Publications by authors named "Eileen Brewer"

25 Publications

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The pediatric solid organ transplant experience with COVID-19: An initial multi-center, multi-organ case series.

Pediatr Transplant 2020 Sep 18:e13868. Epub 2020 Sep 18.

Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA.

The clinical course of COVID-19 in pediatric solid organ transplant recipients remains ambiguous. Though preliminary experiences with adult transplant recipients have been published, literature centered on the pediatric population is limited. We herein report a multi-center, multi-organ cohort analysis of COVID-19-positive transplant recipients ≤ 18 years at time of transplant. Data were collected via institutions' respective electronic medical record systems. Local review boards approved this cross-institutional study. Among 5 transplant centers, 26 patients (62% male) were reviewed with a median age of 8 years. Six were heart recipients, 8 kidney, 10 liver, and 2 lung. Presenting symptoms included cough (n = 12 (46%)), fever (n = 9 (35%)), dry/sore throat (n = 3 (12%)), rhinorrhea (n = 3 (12%)), anosmia (n = 2 (8%)), chest pain (n = 2 (8%)), diarrhea (n = 2 (8%)), dyspnea (n = 1 (4%)), and headache (n = 1 (4%)). Six patients (23%) were asymptomatic. No patient required supplemental oxygen, intubation, or ECMO. Eight patients (31%) were hospitalized at time of diagnosis, 3 of whom were already admitted for unrelated problems. Post-transplant immunosuppression was reduced for only 2 patients (8%). All symptomatic patients recovered within 7 days. Our multi-institutional experience suggests the prognoses of pediatric transplant recipients infected with COVID-19 may mirror those of immunocompetent children, with infrequent hospitalization and minimal treatment, if any, required.
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http://dx.doi.org/10.1111/petr.13868DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7537006PMC
September 2020

ESRD Policies and the Delivery of Pediatric Long-term Dialysis Care in the United States.

Authors:
Eileen D Brewer

Am J Kidney Dis 2021 02 10;77(2):264-267. Epub 2020 Sep 10.

Pediatric Renal Section, Department of Pediatrics, Baylor College of Medicine and Renal Service, Texas Children's Hospital, Houston, TX. Electronic address:

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http://dx.doi.org/10.1053/j.ajkd.2020.08.006DOI Listing
February 2021

Chronic kidney disease impacts health-related quality of life of children in Uganda, East Africa.

Pediatr Nephrol 2021 Feb 31;36(2):323-331. Epub 2020 Jul 31.

Department of Pediatrics, Renal Section, Texas Children's Hospital/Baylor College of Medicine, Houston, TX, USA.

Background: Limited data exist about causes of chronic kidney disease (CKD) and impact on health-related quality of life (HRQoL) in African children. We evaluated types of kidney disease in Ugandan children 0-18 years and compared HRQoL in children with CKD or with benign or resolving kidney disease (non-CKD) to assess predictors of HRQoL.

Methods: Demographic, socioeconomic, and clinical data were obtained for this cross-sectional study. Pediatric Quality of Life Core Scale™ (PedsQL) was used to survey 4 domains and overall HRQoL. CKD and non-CKD scores were compared using unpaired t test. HRQoL predictors were evaluated using linear and logistic regression analyses.

Results: One hundred forty-nine children (71 CKD, 78 non-CKD; median age 9 years; male 63%) had the following primary diseases: nephrotic syndrome (56%), congenital anomalies of the urinary tract (CAKUT) (19%), glomerulonephritis (17%), and other (8%). CAKUT was the predominant etiology (39%) for CKD; 63% had advanced stages 3b-5. Overall HRQoL scores were significantly lower for CKD (57 vs. 86 by child report, p < 0.001; 63 vs. 86 by parent proxy report, p < 0.001). Predictors of lower HRQoL were advanced CKD stages 3b-5, primary caregiver non-parent, vitamin D deficiency, and anemia.

Conclusion: Like other parts of the world, CAKUT was the main cause of CKD. Most CKD children presented at late CKD stages 3b-5. Compared with non-CKD, HRQoL in CKD was much lower; only two-thirds attended school. Vitamin D deficiency and anemia were potentially modifiable predictors of low HRQoL. Interventions with vitamin D, iron, and erythropoietin-stimulating agents might lead to improved HRQoL.
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http://dx.doi.org/10.1007/s00467-020-04705-1DOI Listing
February 2021

Successful kidney transplantation in a small child with end-stage renal disease due to angiotensin receptor blocker fetopathy and atretic inferior vena cava.

Pediatr Transplant 2019 09 18;23(6):e13497. Epub 2019 Jun 18.

Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.

Kidney transplantation is the treatment of choice in pediatric patients with end-stage renal disease. This population presents technical challenges particularly in those less than 20 kg due to anomalous anatomy, vascular access issues prior to transplantation, and a generally small size for age. Standard allograft outflow is usually achieved utilizing the iliac veins or IVC. When use of the iliocaval system is not feasible, alternative anastomosis must be considered. Herein, we report a case of a pediatric kidney transplantation where successful allograft outflow was achieved using the SMV when he was found to have an atretic IVC intraoperatively. In this setting, use of the portal system was required to achieve adequate allograft outflow. We created a donor iliac graft for added length to anastomose the renal vein with the SMV. In the setting of IVC occlusion with poor drainage, we utilized a patent vessel with larger caliber for outflow to reduce the risk of high venous pressures, allograft failure, venous rotation, and thrombosis. We conclude that the SMV may serve as an alternative outflow tract in the small pediatric patient and provides the vessel caliber needed to reduce the risks of complications.
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http://dx.doi.org/10.1111/petr.13497DOI Listing
September 2019

Correction to: Recurrence of nephrotic syndrome following kidney transplantation is associated with initial native kidney biopsy findings : A Midwest Pediatric Nephrology Consortium (MWPNC) study.

Pediatr Nephrol 2019 Mar;34(3):539

Department of Pediatrics, Divisions of Nephrology and Critical Care, Duke University Medical Center, Durham, NC, 27710, USA.

The original version of this article unfortunately contained a mistake. The subtitle "A Midwest Pediatric Nephrology Consortium (MWPNC) study" was missing. The correct title including subtitle is given above.
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http://dx.doi.org/10.1007/s00467-018-4103-3DOI Listing
March 2019

Recurrence of nephrotic syndrome following kidney transplantation is associated with initial native kidney biopsy findings.

Pediatr Nephrol 2018 10 7;33(10):1773-1780. Epub 2018 Jul 7.

Department of Pediatrics, Divisions of Nephrology and Critical Care, Duke University Medical Center, Durham, NC, 27710, USA.

Background And Objectives: Steroid-resistant nephrotic syndrome (SRNS) due to focal segmental glomerulosclerosis (FSGS) and minimal change disease (MCD) is a leading cause of end-stage kidney disease in children. Recurrence of primary disease following transplantation is a major cause of allograft loss. The clinical determinants of disease recurrence are not completely known. Our objectives were to determine risk factors for recurrence of FSGS/MCD following kidney transplantation and factors that predict response to immunosuppression following recurrence.

Methods: Multicenter study of pediatric patients with kidney transplants performed for ESKD due to SRNS between 1/2006 and 12/2015. Demographics, clinical course, and biopsy data were collected. Patients with primary-SRNS (PSRNS) were defined as those initially resistant to corticosteroid therapy at diagnosis, and patients with late-SRNS (LSRNS) as those initially responsive to steroids who subsequently developed steroid resistance. We performed logistic regression to determine risk factors associated with nephrotic syndrome (NS) recurrence.

Results: We analyzed 158 patients; 64 (41%) had recurrence of NS in their renal allograft. Disease recurrence occurred in 78% of patients with LSRNS compared to 39% of those with PSRNS. Patients with MCD on initial native kidney biopsy had a 76% recurrence rate compared with a 40% recurrence rate in those with FSGS. Multivariable analysis showed that MCD histology (OR; 95% CI 5.6; 1.3-23.7) compared to FSGS predicted disease recurrence.

Conclusions: Pediatric patients with MCD and LSRNS are at higher risk of disease recurrence following kidney transplantation. These findings may be useful for designing studies to test strategies for preventing recurrence.
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http://dx.doi.org/10.1007/s00467-018-3994-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6129203PMC
October 2018

Intra-procedural continuous dialysis to facilitate interventional catheterization in pediatric patients with severe renal failure.

Catheter Cardiovasc Interv 2017 Nov 12;90(5):784-789. Epub 2017 Jul 12.

Lillie Frank Abercrombie Section of Cardiology, Baylor College of Medicine, and Texas Children's Hospital, Houston, Texas.

Background: Interventional catheterization procedures may be needed for patients with severe renal failure who are dependent on dialysis. To avoid the risk of fluid overload and electrolyte derangement during complex procedures in this oliguric/anuric patient population, we performed intra-procedural dialysis, either continuous renal replacement therapy (CRRT) or continous cycling peritoneal dialysis (CCPD).

Methods: We performed a retrospective review of a cohort of pediatric patients, ages 0-18 years, with dialysis-dependent renal failure who received CRRT or CCPD during catheterization procedures from January 2013 to March 2016.

