Update on Pediatric Hemodialysis Adequacy.

The use of high reflux dialyzers to achieve a Kt/Vurea above 1.2 did not improve patient survival in most literature reports. After an electronic search in many sites, guidelines, systematic reviews, and review articles (cited references): We recommend (1) using the equilibrated double-pool, weekly rather than per session, Kt/Vurea, (2) Use of UF-dry weight to avoid V changes, (3) consider protein catabolic Rate (4) Use of double pool to avoid urea generation rebound effect. Beyond the urea model, other recommended parameters include the middle molecule clearance and patient clinical data as blood pressure control, normal ventricular morphology, and function, absence of anemia, bone mineral disease, vascular calcifications, good nutrition and growth, long-lasting vascular access, less intra-dialysis hypotension, fewer hospitalizations related to complications as infection, long-term patient survival with better life quality. All mentioned parameters are the good markers for adequate dialysis. Since (1) frequent short and (or) slow long dialysis sessions show better solute clearance and hemodynamic stability associated with better control of cardiovascular and bone disease, anemia, nutrition, and growth with better quality of life and survival. (2) The spare in the cost of the antihypertensive medications, erythroid-stimulating drugs, phosphate binders, and frequent hospitalization, compensates for the high dialysis cost. (3) The use of some advisable techniques can minimize access trauma; therefore, HD Model can be changeable according to each patient's clinical and biochemical follow-up dialysis adequacy progress pattern.

Echocardiographic findings in children with chronic kidney disease.

Cardiovascular diseases (CVD) are considered major cause of morbidity and mortality among children with chronic kidney disease (CKD). This study aims to determine the incidence of CVD in children with CKD, to analyze risk factors and early predictors for late onset atherosclerosis. Thirty-five CKD children [25 on regular hemodialysis (HD) and 10 on conservative management] were evaluated clinically. Left ventricular (LV) functions and carotid artery intima-media thickness (c-IMT) were assessed using conventional echocardiography, pulsed wave Doppler (PWD) and tissue Doppler imaging (TDI). There was decreased E/A ratio and increased E/E' ratio in 66% and 77% of patients, respectively signifying diastolic cardiac dysfunction. There was a significant correlation between increased A' value (peak late diastolic annular velocity) and both increased serum cholesterol and anemia (P = 0.009, 0.004 respectively). Serum high density lipoprotein (HDL) significantly correlated negatively with inter-ventricular septal thickness and LV end-diastolic dimensions (P = 0.05, 0.02, respectively) and positively with E' value (peak early diastolic annular velocity) (P = 0.04). Abnormal c-IMT correlated significantly with HD duration (correlation coefficient = 0.428, P = 0.01) and with both increased serum cholesterol and decreased serum HDL (P = 0.021, 0.031, respectively). Diastolic dysfunction and abnormal LV dimensions are present in patients with CKD even those on conservative management. TDI appears to be more impressive than PWD in assessing early myocardial dysfunction. Increased c-IMT and dyslipidemia are prevalent in patients with CKD and more prevalent in patients on HD.

Immunosuppressive therapy in children with steroid-resistant, frequently-relapsing, and steroid-dependent idiopathic nephrotic syndrome: a single center experience.

INTRODUCTION: Immunosuppressive agents are recommended for the management of children with steroid-resistant, frequently-relapsing, and steroid-dependent idiopathic nephrotic syndrome, i.e., SRNS, FRNS, and SDNS. This study evaluated the efficacy of immunosuppressive agents in these cases. METHODS: This is a retrospective analysis of the records of 130 pediatric cases recruited from a tertiary-care center over a period of two years. They were divided into two groups, i.e., 51 patients with SRNS (Group I) and 79 cases with SDNS and FRNS (Group II). They were treated with immunosuppressive agents in addition to steroids, either as double- or triple-combination therapy. Complete or partial remission was considered a good response. RESULTS: In group I, the proportions of good response to cyclophosphamide, cyclosporine A, and mycophenolate mofetil were 48.6, 60, and 80%, respectively (p = 0.162). In group II, the resistance rate was significantly higher with levamisole than with cyclophosphamide and azathioprine (p = 0.046). Leukopenia was reported infrequently after the administration of cyclophosphamide or azathioprine. The most serious adverse reaction was to cyclosporine A, which induced nephrotoxicity (6.4%), while no adverse effects were reported to be related to levamisole. Histopathological diagnoses were available in only 39 patients. CONCLUSION: The high potency of cyclosporine with steroids makes it useful in patients with idiopathic SRNS with a normal glomerular filtration rate. Its efficacy is augmented when combined with mycophenolate mofetil. Cyclophosphamide, orally or as intravenous boluses, together with alternate-day steroids, could be a good option outside the peripubertal age. The outcomes with FRNS and SDNS could be improved by encouraging compliance with the use of levamisole.