Hepcidin and its Related Hematological Biomarkers of Anemia in Children on Hemodialysis: Role of Carnitine Deficiency

BACKGROUND: Anemia is one of the most common complications in end-stage renal disease (ESRD) patients. Hepcidin is a hormone that regulates iron homeostasis in patients with ESRD. Carnitine deficiency is commonly seen in hemodialysis (HD) patients. AIM: This study aimed to investigate the relationship between hepcidin and inflammatory and other anemia markers in children with ESRD and to evaluate the association of carnitine deficiency with anemia in these patients. SUBJECTS AND METHODS: Thirty pediatric patients with ESRD undergoing HD, and thirty healthy, age- and sex-matched children served as controls were included in the study. Serum levels hepcidin, iron status, high-sensitivity C-reactive protein, and total carnitine were measured. RESULTS: Statistically significant increases in serum levels of hepcidin (100.7 ± 0.99 ng\ml vs. 77.43 ± 0.8 ng\ml, p = 0.000), was found in HD children as compared to healthy controls. Statistically significant increase in serum levels of hs-CRP (3.94 ± 0.19 mg/l vs. 1.36 ± 0.07 mg/l, p = 0.04) was found in HD children as compared to healthy controls. However, serum levels of carnitine (29.59 ± 2.46 μmol/L vs. 36 ± 2.39 μmol/L, p = 0.000) showed statistically significant decreases in HD children as compared to healthy controls positive correlation was found between hepcidin and hs-CRP (r = 0.059, p = 0.042). Furthermore, a positive correlation was present between serum carnitine levels and serum iron levels (r = 0.651, p = 0.042). CONCLUSION: Serum hepcidin may be a more useful biomarker of functional iron deficiency in children on HD. The efficacy of carnitine treatment for children on HD with carnitine deficiency and its effect on anemia needs to be studied

Visfatin versus Flow-Mediated Dilatation as a Marker of Endothelial Dysfunction in Pediatric Renal Transplant Recipients

BACKGROUND: Renal transplantation (RTx) is the treatment of choice for paediatric end-stage renal disease (ESRD). A major cause of morbidity and mortality after RTx is cardiovascular disease. Independent predictors of cardiovascular events were shown to constitute an endothelial dysfunction (ED). This study aims to evaluate Visfatin serum level in comparison to brachial artery flow-mediated dilatation (FMD) as a marker of endothelial dysfunction in paediatric RTx recipients.METHODS: Visfatin serum level has been evaluated in 30 patients on regular hemodialysis (HD), 36 patients post-RTx and 30 controls as a measure for ED, and has been compared to brachial artery FMD.RESULTS: Visfatin level in transplant recipients was significantly lower than the hemodialysis group as well as FMD was better in transplant recipients. In spite of marked improvement of FMD and marked reduction of visfatin in post-RTx no direct statistical correlation was found between serum Visfatin level and flow-mediated dilatation.CONCLUSION: Pediatric RTx recipients show lower serum Visfatin level and better FMD than those on regular hemodialysis, reflecting less endothelial dysfunction (ED) and less cardiovascular risk. FMD in kidney transplant recipients tends to be less than normal subjects while visfatin level of the same group is similar to controls. Pediatric RTx appears to have a positive impact on the growth development of children with ESRD

Rapid accelerated hemodialysis in children with end-stage renal disease: A randomized clinical trial

In rapid accelerated hemodialysis (R-AHD), blood partially recirculates from the venous (outflow) to the arterial (inflow) line through a recirculation line (R) to selectively increase the filter blood flow rate (BFR). R-AHD PR uses two blood pump segments at the patient segment of the arterial line and at (R). To determine the effectiveness of R-AHD with regard to increasing anticoagulation and dialysis efficiency, we studied ten children with end-stage renal disease in two stages: stage 1 with 10 routine heparin R-AHD, then 10 half-dose heparin R-AHD, then 145 routine heparin R-AHD sessions for 1 month and then routine heparin double needle hemodialysis (DNHD) for one month (control). In stage 2, we dialyzed the patients with 10 routine heparin-mixed AHD PR and DNHD sessions, then eight low-dose heparin R-AHD PR" sessions, then one of the children with 10 no-heparin R-AHD PR sessions and then 10 routine heparin DNHD sessions" (control). Signs of blood clotting and dialysis efficiency were monitored. Blood clots appeared in four out of 165 R-AHD 0 (one pump circuit) sessions but in none of the 28 R-AHD PR sessions. In stage 1, the mean urea reduction rate was 0.60, 0.60 and 0.70 for the R-AHD protocols, compared with 0.71 for the control (P >0.05). In stage 2, the arterial blood urea nitrogen was reduced by 0.66 ± 0.15 after an R-AHD PR period, compared with 0.79 ± 0.18 after a DNHD period (P = 0.059). In conclusion, R-AHD PR allowed successful low heparin and no heparin hemodialysis in children without increasing the patients′ BFR. However, the technique did not increase the efficiency of dialysis

