Pediatric Dialysis Research Articles

Beyond playing games: nephrologist vs machine in pediatric dialysis prescribing

In a recent article in Pediatric Nephrology, Olivier Niel and colleagues applied an artificial intelligence algorithm to a clinical problem that continues to challenge experienced pediatric nephrologists: optimizing the target weight of children on dialysis. They compared blood pressure, antihypertensive medication and intradialytic symptoms in children whose target weight was prescribed firstly by a nephrologist, then subsequently using a machine learning algorithm. Improvements in all outcome measures are reported. Their innovative approach to tackling this important clinical problem appears promising. In this editorial, we discuss the strengths and weaknesses of their study and consider to what extent machine learning strategies are suited to optimizing pediatric dialysis outcomes.

Leptin and ghrelin in chronic kidney disease: their associations with protein-energy wasting.

This study aimed to evaluate plasma concentrations of leptin and total ghrelin in children with chronic kidney disease (CKD) and assess their roles in protein-energy wasting (PEW). This study consisted of three different CKD populations [CKD group (20 patients with non-dialysis CKD), dialysis group (39 patients on dialysis), and kidney transplant (KTx) group (35 KTx recipients)] and control group (18 healthy children). Plasma leptin and total ghrelin levels were measured. Multi-frequency bioimpedance analysis was used for the assessment of fat and lean mass. PEW was defined using criteria including body mass, muscle mass, growth, serum albumin level, and protein intake. While plasma leptin levels did not differ among the study groups, total ghrelin levels were significantly higher in the dialysis group (P< 0.001). Seven dialysis patients (18%) and one CKD patient (5%) but none of the KTx recipients met the criteria of PEW. Dialysis patients with PEW had lower plasma leptin levels compared to their counterparts (P= 0.018); however, total ghrelin levels did not differ between the two groups (P= 0.10). Low leptin level in dialysis patients was independently associated with lower fat mass index (P< 0.001) and lower height-specific SD scores of BMI (P= 0.019). PEW is prevalent in dialysis patients. Low levels of leptin seem to be associated with PEW. Our result suggests that low leptin levels may be a consequence rather than a cause of PEW. Longitudinal studies are required to investigate this complex relationship between leptin and PEW in pediatric dialysis patients.

Clinical experience with the use of ferric citrate as a phosphate binder in pediatric dialysis patients.

Ferric citrate, an iron-based phosphate binder, has been shown to improve both hyperphosphatemia and iron deficiency in adult chronic kidney disease patients, but its use in the pediatric dialysis population has not been described. This is a retrospective analysis of 11 unselected pediatric dialysis patients who received ferric citrate as a phosphate binder between 2015 and 2017. Time-averaged laboratory values were compared pre- and post-ferric citrate initiation using the Wilcoxon signed-rank test. The median age of this cohort was 13years old (range 4-17years old). Five patients were on hemodialysis, and six patients were on peritoneal dialysis. The median duration of ferric citrate therapy was 214days (range 39-654days), with a median time-averaged ferric citrate dose of 3.5 tablets per day (range 1.5-8.4 tablets per day). Compared to the pre-ferric citrate period, ferric citrate treatment was associated with decreased serum phosphate (6.5 to 5.2mg/dl, p = 0.014), decreased phosphate age-related standard deviation score (SDS) (2.3 to 0.9, p = 0.019), increased transferrin saturation (26 to 34%, p = 0.049), increased ferritin (107 to 230ng/ml, p = 0.074), and maintenance of hematocrit. In pediatric dialysis patients, ferric citrate may be able to concurrently lower phosphate levels and treat iron deficiency. However, larger studies are needed to further evaluate safety and efficacy in the pediatric chronic kidney disease population.

Hypertension in Pediatric Dialysis Patients: Etiology, Evaluation, and Management.

