Dialysis-associated peritonitis in children

Peritonitis remains a frequent complication of peritoneal dialysis in children and is the most common reason for technique failure. The microbiology is characterized by a predominance of Gram-positive organisms, with fungi responsible for less than 5% of episodes. Data collected by the International Pediatric Peritonitis Registry have revealed a worldwide variation in the bacterial etiology of peritonitis, as well as in the rate of culture-negative peritonitis. Risk factors for infection include young age, the absence of prophylactic antibiotics at catheter placement, spiking of dialysis bags, and the presence of a catheter exit-site or tunnel infection. Clinical symptoms at presentation are somewhat organism specific and can be objectively assessed with a Disease Severity Score. Whereas recommendations for empiric antibiotic therapy in children have been published by the International Society of Peritoneal Dialysis, epidemiologic data and antibiotic susceptibility data suggest that it may be desirable to take the patient- and center-specific history of microorganisms and their sensitivity patterns into account when prescribing initial therapy. The vast majority of patients are treated successfully and continue peritoneal dialysis, with the poorest outcome noted in patients with peritonitis secondary to Gram-negative organisms or fungi and in those with a relapsing infection

Antenatal oligohydramnios of renal origin: long-term outcome

Background. Prognosis of fetuses with renal oligohydramnios (ROH) is often still regarded as poor. Neonatal complications and the long-term follow-up of fetuses with ROH in two pediatric centres are described. Method. 23 fetuses (16 males, 7 females) were included as patients. Primary diseases included congenital anomalies of the kidney and urinary tract (n = 16), autosomal recessive polycystic kidney disease (n = 4) and renal tubular dysgenesis (n = 3). The analysis includes retrospective chart review. Results. Seven children died (30%), the majority (n = 4, 17%) within the neonatal period due to pulmonary hypoplasia and renal insufficiency. Fourteen patients (61%) required postnatal mechanical ventilation for a median of 4 (range 1-60) days; 11 infants had an associated pneumothorax. All 16 surviving children have chronic kidney disease (CKD) at a current median age of 5.7 years (range 0.5-14.5), managed conservatively in eight patients [median glomerular filtration rate 51 (range 20-78) ml/min/1.73 m2]. Eight patients reached end-stage renal disease at a median age of 0.3 years (range 2 days to 8.3 years), including one patient with pre-emptive kidney transplantation. Five of the patients requiring dialysis underwent successful renal transplantation at a median age of 3.5 years (range 2.5-4). Growth was impaired in seven children requiring growth hormone treatment. Cognitive and motor development was normal in 12 (75%) of the 16 patients and showed a delay in four children, including two with associated syndromal features. Conclusion. ROH is not always associated with a poor prognosis and long-term outcome in survivors is encouraging. The high incidence of neonatal complications and long-term morbidity due to CKD requires a multidisciplinary management of these childre

Recurrence of severe steroid dependency in cyclosporin A-treated childhood idiopathic nephrotic syndrome

Background. In patients with steroid-dependent nephrotic syndrome (SDNS), long-term remission (LTR) can usually be achieved with cyclosporin A (CSA), after alternative treatment with cytotoxic drugs or levamisole has failed. Nevertheless, severe SDNS recurs in some patients despite CSA maintenance therapy. Few data are available on the clinical course and treatment strategies in these patients. Methods. We carried out a retrospective chart analysis of 46 patients with SDNS treated with CSA, after failure of cyctotoxic treatment with cyclophosphamide (CPO). Median age at primary manifestation was 3.0 years (range 0.8-6.9) and median current age is 20.4 years (range 8.6-29.1). Patients were recruited from three centres caring for a total of 186 patients with steroid-sensitive nephrotic syndrome. Results. In 14 of the 46 patients (30%; 10 male), severe SDNS recurred again despite CSA maintenance therapy. Seven patients relapsed beyond the age of 18 years. Nine of 14 patients received a further course of cytotoxic treatment as first intervention: six were treated with chlorambucil (CLA) and three with CPO. Four of the CLA-treated patients remained in LTR in contrast to none after CPO. Five patients received levamisole after CSA: only one went into LTR, while in one other CSA could be discontinued although further relapses occurred. One further patient was switched to CLA after levamisole, finally inducing LTR. Overall, six patients required two or more drugs, and in four of these CSA maintenance ultimately had to be restarted. Conclusion. We conclude that SDNS can recur in patients despite CSA maintenance therapy. Treatment strategies for this subgroup of patients are complex and should be standardized to optimize long-term outcome. A subgroup of patients with childhood SDNS continues to relapse into adulthoo