Indications of continuous renal replacement therapy in critically ill pediatric patients

Background: Despite the increasing role of continuous renal replacement therapy (CRRT) in management of acutely ill patients requiring dialysis, the procedure remains demanding in terms of human resources and cost. Aim of the work: identification of the indications of CRRT in critically ill pediatric patients. Methods: A descriptive study of 35 pediatric patients requiring CRRT. Data regarding patients’ conditions and indications of CRRT were reported. Results: metabolic acidosis and volume overload were the most common indication of CRRT. Conclusion: CRRT is a useful therapy in critically ill children. The most frequent indications are metabolic acidosis and hypervolemia

Causes of chronic kidney disease in Egyptian children

There are very few published reports on the causes of chronic kidney disease (CKD) in Egyptian children. We reviewed the records of 1018 (males 56.7%, age ranged from 1 to 19 years) Egyptian patients suffering from CKD and followed-up at the pediatric nephrology units (outpatient clinics and dialysis units) of 11 universities over a period of two years. The mean of the estimated glomerular filtration rate was 12.5 mL/min/1.73 m 2 . Children with CKD stage I and stage II comprised 4.4% of the studied group, while those with stage III, IV and V comprised 19.7%, 18.3% and 57.6%, respectively. The most common single cause of CKD was obstructive uropathy (21.7%), followed by primary glomerulonephritis (15.3%), reflux/urinary tract infection (14.6%), aplasia/hypoplasia (9.8%) and familial/metabolic diseases (6.8%); unknown causes accounted for 20.6% of the cases. Of the 587 patients who had reached end-stage renal disease, 93.5% was treated with hemodialysis and only 6.5% were treated with peritoneal dialysis

Prevalence of Viral Infection among Egyptian Children with End Stage Renal Disease

Abstract: Background: Viral infections are frequent in hemodialysis patients, notably those due to hepatitis C virus (HCV), hepatitis B virus (HBV), hepatitis G virus (HGV) cytomegalovirus (CM V) and human immunodeficiency virus (HIV). Objective: The aim of this work is to study the prevalence of viral infections among Egyptian children with end stage renal disease whether on conservative management or on hemodialysis and to identify the possible associations between viral infections and some clinical parameters. Subjects: This cross-section study included 50 patients with end stage renal disease. They were divided into two groups; the first group consisted of 20 patients on conservative management. The second group consisted of 30 patients on regular hemodialysis. Inclusion criteria: Children below 18 years, both gender, end stage renal disease patients whether on conservative management or on hemodialysis. Exclusion criteria: Patients on immunosuppressant treatment for any particular disease. M ethods: All patients were subjected to full history, thorough clinical examination and laboratory investigations in the form of complete blood count, renal function tests, and serum electrolytes. Abdominal ultrasound and echocardiography were also done. In addition virological screen was assessed (conventional PCR for HCV, HGV and CMV and ELISA for HBV, HCV and HIV). Results: The comparative study between patients on conservative management (group I) and patients on hemodialysis (group II) showed no statistical significant difference between the two groups as regard to gender and age. 60% of the examined patients in each group were male. The mean age in group I was 11.48 ± 4.06 year while in group II it was 10.27 ± 3.20 year (P=0.253). However, great statistical differences was found between both groups in the mean onset of chronic renal failure it was 5.93 ±2.67 year in group I and 3.40 ± 1.30 year in group II (P=0.002). Also significant statistical differences were found between both groups as regard to the presence of anemia, (P=0.000) and history of blood transfusions (P =0.002). 100% of hemodialysis patients had anemia and 86.7% of them received blood. Hypertension was present in 35% of group I and in 63.3% of group II patients (P= 0.049). Stunted growth was found in 50% of patients on conservative management and in 83.3% of patients on hemodialysis (P=0.012). Laboratory studies showed no statistical significant differences between both groups as regard to hemoglobin, hematocrit, ALT, AST, calcium, phosphorus and alkaline phosphatase enzyme. Also no statistical significant difference was found in blood urea between both groups. W hereas there was a significant statistical difference in creatinine level between the two groups. The mean creatinine level in group I patients = 3.49 ± 1.72 mg/dl while in hemodialysis patients =7.16 ± 1.41 mg/dl (P=0.000). Abdominal ultrasound showed that the common cause of chronic renal failure (CRF) in patients on conservative management was obstructive uropathies (60% of cases). W hile congenital malformations were the commonest cause of CRF in hemodialysis patients (60%). Echocardiography showed that 50% and 10% of hemodialysis patients had left ventricular hypertrophy and pericardial effusion respectively. The virological studies showed that the commonest viral infection in both groups was HCV. It was detected by PCR in 35% of group I and in 50% of group II patients as single infection or as coinfection with other viruses. Cytomegalovirus was present in 20% of group I and in 10% of group II patients. HGV was only present in hemodialysis patients (13.3% of cases). HCV antibodies were detected by ELISA test in 15% of patient on conservative management and in 43.3% of patients on hemodialysis therapy P =0.035. No antibodies for HBV and HIV were detected in our patients. Significant association was found between viral infections and patient's age (P= 0.043). Also significant association was found between viral infections and duration of hemodialysis (P=0.015). But no significant associations were found between viral infections and both frequency of dialysis settings (P=0.485) and patient's gender (p=0.361). Conclusion and Recommendations: Viral infections are frequent in hemodialysis patients. Aust. J. Basic & Appl. Sci., 3(4): 3479-3491, 2009 3480 Strict infection control measures in dialysis units may help in decreasing the risk of infection. Both PCR and ELISA tests are required to maximize HCV diagnostic sensitivity. W e also recommended more researches to explore the prevalence of viral infections among children with end stage renal disease in the different nephrology departments and renal dialysis units