Review epidemiology, pathophysiology, and management of hypertension in the pediatric dialysis population. Interdialytic blood pressure measurement, especially with ambulatory blood pressure monitoring, is the gold standard to assess for hypertension. Tools to assess dry weight aid in achievement of euvolemia, the primary therapy for management of hypertension. Persistent hypertension should be treated with antihypertensive medications and potentially with native nephrectomies. Cardiovascular disease continues to be the primary cause of morbidity and mortality in the dialysis population with hypertension as an important modifiable factor. Achievement on dry weight and limiting both aggressiveness of interdialytic weight gain and ultrafiltration rate underlie the best approach. Tools to assess volume status beyond clinical assessment have shown promise in achieving euvolemia. When hypertension persists despite achievement of euvolemia, antihypertensive medications may be required and in some cases native nephrectomies. Future studies in children are needed to determine the best antihypertensive class and ideal rate of ultrafiltration on hemodialysis towards achievement of normotension and reduction of cardiovascular risk.

Abstract P-199: THE FIRST SUCCESSFUL EXPERIENCE IN THE BALTIC COUNTRIES USING A CARPEDIEM DIALYSIS MACHINE IN A SEPTIC SHOCK PATIENT

Aims & Objectives: Invasive meningococcal infection (IMI) is one of the most devastating infections with challenging recognition, high fatality rate, long-term sequelae. One of the most common sequelae is acute kidney failure (AKF). Peritoneal dialysis remains the gold standard for managing AKF, although treatment effect can be limited due to patient’s low weight. The aim was to describe appliance of a Carpediem (Cardio-Renal Pediatric Dialysis Emergency Machine) in treatment of AKF in a low weight patient. Methods Clinical data of a case report was retrieved from Vilnius University Children’s Hospital database. Results A 16-month old male patient with a weight of 9 kilograms was admitted to PICU 15 hours after disease onset. A patient presented with spreading hemorrhagic lesions, clonic seizures, bulging fontanel, cardiopulmonary insufficiency and acute kidney failure. Metabolic acidosis with hyperlactatemia, uremia and compromised blood coagulation were found. Mechanical ventilation was started together with fluid therapy, vasoactive drugs and ceftriaxone. Due to progression of AKF a slow continuous ultrafiltration (SCUF) using Carpediem was initiated 18 hours after anuria onset with fluid overload of 590 ml in the past 29 hours. 3 days after SCUF was replaced with peritoneal dialysis. Despite of high IMI fatality rate, a patient’s condition improved and kidney function restored in 10 days, whereas in first 43 hours of renal replacement therapy 1270 ml of ultrafiltrate was removed. A patient was discharged from the hospital 3 months after without signs of AKF. Conclusions SCUF using a Carpediem machine in a low weight patient was effective and promising in AKF treatment.

Teaching Pediatric Peritoneal Dialysis Globally through Virtual Simulation.

Despite the increasing prevalence of childhood kidney disease worldwide, there is a shortage of clinicians trained to provide peritoneal dialysis (PD). E-learning technologies may provide a solution to improve knowledge in PD. We describe the development of a virtual PD simulator and report the first 22 months of online usage. The PD simulator was developed and released on OPENPediatrics in January of 2016. A prospective study of international, multidisciplinary healthcare providers was conducted from January of 2016 through October of 2017. User action data were analyzed with descriptive statistics and linear regression. Paired t tests compared user pre- and post-test scores. User satisfaction was assessed by survey. The simulator was accessed by 1066 users in 70 countries. Users spent a median of 35 minutes (interquartile range [IQR] 14-84) in the simulator. Users who completed the structured learning curriculum (n=300) spent a median of 85 minutes (IQR 46-95), and those who completed the entire simulator (n=63) spent a median of 122 minutes (IQR 69-195). Users who completed the simulator were more likely to scroll through text and access the simulator in multiple sessions. The 300 users that completed testing showed statistically significant increases in the post- versus pretest scores, with a mean increase of 36.4 of 100 points, SD 19.9 (95% confidence interval, 34.1 to 38.6, P<0.001). Eighty-seven percent (20 of 23) of survey respondents felt the simulator was relevant to their clinical practice, and 78% (18 of 23) would recommend it to others. This is the first reported virtual PD simulator. Increased test scores were observed between pre- and post-tests by clinicians who completed testing, across disciplines, training levels, and resource settings.

