Dialysis and pediatric acute kidney injury: choice of renal support modality

Dialytic intervention for infants and children with acute kidney injury (AKI) can take many forms. Whether patients are treated by intermittent hemodialysis, peritoneal dialysis or continuous renal replacement therapy depends on specific patient characteristics. Modality choice is also determined by a variety of factors, including provider preference, available institutional resources, dialytic goals and the specific advantages or disadvantages of each modality. Our approach to AKI has benefited from the derivation and generally accepted defining criteria put forth by the Acute Dialysis Quality Initiative (ADQI) group. These are known as the risk, injury, failure, loss, and end-stage renal disease (RIFLE) criteria. A modified pediatrics RIFLE (pRIFLE) criteria has recently been validated. Common defining criteria will allow comparative investigation into therapeutic benefits of different dialytic interventions. While this is an extremely important development in our approach to AKI, several fundamental questions remain. Of these, arguably, the most important are “When and what type of dialytic modality should be used in the treatment of pediatric AKI?” This review will provide an overview of the limited data with the aim of providing objective guidelines regarding modality choice for pediatric AKI. Comparisons in terms of cost, availability, safety and target group will be reviewed

Antiinflammatory Therapy with Canakinumab for Atherosclerotic Disease

Background: Experimental and clinical data suggest that reducing inflammation without affecting lipid levels may reduce the risk of cardiovascular disease. Yet, the inflammatory hypothesis of atherothrombosis has remained unproved. Methods: We conducted a randomized, double-blind trial of canakinumab, a therapeutic monoclonal antibody targeting interleukin-1β, involving 10,061 patients with previous myocardial infarction and a high-sensitivity C-reactive protein level of 2 mg or more per liter. The trial compared three doses of canakinumab (50 mg, 150 mg, and 300 mg, administered subcutaneously every 3 months) with placebo. The primary efficacy end point was nonfatal myocardial infarction, nonfatal stroke, or cardiovascular death. RESULTS: At 48 months, the median reduction from baseline in the high-sensitivity C-reactive protein level was 26 percentage points greater in the group that received the 50-mg dose of canakinumab, 37 percentage points greater in the 150-mg group, and 41 percentage points greater in the 300-mg group than in the placebo group. Canakinumab did not reduce lipid levels from baseline. At a median follow-up of 3.7 years, the incidence rate for the primary end point was 4.50 events per 100 person-years in the placebo group, 4.11 events per 100 person-years in the 50-mg group, 3.86 events per 100 person-years in the 150-mg group, and 3.90 events per 100 person-years in the 300-mg group. The hazard ratios as compared with placebo were as follows: in the 50-mg group, 0.93 (95% confidence interval [CI], 0.80 to 1.07; P = 0.30); in the 150-mg group, 0.85 (95% CI, 0.74 to 0.98; P = 0.021); and in the 300-mg group, 0.86 (95% CI, 0.75 to 0.99; P = 0.031). The 150-mg dose, but not the other doses, met the prespecified multiplicity-adjusted threshold for statistical significance for the primary end point and the secondary end point that additionally included hospitalization for unstable angina that led to urgent revascularization (hazard ratio vs. placebo, 0.83; 95% CI, 0.73 to 0.95; P = 0.005). Canakinumab was associated with a higher incidence of fatal infection than was placebo. There was no significant difference in all-cause mortality (hazard ratio for all canakinumab doses vs. placebo, 0.94; 95% CI, 0.83 to 1.06; P = 0.31). Conclusions: Antiinflammatory therapy targeting the interleukin-1β innate immunity pathway with canakinumab at a dose of 150 mg every 3 months led to a significantly lower rate of recurrent cardiovascular events than placebo, independent of lipid-level lowering. (Funded by Novartis; CANTOS ClinicalTrials.gov number, NCT01327846.

A Machine Vision System for the Apple Harvesting Robot

Rosana G. Moreira, Editor-in-Chief; Texas A&M UniversityThis is a Technical article from International Commission of Agricultural Engineering (CIGR, Commission Internationale du Genie Rural) E-Journal Volume 3 (2001): D.M. Bulanon, T. Kataoka, Y. Ota, and T. Hiroma. A Machine Vision System for the Apple Harvesting Robot. Vol. III, December 2001

PETCO2 measured by a new lightweight mainstream capnometer with very low dead space volume offers accurate and reliable noninvasive estimation of PaCO2