Results: Eight patients underwent a total of nine interventional catheterization procedures while receiving intra-procedural dialysis. Median age was 4.5 years (range 8 months to 17 years) and weight, 11.6 kg (11.2-62.6 kg). Six patients had end-stage renal disease (ESRD) and two patients had acute kidney injury (AKI), one due to hepatorenal syndrome and one due to multifactorial causes associated with congenital heart disease. The most common reason for catheterization was occlusive venous thrombosis requiring recanalization. CRRT was used during five cases and CCPD during four cases. Median procedure time was 337 min (95-651 min) and median contrast dose 4.2 mL kg (1.2-8.2 mL kg ). Euvolemia was maintained based on pre- and post-catheterizations weights, and no significant electrolyte abnormalities occurred based on lab monitoring during and post-procedure.

Conclusions: Intra-procedural dialysis using CRRT or CCPD enables even small pediatric patients with severe renal failure to undergo long and complex interventional catheterizations by reducing the risk of fluid overload and electrolyte abnormalities. Collaboration between nephrology, cardiology, and dialysis teams is necessary for successful management of this challenging patient population.
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http://dx.doi.org/10.1002/ccd.27188DOI Listing
November 2017

Decreasing living donor rates in pediatric kidney transplantation: A time for action.

Pediatr Transplant 2017 03;21(2)

Department of Pediatrics, Renal Section, Baylor College of Medicine, Houston, TX, USA.

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http://dx.doi.org/10.1111/petr.12883DOI Listing
March 2017

Poor outcomes for children on the wait list at low-volume kidney transplant centers in the United States.

Pediatr Nephrol 2017 04 18;32(4):669-678. Epub 2016 Oct 18.

Department of Surgery, Division of Abdominal Transplantation, Texas Children's Hospital, Houston, TX, USA.

Background: Low case volume has been associated with worse survival outcomes in solid organ transplantation. Our aim was to analyze wait-list outcomes in conjunction with posttransplant outcomes.

Methods: We studied a cohort of 11,488 candidates waitlisted in the Organ Procurement and Transplantation Network (OPTN) for pediatric kidney transplant between 2002 and 2014, including both deceased- and living-donor transplants; 8757 (76 %) candidates received a transplant. Candidates were divided into four groups according to the average volume of yearly transplants performed in the listing center over a 12-year period: more than ten, six to nine, three to five, and fewer than three. We used multivariate Cox regression analysis to identify independent risk factors for wait list and posttransplant mortality.

Results: Twenty-seven percent of candidates were listed at low-volume centers in which fewer than three transplants were performed annually. These candidates had a limited transplant rate; only 49 % received a transplant versus 88 % in high-volume centers (more than ten transplants annually) (p < 0.001). Being listed at a low-volume center showed a fourfold increased risk for death while on the wait list [hazard ratio (HR) 4.0 in multivariate Cox regression and 6.1 in multivariate competing risk regression]. It was not a significant risk factor for posttransplant death in multivariate Cox regression.

Conclusions: Pediatric transplant candidates are listed at low-volume transplant centers are transplanted less frequently and have a much greater risk of dying while on the wait list. Further studies are needed to elucidate the reasons behind the significant outcome differences.
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http://dx.doi.org/10.1007/s00467-016-3519-xDOI Listing
April 2017

Whole-exome sequencing in the molecular diagnosis of individuals with congenital anomalies of the kidney and urinary tract and identification of a new causative gene.

Genet Med 2017 04 22;19(4):412-420. Epub 2016 Sep 22.

Center for Reproductive Medicine, Baylor College of Medicine, Houston, Texas, USA.

Purpose: To investigate the utility of whole-exome sequencing (WES) to define a molecular diagnosis for patients clinically diagnosed with congenital anomalies of kidney and urinary tract (CAKUT).

Methods: WES was performed in 62 families with CAKUT. WES data were analyzed for single-nucleotide variants (SNVs) in 35 known CAKUT genes, putatively deleterious sequence changes in new candidate genes, and potentially disease-associated copy-number variants (CNVs).

Results: In approximately 5% of families, pathogenic SNVs were identified in PAX2, HNF1B, and EYA1. Observed phenotypes in these families expand the current understanding about the role of these genes in CAKUT. Four pathogenic CNVs were also identified using two CNV detection tools. In addition, we found one deleterious de novo SNV in FOXP1 among the 62 families with CAKUT. The clinical database of the Baylor Miraca Genetics laboratory was queried and seven additional unrelated individuals with novel de novo SNVs in FOXP1 were identified. Six of these eight individuals with FOXP1 SNVs have syndromic urinary tract defects, implicating this gene in urinary tract development.

