks, +/- = SD); group two (n = 21) were patients who had had more than 10 weeks of dialysis (142 + +/- -148 weeks). Both groups had two years of follow-up data. Group three (n = 13) consisted of patients who had had less than two years of follow-up (18.7 +/-/-7 months) but no dialysis before transplantation. There were no differences in mode of dialysis between groups one and two nor in the type of transplant (living-related donor vs. cadaveric). Significantly, the patients in group three received more cyclosporine A and less anti-lymphocyte globulin than the other two groups (p less than 0.05). Patients in group two received more transfusions (11.9 +/- 14.3) than patients in group one (4.0 +/- 2.7) and group three (3.5 +/- 7.3). There were no differences in number of patients who experienced at least one rejection episode among the three groups. Although the mean serum creatinine concentration at two years of follow-up was higher in group two (3.6 +/- -3.9 mg/dl), this was not significantly different from group one (1.7 +/- -0.7 mg/dl) or group three (1.9 +/- -0.5, n = 7). Sixty-three percent of patients in group one, 60% of patients in group two and 91% in group three had functioning allografts at two years follow-up. Although there may be other considerations, our data do not indicate any increase in rejection or decrease in graft survival in children who do not receive prolonged dialysis.