Assessment and management of fluid overload in children on dialysis

Dysregulation of intravascular fluid leads to chronic volume overload in children with end-stage kidney disease (ESKD). Sequelae include left ventricular hypertrophy and remodeling and impaired cardiac function. As a result, cardiovascular complications are the commonest cause of mortality in the pediatric dialysis population. The clinical need to optimize intravascular volume in children with ESKD is clear; however, its assessment and management is the most challenging aspect of the pediatric dialysis prescription. Minimizing chronic fluid overload is a key priority; however, excessive ultrafiltration is toxic to the myocardium and can precipitate intradialytic symptoms. This review outlines emerging objective techniques to enhance the assessment of fluid overload in children on dialysis and outlines evidence for current management strategies to address this clinical problem.

Klotho G-395A gene polymorphism: impact on progression of end-stage renal disease and development of cardiovascular complications in children on dialysis.

Klotho G-395-A gene polymorphism may impact children with end-stage renal disease (ESRD). We investigated the relevance of Klotho G-395-A on ESRD development and progression, and its relationship with evolution of cardiovascular complications in pediatric dialysis patients. Fifty-five children with chronic kidney disease (CKD) and seventy healthy children were genotyped for Klotho G-395A. Incidence of GA/AA genotypes and A allele were higher in ESRD patients compared with controls (54.5 vs. 7.1%, P < 0.001; 30.9 vs. 13.6%, P = 0.001, respectively). Also, children with GA/AA genotypes were 15.6 times more likely to develop ESRD than with GG genotype (95% CI 5.4-44.7, P < 0.001). A allele carriers have 2.8 times higher risk of developing ESRD than those with G allele (95% CI 1.5-5.35, P = 0.001). Also, the A allele could be considered a predictor of cardiovascular disease (CVD), as carriers have 161 times higher risk of cardiovascular complications than non-carriers (95% CI 21-1233, P < 0.001). All ESRD patients with CVD presented with left ventricular hypertrophy (LVH) and the frequency of A allele was significantly higher among ESRD children with LVH, whereas G allele frequency was significantly higher among ESRD children without LVH. The A allele of the G-395A Klotho gene polymorphism shows a significantly higher frequency among children with CKD and those with CVD and LVH. This mutant allele could be used as a risk marker for the development of ESRD as well as a predictor of CVD in these children.

Fungal peritonitis in the Standardizing Care to Improve Outcomes in Pediatric End Stage Renal Disease (SCOPE) Collaborative.

Fungal peritonitis is a serious complication among peritoneal dialysis (PD) patients. The Standardizing Care to Improve Outcomes in Pediatric End Stage Renal Disease (SCOPE) Collaborative is a North American multicenter quality improvement initiative with the primary aim to reduce catheter-related infections in children on chronic dialysis. To describe the epidemiology of fungal peritonitis and outcomes of affected patients among pediatric subjects receiving chronic PD and enrolled in SCOPE. Data pertaining to PD characteristics, peritonitis episodes and patient outcome were collected between October 2011 and September 2015 from 30 pediatric dialysis centers participating in the SCOPE collaborative. Peritonitis-related data were stratified by etiology, fungal versus bacterial/culture-negative peritonitis. Differences among groups were assessed by Chi-square analysis. Of 994 patients enrolled in the registry, there were 511 peritonitis episodes of which 41 (8.0%) were fungal. Thirty-six individual patients with 39 unique catheters accounted for the fungal peritonitis episodes. Twenty-three (59%) of the episodes occurred in patients aged < 2years (p= 0.03). Fungal peritonitis was the initial episode of peritonitis in 48.8% of affected patients, and only 17.1% of these patients had had a previous peritonitis episode within 30days of the fungal infection. Insertion of the PD catheter at < 2years of age was associated with an adjusted odds ratio of 2.8 (95% confidence interval 1.24, 6.31) for development of fungal peritonitis compared to older children (p= 0.01). Fungal peritonitis was associated with an increased rate of hospitalization (80.5 vs. 63.4%; p= 0.03), increased length of hospitalization (median of 8 vs. 5days; p< 0.001) and increased rates of catheter removal (84.6 vs 26.9%; p= 0.001) and technique failure (68.3 vs. 8%; p= 0.001) compared to other causes of peritonitis. Fungal infections were responsible for 8.0% of peritonitis episodes in the SCOPE collaborative, with the majority of fungal peritonitis episodes occurring in children aged < 2years. Although no risk factors for infection other than young age were identified, fungal peritonitis was associated with an increased risk of hospitalization, longer hospital stay and an increased frequency of technique failure.