Decreasing intra-dialytic morbid events and assessment of dry weight in children on chronic hemodialysis using non-invasive changes in hematocrit

Achieving dry weight after hemodialysis (HD) is critical as chronic fluid over-load can result in left ventricular hypertrophy, while small fluid shifts may result in intra-dialytic morbid events (IME). In the pediatric population, estimating dry weight can be difficult due to growth while on dialysis. Continuous non-invasive monitoring of the hematocrit (NIVM) has been proposed as a more accurate method of estimating dry weight. Fifteen pediatric patients on chronic HD (6 males and 9 females; mean age 11.4 ± 2.28 years) were included in an uncontrolled prospective study involving three phases. In phase 1, patients were observed for one month for their dry weight and frequency of IME. Phase 2 consisted of using NIVM-guided ultrafiltration algorithm for rate of blood volume (BV) reduction and post-dialysis refill, recommending an intra-dialytic reduction in BV of 8% in the first hour and 0.1). In phase 1, 40% of patients experienced no IME, 33% experienced one or two IME while 27% experienced more than two IME; during phase 3, 80% experienced no IME, 20% experienced one or two IME while no one experienced more than two IME. NIVM can serve as an objective method for determining dry weight as well as predicting and preventing IME in the pediatric population on maintenance HD

Assessment of Quality of Life among Children with End-Stage Renal Disease: A Cross-Sectional Study

Background. Measuring health-related quality of life is considered an important outcome indicator in evaluating health-care interventions and treatments and in understanding the burden of diseases. Objectives. This study aimed at assessing quality of life among children with end-stage renal disease, either undergoing hemodialysis or had renal transplantation therapy and comparing it with healthy controls. Methods. A cross-sectional study was conducted between December 2016 and May 2017 in Abo El-Reesh Pediatric Hospital using parent/child reports of generic module for QoL assessment: PedsQLTM Inventory version 4 for both cases and controls. Disease-specific module: PedsQLTM ESRD version 3 was used for ESRD cases. 55 ESRD cases and 86 controls were enrolled in the study. Results. Statistically significant difference between ESRD cases and controls regarding all aspects of QoL was found; total QoL mean score was 58.4 ± 15.3 and 86.8 ± 10 among cases and controls, respectively. All individual QoL domains were significantly worse in ESRD cases. Transplantation group had better Spearman’s correlation between child and parents’ scores which showed significant positive moderate correlation. Conclusions. ESRD and its treatment modalities are affecting negatively all aspects of quality of life; incorporating QoL assessment and management is highly recommended

Plasma Netrin-1 & cardiovascular risk in children with end stage renal disease

Background: Cardiovascular disease (CVD) is the most common cause of mortality and morbidity in children with end stage kidney disease (ESKD) which arises from the interaction of several risk factors. The aim of the study is to assess CV risk of ESKD children and outline the impact of KTX on this CV risk. Also valuate the relation between plasma Netrin-1, chronic inflammatory markers and CV risk. Methods: Sixty ESKD (30 on regular hemodialysis (HD), 30 recipients of kidney transplant (KTX)) were assessed using 24 hour AMBP assessment, laboratory (including lipid profile and markers of chronic inflammation namely N/L and HsCRP) and echocardiographic data. Plasma netrin-1 was assessed by ELISA technique for all patients. Results: showed significant higher prevalence of hypertension, higher number of patients with 24hrs BP> 95th percentile by ABPM, more prevalence of nocturnal non-dipping BP, higher percentage of obese and overweight patients, worse biochemical analysis, higher chance of medical calcification by higher Po4 and Ca X Po4, higher triglyceride level and lower HDL level and higher N/L in HD than KTX group. Significant inverse relation was detected between plasma netrin 1 and Hs CRP and between netrin 1 and N/L (p<0.001)