Chronic dialysis in the infant less than 1 year of age

Dialysis in the infant carries a mortality rate of 16%. Institution of dialysis may be the result of adequate nutritional intake, but avoidance of nutritional intake should never be seen as a way to prevent dialysis. Increased caloric intake, usually via enteral feeding tubes, is needed for optimal growth in the infant with end-stage renal disease (ESRD) in order to attain adequate nutrition with resulting good growth. “Renal” formulae may be constituted as dilute (as in the polyuric infant) or concentrated (as in the anuric infant) to fit the infants needs. Peritoneal dialysis (PD) is the usual mode of renal replacement therapy (97%), with access via a surgically placed cuffed catheter with attention to the placement of the exit site in order to avoid fecal or urinary contamination. PD volumes of 30–40 ml/kg per pass or 800–1,200 ml/m 2 per pass usually result in dialysis adequacy. Additional dietary sodium (3–5 mEq/kg per day) and protein (3–4 g/kg per day) are needed, due to sodium and protein losses in the dialysate. Protein losses are associated with significant infectious morbidity and nonresponsiveness to routine immunizations. Hemodialysis (HD) can be performed either as single- or dual-needle access that have minimal dead space (less then 2 ml) and recirculation rate (less then 5%). Attnetion to extracorporeal blood volume (<10% of intravascular volume), blood flow rates (3–5 ml/kg per min), heparinization (activated clotting times), ultrafiltration (ultrafiltration monitor), and temperature control is imperative during each treatment. Because infants' nutrition is mostly fluid, HD may be needed 4–6 days/week (especially in the oligoanuric infant) to avoid excessive volume overload between treatments. At the end of the treatment a slow blood return with minimal saline rinse is needed to avoid hemodynamic compromise. Infant dialysis, although technically challenging with a significant morbidity and mortality rate, can be safely carried out in the infant with ESRD but requires infant-specific equipment and trained personnel.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/47836/1/467_2004_Article_BF00867678.pd

Selection of modalities, prescription, and technical issues in children on peritoneal dialysis

Peritoneal dialysis (PD) is widely employed as a dialytic therapy for uraemic children, especially in its automated form (APD), that is associated with less burden of care on patient and family than continuous ambulatory PD. Since APD offers a wide range of treatment options, based on intermittent and continuous regimens, prescription can be individualized according to patient’s age, body size, residual renal function, nutritional intake, and growth-related metabolic needs. Transport capacity of the peritoneal membrane of each individual patient should be assessed, and regularly monitored, by means of standardized peritoneal function tests validated in pediatric patients. To ensure maximum recruitment of peritoneal exchange area, fill volume should be scaled to body surface area and adapted to each patient, according to clinical tolerance and intraperitoneal pressure. PD solutions should be employed according to their biocompatibility and potential ultrafiltration capacity; new pH-neutral, glucose-free solutions can be used in an integrated way in separate dwells, or by appropriately mixing during the same dialytic session. Kinetic modelling software programs may help in the tailoring of PD prescription to individual patients’ characteristics and needs. Owing to advances in the technology of new APD machines, greater programming flexibility, memorized delivery control, and tele-dialysis are currently possible

Peritoneal dialysis prescription in children: bedside principles for optimal practice

There is no unique optimal peritoneal dialysis prescription for all children, although the goals of ultrafiltration and blood purification are universal. In turn, a better understanding of the physiology of the peritoneal membrane, as a dynamic dialysis membrane with an exchange surface area recruitment capacity and unique permeability characteristics, results in the transition from an empirical prescription process based on clinical experience alone to the potential for a personalized prescription with individually adapted fill volumes and dwell times. In all cases, the prescribed exchange fill volume should be scaled for body surface area (ml/m2), and volume enhancement should be conducted based on clinical tolerance and intraperitoneal pressure measurements (IPP; cmH2O). The exchange dwell times should be determined individually and adapted to the needs of the patient, with particular attention to phosphate clearance and ultrafiltration capacity. The evolution of residual kidney function and the availability of new, more physiologic, peritoneal dialysis fluids (PDFs) also influence the prescription process. An understanding of all of these principles is integral to the provision of clinically optimal PD

A aplicação de adesivo de cianoacriato por histeroscopia e os testes de perviedade na esterilização tubária de ovelhas