The Dialysis Facility Compare Five-Star Rating System at 2 Years.

The 1997 Balanced Budget Act required the Centers for Medicare and Medicaid Services (CMS) to develop and implement a method to measure and report the quality of kidney dialysis services provided by Medicare ([1][1]). As a result, CMS launched the Dialysis Facility Compare (DFC) website in 2001,

Peritonitis in Children on Chronic Peritoneal Dialysis: The Experience of a Large National Pediatric Cohort

Background: We performed this study to evaluate the incidence, risk factors, microbiology, treatment, and outcome of peritonitis in pediatric Peritoneal dialysis (PD) patients at a nationwide prospective study. Methodology: Patients younger than 18 years recruited in the BRAZPD II study from 2004 to 2011, who presented their first peritonitis episode, were included in the study. Results: We found 125 first episodes of peritonitis in 491 children PD patients (0.43 episodes/patient-year). Patients free of peritonitis episode constituted 75.6% in 1 year. Culture-negative episodes were very high (59.2%) and gram-positive (GP) bacteria were the most commonly found organisms (58.8%). First-generation cephalosporin was the initial choice to cover GP (40.5%) and aminoglycosides was the most prescribed antibiotics used for gram-negative agents (27.5%). Treatment failure was 26.4%. Technique failure (TF) occurred in 12.1% and peritonitis was the main cause (65.1%). Pseudomonas (p = 0.04) and negative cultures (p < 0.001) were identified as predictors of TF. Conclusion: Peritonitis remains a common complication of PD in children and negative cultures and pseudomonas had a negative impact on TF.

Vaccination Practices in Pediatric Dialysis Patients Across Europe. A European Pediatric Dialysis Working Group and European Society for Pediatric Nephrology Dialysis Working Group Study

Background: Data on the immunization practices in pediatric chronic kidney disease (CKD) patients are scarce. The purpose of this study was to evaluate current vaccination practices for children on dialysis across European pediatric nephrology centers. Methods: A total of 18 tertiary pediatric nephrology centers from 12 European countries were included in the study. The data on universal national immunization programs and immunization practices for children with chronic disease or risk were recorded from European Center for Disease Prevention and Control and the World Health Organization. The immunization practices and center protocols for monitoring antibody titers after vaccination in dialysis patients were obtained through a questionnaire. Results: All centers included in the study recommended immunization against hepatitis B virus (HBV), diphtheria, tetanus, pertussis, Hemophilus influenzae type b (Hib), poliomyelitis, measles, mumps, rubella (MMR), and streptococcus pneumonia in dialysis patients. In 16 centers, dialysis patients were vaccinated against influenza virus annually. HBV protective antibody titers were measured in 17 centers (during dialysis period in 14 centers, during pre-renal transplantation preparations in 14 centers or in both times in 11 centers). Hepatitis A virus (HAV) was reported to be followed in 13 centers, in 8 centers during dialysis period, and in 11 centers during pre-RTx preparations. MMR and varicella-zoster virus (VZV) protective antibody titers were measured during the dialysis period or before renal transplantation (RTx) in 12 and 15 centers, respectively, and in 6 centers both titers were checked both times. Conclusion: There are variations in vaccination practice across Europe. Children with CKD, those undergoing dialysis, and transplant candidates should receive age-appropriate vaccinations before RTx as well as before the transition to adult nephrology clinics and antibody levels should be monitored to evaluate the immunization status before and after RTx.

Epidemiology of peritonitis following maintenance peritoneal dialysis catheter placement during infancy: a report of the SCOPE collaborative.