Conclusion: We conclude that WES can be used to identify molecular etiology (SNVs, CNVs) in a subset of individuals with CAKUT. WES can also help identify novel CAKUT genes.Genet Med 19 4, 412-420.
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http://dx.doi.org/10.1038/gim.2016.131DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5362362PMC
April 2017

Outcomes of two-drug maintenance immunosuppression for pediatric renal transplantation: 10-yr follow-up in a single center.

Pediatr Transplant 2016 Feb 2;20(1):49-58. Epub 2015 Nov 2.

Renal Section, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA.

Minimizing IS to reduce side effects without compromising long-term renal transplant survival is the goal of all IS protocols. We conducted a retrospective study of pediatric renal transplants performed August 1988 to July 2008 and treated with two-drug maintenance therapy by one of three protocols: prednisone/cyclosporine without induction (SB) or with daclizumab induction (SBI), or tacrolimus/mycophenolate with daclizumab induction (SF). Kaplan-Meier survival curves were used to determine graft and patient survival at one, three, five, and 10 yr. Associations between graft survival and patient/transplant characteristics were determined using log-rank test and CPH model adjusting for treatment group. About 208 patients were included in the analysis (96 SB, 97 SBI, 15 SF; 148 DD, 60 LD, 37 pre-emptive). Overall graft and patient survival at one, three, five, and 10 yr were similar to the previously published results of pediatric renal transplants in similar years treated predominantly with three-drug maintenance therapy (https://web.emmes.com/study/ped/annlrept/2010). Only biopsy-proven TG was significantly associated with worse graft survival (HR 11.5, 95% CI: 3.4, 38.7). Malignancy rate was low (2.4%) with little PTLD (0.5%). Few opportunistic or other infections occurred (<5% patients). Minimizing IS to a two-drug maintenance regimen had no adverse effect on long-term transplant outcome and had low malignancy and infection rates.
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http://dx.doi.org/10.1111/petr.12627DOI Listing
February 2016

Application of the resource-based relative value scale system to pediatrics.

Pediatrics 2014 Jun;133(6):1158-62

The majority of public and private payers in the United States currently use the Medicare Resource-Based Relative Value Scale as the basis for physician payment. Many large group and academic practices have adopted this objective system of physician work to benchmark physician productivity, including using it, wholly or in part, to determine compensation. The Resource-Based Relative Value Scale survey instrument, used to value physician services, was designed primarily for procedural services, leading to current concerns that American Medical Association/Specialty Society Relative Value Scale Update Committee (RUC) surveys may undervalue nonprocedural evaluation and management services. The American Academy of Pediatrics is represented on the RUC, the committee charged with maintaining accurate physician work values across specialties and age groups. The Academy, working closely with other primary care and subspecialty societies, actively pursues a balanced RUC membership and a survey instrument that will ensure appropriate work relative value unit assignments, thereby allowing pediatricians to receive appropriate payment for their services relative to other services.
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http://dx.doi.org/10.1542/peds.2014-0866DOI Listing
June 2014

Elevated FGF 23 and phosphorus are associated with coronary calcification in hemodialysis patients.

Pediatr Nephrol 2011 Jun 27;26(6):945-51. Epub 2011 Feb 27.

Department of Pediatrics, Renal Section, Baylor College of Medicine, Houston, TX, 77030, USA.

Increased mortality of adult chronic hemodialysis (HD) patients is associated with coronary calcifications (CC), increased serum phosphorus (P), use of calcium (Ca)-containing P-binders, and vitamin D deficiency. Serum concentration of fibroblast growth factor 23 (FGF 23) is markedly elevated in adults receiving dialysis and is independently associated with increased mortality. Although coronary calcifications have been described in pediatric and adult HD patients, no significant association between serum FGF 23 and CC has been reported. In our study, 5/16 patients had CC. Patients with CC were older, had longer dialysis vintage and higher serum P. Serum Ca, total PTH, elemental Ca intake, and calcitriol doses were not different for CC patients. Serum FGF 23 levels were markedly elevated in all patients (mean 4,024, range 874-8,253), but significantly higher in patients with CC (4,247 ± 10,35 vs 2,427 ± 11,92, p = 0.01) and positively correlated with Agatston calcification score (r = 0.69, p = 0.003) and serum P (r = 0.49, p = 0.05). Using multivariate analysis, serum FGF 23 and serum P remained the most significant factors associated with Agatston score. This study confirms the occurrence of CC in pediatric HD patients and is the first to show a significant association between CC and elevated serum FGF 23 in children.
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http://dx.doi.org/10.1007/s00467-011-1822-0DOI Listing
June 2011

Topical mupirocin/sodium hypochlorite reduces peritonitis and exit-site infection rates in children.