Objetivo: avaliar, por meio de testes de prenhez e de perviedade, a eficácia da obstrução tubária de ovelhas com adesivo de cianoacrilato aplicado por via histeroscópica. Método: 12 ovelhas adultas, com uma gestação anterior, foram distribuídas em três grupos: G-PO (n=3) submetidas à laqueadura tubária tipo Pomeroy; G-SH (n=3) aplicação de solução salina no istmo tubário por histeroscopia, e G-AD (n=6) aplicação de 0,5mL de n-butil-2-cianoacrilato no interior do istmo tubário, por histeroscopia. Depois de acasaladas por 90 dias com machos de comprovada fertilidade, as ovelhas não prenhas foram submetidas à laparotomia, retiradas as tubas uterinas, medidos os seus diâmetros e preparadas para testes de perviedade pela aplicação de azul de metileno e de pressão hidráulica (80mmHg). Resultados: As ovelhas de G-PO e G-AD não ficaram prenhas (0%), em contraste com as SH (100%). O GPO apresentou maior concentração de aderências (66,6%) e de granulomas (100%) em relação ao grupo AD (0%); o adesivo manteve-se íntegro no lúmen tubário. O diâmetro da tuba uterina em G-AD (0,650 ± 0,16 cm) foi significantemente maior do que o das tubas em G-PO (0,195 ± 0,04* cm) (p=0,01). Os testes de perviedade de pressão e corante foram negativos para todo o grupo PO e somente um animal em AD mostrou-se positivo para o teste de pressão. Conclusão: a aplicação histeroscópica de cianoacrilato no lúmen tubário de ovelhas impediu eficientemente a fecundação, constituindo procedimento eficaz e de boas perspectivas para aplicação futura em humanos.Background: To evaluate, through pregnancy and pressure burst tests, the effectiveness of sheep uterine tube sterilization through hysteroscopic insertion of cyanoacrylate adhesive. Methods: Adult sheep (n=12), with one previous pregnancy, were distributed as follows: PO Group (n=3) submitted to laparotomy and Pomeroy surgical procedure of tubal obstruction, Group SH (n=3) submitted to hysteroscopy application of saline solution inside the tubal isthmus, and Group AD (n=6) submitted to hysteroscopy application of 0.5 mL of n-2-butil-cyanoacrylate inside the tubal isthmus. They were allowed to copulate with fertile males during ninety days. The non pregnant sheep, at the 90th day, were submitted to laparotomy, the uterine tubes were removed and their diameters analyzed. The uterine tubes were evaluated for patency with methylene blue dye injection. The overpressure burst test (80mmHg) was then applied through the uterine cervix. Data were evaluated by t Student and Fisher test. Results: All sheep from groups PO and AD did not get pregnant (0%) in contrast with sheep from group SH (100%); the adhesive remained stable inside the tubal lumen. The diameter of the proximal tube in AD group (0.650 ± 0.16cm) was significantly wider than the PO group (0.195 ± 0.04* cm) (p= 0.01). The overpressure burst and dye patency tests were negative for all animals from PO group and only one animal in AD group was positive for the pressure burst test. Conclusion: The hysteroscopic insertion of cyanoacrylate inside the tubal lumen of the sheep was effective to obstruct the uterine tube and to promote the sterilization, and would be an option for future applying in human beings

Hysteroscopic sterilization with occlusion of sheep uterine tube using n-butyl-2-cyanoacrylate adhesive

Purpose: To evaluate the fertility and analyze the macroscopic, microscopic and morphometric aspects of sheep uterine tube sterilization with a hysteroscopically insert of n-butyl-2-cyanoacrylate adhesive. Methods: 12 adult sheep, with one previous pregnancy, were distributed as follows: group L (n=3) subjected to laparotomy and Pomeroy uterine tube ligation, group S (n=3) subjected to hysteroscopic application of saline solution in tube isthmus and group AD(n=6), that was subjected to hysteroscopic application of 0.5 ml of n-2-butil-cyanoacrylate in tube isthmus. They were mated with fertile males for ninety days. The non pregnant sheep, at the 90th day, were subjected to laparotomy with uterus and tubes uterine resection. The fragments of uterine tubes were fixated in 10% formalin and processes for histology evaluated, and slices dyes for H.E. Data were evaluated by Wilcoxon and Mann-Whitney and Fisher’s exact test. Results: All sheep from groups L and AD did not get pregnant (0%) in contrast with sheep from group S (100%); the adhesive remained integral in the uterine tube lumen. The percentual of adherences (66.6%) and fibrosis responses (100%) was significantly higher in the group L than group AD (0%) (p≤0.01). The diameter of the caudal tube in group AD (2652.15 ± 45.76 mm) was significantly wider than that of the group L (1868.27 ± 56.11* mm) (p ≤ 0.05). Conclusion: The hysteroscopic insertion of cyanoacrylate in the uterine tube lumen of sheep was effective to obstruct the uterine tube and to promote the sterilization.Objetivo: Avaliar a fertilidade e aspectos macroscópicos, microscópicos e morfométricos da esterilização histeroscópica de tubas uterinas de ovelhas com o adesivo de n-butil-2-cianoacrilato. Métodos: 12 ovelhas adultas, com uma prenhez anterior, foram distribuídas como segue: o grupo L (n=3) submetidas à laparotomia e laqueadura tipo Pomeroy, grupo S (n=3) submetidas à aplicação histeroscópica de solução salina no istmo tubário e grupo AD (n=6), com aplicação histeroscópica de 0,5 ml de cianoacrilato. As ovelhas foram acasaladas com machos de comprovada fertilidade por noventa dias. As ovelhas não prenhes aos 90 dias, foram submetidas à laparotomia com ressecção do útero e tubas uterinas, que foram fixadas em formalina 10%s e os cortes histológicos corados em hematoxilina/eosina. Os resultados foram avaliados pelo teste de Wilcoxon e teste exato de Fisher. Resultados: Todas as ovelhas dos grupos L e AD não ficaram prenhes (0%) ao contrário das ovelhas do grupo S (100%); o adesivo permaneceu íntegro no lúmen tubário. O percentual de aderências (66.6%) e de fibrose (100%) foi significativamente maior no grupo L do que no grupo AD (0%) (p≤0,01). O diâmetro da porção caudal no grupo AD (2652,15 ± 45,76 mm) foi significativamente maior do que grupo L (1868,27 ± 56.11 mm) (p≤0,05). Conclusão: A inserção histeroscópica do cianoacrilato no lúmen tubário de ovelhas foi eficaz para obstruir a tuba uterina e promover a esterilização