Maintenance peritoneal dialysis (PD) is the dialysis modality of choice for infants and young children. However, there are limited outcome data for those who undergo PD catheter insertion and initiate maintenance PD within the first year of life. Using data from the Children's Hospital Association's Standardizing Care to Improve Outcomes in Pediatric End Stage Renal Disease (ESRD) Collaborative (SCOPE), we examined peritonitis rates and patient survival in 156 infants from 29 North American pediatric dialysis centers who had a chronic PD catheter placed prior to their first birthday. In-hospital and overall annualized rates of peritonitis were 1.73 and 0.76 episodes per patient-year, respectively. Polycystic kidney disease was the most frequent renal diagnosis and pulmonary hypoplasia the most common co-morbidity in infants with peritonitis. Multivariable regression models demonstrated that nephrectomy at or prior to PD catheter placement and G-tube insertion after catheter placement were associated with a nearly sixfold and nearly threefold increased risk of peritonitis, respectively. Infants with peritonitis had longer initial hospital stays and lower overall survival (86.3 vs. 95.6%, respectively; P<0.02) than those without an episode of peritonitis. In this large cohort of infants with ESRD, the frequency of peritonitis was high and several risk factors associated with the development of peritonitis were identified. Given that peritonitis was associated with a longer duration of initial hospitalization and increased mortality, increased attention to the potentially modifiable risk factors for infection is needed.

Barriers for implementation of intensified hemodialysis: survey results from the International Pediatric Dialysis Network.

In patients on conventional hemodialysis (HD), morbidity is high and quality of life is poor. Intensified HD programs have been developed to help overcome these shortcomings, , but very few pediatric dialysis centers have reported the implementation of such a HD program. An online survey was sent to all 221 pediatric dialysis centers which participate in the International Pediatric Dialysis Network (IPDN). The aim of the survey was to assess the attitude of pediatric nephrologists towards intensified HD, the penetrance of intensified HD into their clinical practice and barriers to implementation. Of the 221 pediatric dialysis centers sent the survey, respondents from 61% (134) replied. Among these respondents, 69% acknowledged being aware of the evidence in support of the use of intensified HD, independent of whether intensified HD was offered at their own center, and 50% associated the use of daily nocturnal HD with the best overall patient outcome. In contrast, only 2% of respondents were in favor of conventional HD. Overall, 38% of the respondents stated that at their center intensified HD is prescribed to a subgroup of patients, most commonly in the form of short daily HD sessions. The most important barriers to expansion of intensified HD programs were lack of adequate funding (66%) and shortage of staff (63%), whereas lack of expertise and of motivation were reported infrequently as obstacles (21 and 14%, respectively). Intensified HD is considered by many pediatric nephrologists to be the dialysis modality most likely associated with the best patient outcome. The limited use of this treatment approach highlights the importance of defining and successfully addressing the barriers to implementation.

Air Displacement Plethysmography Versus Bioelectrical Impedance to Determine Body Composition in Pediatric Hemodialysis Patients

Protein energy wasting is difficult to assess in pediatric hemodialysis (HD) populations because of fluid shifts. Body composition (BC) analysis aids in monitoring nutrition therapy's effects on fat and lean mass. Air displacement plethysmography (ADP) is a "practical" gold standard for fat mass (FM) measurements. We aim to compare BC measures in a pediatric HD population via anthropometry, ADP, and bioelectrical impedance (BIA). The study was prospective cohort study and the setting was 1 pediatric HD unit in Houston, Texas. A total of 15 pediatric and young adult patients receiving maintenance HD. ADP, BIA, and anthropometry were obtained mid-week post HD for 3 consecutive months. The primary outcome was the difference in FM as defined by various assessment methods. Secondary outcomes included correlations with anthropometry. ADP demonstrated a strong positive correlation to body mass index, mid-upper arm circumference, and triceps skin fold (all P<.0001). No differences in FM assessment using ADP or BIA were found except in males with advanced tanner (P=.0004). BIA underestimated FM in obese subjects (P=.005). Analysis of malnutrition status by mid-upper arm circumference revealed an overestimation of FM in BIA measures (P=.02). This is the first pediatric dialysis study using ADP to assess BC. Estimation of FM in pediatric HD patients via ADP and BIA has significant error rates in 2 populations: (1) males tanner ≥4: BIA underestimates FM and (2) weight extremes: BIA underestimates FM for obese and overestimates FM for malnourished. BIA should be used with caution in these populations when estimating fluid content and leads to false estimates of dry weight. ADP is a useful adjunct in assessment of nutritional status via BC in pediatric HD patients.