Daijiro Takahashi, Takehiko Hiroma, Tomohiko NakamuraDivision of Neonatology, Nagano Children’s Hospital, Nagano, JapanObjective: Although capnometers are widely used in adult and pediatric intensive care units, they are not widely used in neonatal intensive care units due to issues such as the weight of sensors, dead space, and leakage from tracheal intubation tubes. These authors developed a light and low dead space airway adaptor of end-tidal carbon dioxide pressure (PETCO2) and evaluated the correlations between PETCO2 and partial CO2 pressure (PaCO2) in rabbits while changing tidal volume and leakage volume.Methods: Firstly, Japanese rabbits weighing 2 kg were divided into three tidal volumes (6 mL/kg, 10 mL/kg, or 15 mL/kg), and PETCO2 and PaCO2 were measured. Secondly, the respiratory apparatus was set to a tidal volume/body weight ratio of 10 mL/kg, leakage rates were divided into seven groups, and PETCO2  and PaCO2 were measured.Results: PETCO2 and PaCO2 were significantly correlated (r2 = 0.9099, P < 0.0001) when there was no leakage in the tracheal intubation tubes. No significant differences were observed between PaCO2 and PETCO2 (Pa-ETCO2) in the three tidal volume/body weight groups or for groups in which leakage rate was <60%, but significant deviations in Pa-ETCO2 were noted in groups with leakage rate 60%.Conclusion: There was a strong correlation between PETCO2 and PaCO2 when tidal volume/body weight ratio was 6–15 mL/kg with leakage rate <60%. Lightweight mainstream capnometer with a low amount of dead space airway adaptor might be useful in very low birth weight infants with small tidal volume.Keywords: capnography, mainstream, neonat

Evaluation of factors influencing stable microbubble test results in preterm neonates at 30–33 gestational weeks

Oxana A Teslova1,2, Takehiko Hiroma1, Elena I Baranovskaya2, Tomohiko Nakamura11Division of Neonatology, Nagano Children's Hospital, Azumino City, Nagano, Japan; 2Department of Obstetrics and Gynecology, Gomel State Medical University, BelarusBackground: The stable microbubble test (SMT) is a sensitive and specific means of predicting respiratory distress syndrome in newborns, using quantitative correlations with concentrations of the protein and lipid components of surfactant. We hypothesized that fetal nutrition would affect the synthesis of surfactant components. The objectives of this study were to evaluate aspects of fetal and maternal nutrition influencing SMT results and related to development of respiratory distress syndrome in preterm neonates.Methods: Data from 194 preterm neonates of gestational age 23–36 weeks were analyzed using multivariate regression modeling to identify factors influencing SMT results. After adjusting for gestational age, we compared obstetric, maternal, neonatal, and placental data using analysis of variance in 99 neonates at 30–33 weeks of gestation based on results of the SMT. Receiver-operating-characteristic analysis was performed to characterize factors predictive of respiratory distress syndrome.Results: SMT results were most strongly associated with the concentration of protein in neonatal blood (P < 0.05) and maternal weight gain during pregnancy (P < 0.05). Cutoff values for predicting respiratory distress syndrome were serum protein <4.7 g/L and maternal weight gain <200 g/week.Conclusion: Inadequate maternal weight gain during pregnancy may play a significant role in immaturity of the surfactant system in the lungs and may be a predictor of respiratory distress syndrome in premature babies.Keywords: stable microbubble test, respiratory distress syndrome, protein concentration, gestational weight gai

Successful treatment of two cases of urorectal septum malformation sequence with oligohydramnios and severe respiratory failure

Kazuhito Sekiguchi, Daijiro Takahashi, Takehiko Hiroma, Tomohiko Nakamura Division of Neonatology, Nagano Children's Hospital, Nagano, Japan Abstract: Urorectal septum malformation sequence can be diagnosed prenatally. We report herein the successful treatment of severe respiratory failure in two patients with urorectal septum malformation sequence and prenatally diagnosed oligohydramnios. The patients showed significant hypoxic deterioration and persistent pulmonary artery hypertension soon after birth. We used high-frequency ventilation (HFO), nitric oxide (NO), and extracorporeal membrane oxygenation (ECMO). The patients were successfully weaned from ECMO and artificial ventilation and discharged to home. Although termination of the pregnancy has often been selected for fetuses with oligohydramnios-related urorectal septum malformation sequence, our results suggest the opportunity for these fetuses to be treated using respiratory supports including HFO, NO, and ECMO after birth. Keywords: urorectal septum malformation sequence, oligohydramnios, pulmonary hypoplasi