PP-13 An analysis of the applications for a paediatric investigation plan (pip) for indications in uro-nephrology

Introduction In order to assess the requirements of the European Medical Agency (EMA) for paediatric clinical trials in nephrology we assessed the decisions on Paediatric Investigation Plans (PIPs), which are required to get approval for new drugs. Paediatric nephrology comprises rare indications, but also frequent paediatric conditions. Clinical trials are needed in order to base therapy on ev-idence, but the relevant population can be very small in paediatric nephrology. Methods All 20 decisions on PIPs published by the EMA on the EMA website under ‘uro-nephrology’ were includ-ed. Data are presented as proportions (categorical data) and median (range) (numerical data). Results Full and partial waivers: 7 of the published decisions granted a full waiver (i.e., no paediatric studies required). For the remaining 13, a PIP was agreed. For 6 of those 13 PIPs, a partial waiver was granted for certain ages (0–6 months (2x), 0–5, 0–6, 0–8, 12–18 years.Agreed PIPs: The PIPs require the conduct of 0–3 (median 1) quality studies, 0–2 (median 0) non-clinical studies, and 1–6 (median 3) clinical studies. As there are ca. 9 paediatric dialysis subjects per million of all paediatric subjects, an estimate of the number of paediatric dialysis patients in EU is roughly ca. 400 patients. At least 4 PIPs require in-clusion of paediatric dialysis subjects, requiring 14 clinical studies, i.e., ca. 14 subjects are available for each of those studies. There are no concessions in powering the studies, and therefore, the required numbers will be much higher than the available number of subjects in EU. Time for decision and time for completion of PIP: The time between start of the procedure and the decision of the PdCo/EMA was 103 days (35–468 days). The time between the date of decision of the PdCO/EMA and the date of the required completion of the PIP ranged from 0.03 years – 13.47 years (median 4.84 years). Conclusion All partial waivers affected the lowest age groups. Although the youngest age groups need an eval-uation of new substances most urgently, the number of granted partial waivers indicates how difficult it is to con-duct clinical trials in this subpopulation. However, only 4 of the 13 agreed PIPs are concerned with frequent indi-cations, while 9 of those aim at rare indications. For those 9, a median of 3 clinical studies is required. It is unlikely that the required number of subjects can realistically be recruited. Further, the required studies make the timely conduct (median time 4.84 years) and completion at the same time as the studies in adults questionable. This could delay approval in adults. In summary, we show some im-balances: a) studies are most difficult in infants, but they need them most, b) the number of subjects required does not fit the indication epidemiology, c) timelinies for com-pleting paediatric studies are difficult to meet.

Trace element and vitamin concentrations in paediatric dialysis patients.

There are few recent data regarding blood micronutrient concentrations and supplementation in children on maintenance dialysis. We investigated micronutrient concentrations following dialysis commencement. Retrospective review, including all children on maintenance dialysis (peritoneal dialysis, PD; intermittent haemodialysis, IHD), for nutritional blood concentrations measured over the first 12months. Patients received pyridoxine and Dialyvit® daily with planned 3-monthly micronutrient concentration monitoring including selenium, manganese, copper, zinc, folate and vitamins A, D, B12 and E. We reviewed 47 children (24 girls) including 19 PD and 28 IHD, median age (IQR) 11.4 (2.8,14.4) years. 33 were white, 5 Asian, 5 black and 4 of other ethnic origins. Vitamin A, B12 and E concentrations were within range in 6%, 20% and 13% respectively, with all others above normal range. Serum folate and vitamin D concentrations were within the desired range of 55%, with the rest above or below target. For trace elements, 37%, 60%, 65% and 89% achieved normal ranges for zinc, manganese, copper and selenium respectively. Deficiencies were seen for zinc (43%), copper (28%), folate (6%) and selenium (4%), whereas 7%, 7%, 20% and 40% had copper, selenium, zinc and manganese levels above normal ranges. Despite standard pyridoxine supplementation, only 6 children were monitored during the study period. Concentrations of several trace elements and vitamins were outside reference ranges. Response to systematic monitoring and targeted supplementation should be evaluated in future studies. Paediatric dialysis centres should consider undertaking routine nutritional bloods monitoring, particularly for vitamin D, zinc and copper.

Vitamin and trace element deficiencies in the pediatric dialysis patient.

Pediatric dialysis patients are at risk of nutritional illness secondary to deficiencies in water-soluble vitamins and trace elements. Unlike 25-OH vitamin D, most other vitamins and trace elements are not routinely monitored in the blood and, consequently, the detection of any deficiency may not occur until significant complications develop. Causes of vitamin and trace element deficiency in patients on maintenance dialysis patient are multifactorial, ranging from diminished nutritional intake to altered metabolism as well as dialysate-driven losses of water-soluble vitamins and select trace elements. In this review we summarize the nutritional sources of key water-soluble vitamins and trace elements with a focus on the biological roles and clinical manifestations of their respective deficiency to augment awareness of potential nutritional illness in pediatric patients receiving maintenance dialysis. The limited pediatric data on the topic of clearance of water-soluble vitamins and trace elements by individual dialysis modality are reviewed, including a brief discussion on clearance of water-soluble vitamins and trace elements with continuous renal replacement therapy.

Cognitive function assessment in adolescent patients on hemodiaylsis

Background Studying the impact of chronic kidney disease on neurocognitive functions is a critical element for providing optimal care to these children who might suffer from its detrimental consequence on their psychosocial life. Aim The aim of the study was to assess the cognitive functions in adolescents with end-stage renal disease (ESRD) under regular hemodialysis compared with healthy controls. Patients and methods We studied 40 adolescents – 20 patients with ESRD on regular dialysis and 20 controls closely matched with the patient in terms of their age, sex, and educational level. Patients were recruited from the pediatric dialysis unit, Menoufia University hospitals, with dialysis durations ranging from 0.5 to 8.5 years with mean 3.25±2.28 years. They were assessed using Raven’s Progressive Matrices tests (for fluid intelligence), and a computerized battery composed of Spatial Span (visual–spatial working memory task), Tower of London task (measuring planning and problem-solving ability), and the Go/No Go task (a task assessing response inhibition, set shifting, and attention). We, furthermore, assessed disease-related variables impacting the cognitive functions of the patients. Results The average age of the patients was 14.4±3.315 years, and that of the controls was 13.7±1.46 years. The fluid IQ for the patients was significantly lower than the controls (P Conclusion Our findings provide evidence that the fluid intelligence and cognitive function of adolescents with ESRD on dialysis fall within the low average on most tasks. Furthermore, hypertension and anemia potentially place children with ESRD at an increased risk for neurocognitive deficits, which consequently places them at risk for poor long-term educational and occupational outcomes.

Clinical practice recommendations for treatment with active vitamin D analogues in children with chronic kidney disease Stages 2-5 and on dialysis.

In patients with chronic kidney disease (CKD), renal synthesis of active vitamin D [1,25-dihydroxyvitamin D (1,25(OH)2D)] declines and is associated with hypocalcaemia, secondary hyperparathyroidism and the spectrum of CKD-mineral and bone disorder (MBD). In advanced CKD, active vitamin D analogues, including alfacalcidol, calcitriol and paricalcitol, are routinely administered. There are few studies on the use of vitamin D analogues in children with CKD and on dialysis. It is difficult to define bone-specific outcomes that can guide treatment with active vitamin D analogues in children with CKD-MBD. A core working group (WG) of the European Society for Paediatric Nephrology (ESPN) CKD-MBD and Dialysis WGs has developed recommendations for the use of active vitamin D therapy in children with CKD and on dialysis. A second document in parallel with this one covers treatment recommendations for native vitamin D therapy. The WGs have performed an extensive literature review to include systematic reviews and randomized controlled trials in adults and children with CKD and prospective observational studies in children with CKD. The Grading of Recommendation, Assessment, Development and Evaluation (GRADE) system was used to develop and grade the recommendations. In the absence of applicable study data, the opinion of experts from the ESPN CKD-MBD and Dialysis WGs is provided, but clearly GRADE-ed as such and must be carefully considered by the treating physician and adapted to individual patient needs as appropriate.