Clin J Am Soc Nephrol 2009 Dec 9;4(12):1939-43. Epub 2009 Oct 9.

Department of Pediatrics, Renal Division, Houston, TX 77030, USA.

Background And Objectives: Peritoneal dialysis (PD) is a common maintenance renal replacement modality for children with ESRD frequently compromised by infectious peritonitis and catheter exit site and tunnel infections (ESI/TI). The effect of topical mupirocin (Mup) and sodium hypochlorite (NaOCl) solution was evaluated as part of routine daily exit site care on peritonitis and ESI/TI rates, causative microorganisms, and catheter survival rates.

Design, Setting, Participants, & Measurements: Retrospective chart review of children on home continuous cycling PD between April 1, 2001 and June 30, 2007 was performed. Infection rates were examined based on exit site protocol used in two different periods: Mup alone, April 1, 2001 to November 17, 2004; and Mup and NaOCl (Mup+NaOCl), November 18, 2004 to June 30, 2007.

Results: Eighty-three patients (mean PD initiation age: 12.1 +/- 5.8 yr) received home PD over 2009 patient months. Annualized rates (ARs) for peritonitis decreased from 1.2 in the Mup period to 0.26 in the Mup+NaOCl period (P < 0.0001). ARs for ESI/TI decreased from 1.36 in the Mup period to 0.33 in the Mup+NaOCl period (P < 0.0001). No infections with Mup-resistant organisms were observed when either Mup or Mup+NaOCl was used for prophylaxis. Gram-negative-organism associated peritonitis decreased from an AR of 0.31 in the Mup period to 0.07 in the Mup+NaOCl period (P < 0.001). Infection-related catheter removal rates decreased from 1 in 38.9 catheter-months in the Mup period to 1 in 94.2 in the Mup+NaOCl period (P = 0.01). Catheter survival rates were longer in the Mup+NaOCl period (Kaplan-Meier, P < 0.009).

Conclusions: The combination Mup+NaOCl in daily exit site care was very effective to reduce PD catheter-associated infections and prolong catheter survival in pediatric patients.
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http://dx.doi.org/10.2215/CJN.02770409DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2798867PMC
December 2009

American Society of Pediatric Nephrology position paper on linking reimbursement to quality of care.

J Am Soc Nephrol 2005 Aug 29;16(8):2263-9. Epub 2005 Jun 29.

James Whitcomb Riley Hospital for Children, Riley Research Room 234B, 699 West Drive, Indianapolis, IN 46202, USA.

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http://dx.doi.org/10.1681/ASN.2005020186DOI Listing
August 2005

Pediatric ARF epidemiology at a tertiary care center from 1999 to 2001.

Am J Kidney Dis 2005 Jan;45(1):96-101

Baylor College of Medicine and Texas Children's Hospital, Houston, TX 77030, USA.

Background: Previous epidemiological data for pediatric patients with acute renal failure (ARF) predate current intensive care unit (ICU) technology and practice, and do not reflect newer disease therapies for bone marrow, hepatic, and cardiac transplantation and congenital heart disease surgery.

Methods: We conducted a retrospective review of 254 ARF episodes in 248 children discharged from a tertiary referral center, Texas Children's Hospital (Houston, TX), between January 1998 and June 2001 to update current pediatric ARF epidemiological characteristics.

Results: The most common causes of ARF were renal ischemia (21%), nephrotoxic medications (16%), and sepsis (11%). Primary renal diseases accounted for only 17 cases (7%), and hemolytic uremic syndrome accounted for only 3 cases. Overall ARF survival for the entire cohort was 176 of 254 patients (70%), whereas 110 of 185 patients (60%) requiring ICU admission and 43 of 77 patients (56%) receiving renal replacement therapy survived.

Conclusion: These current pediatric ARF data show that pediatric ARF epidemiological characteristics have changed from primary renal disease to renal involvement secondary to other systemic illness. Longitudinal data from this cohort are underway to determine the long-term sequelae of pediatric ARF.
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http://dx.doi.org/10.1053/j.ajkd.2004.09.028DOI Listing
January 2005

Iron therapy in the pediatric hemodialysis population.

Pediatr Nephrol 2004 Jun 3;19(6):655-61. Epub 2004 Apr 3.

Section of Pediatric Nephrology, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA.

Iron therapy maintains iron stores and optimizes the response to recombinant human erythropoietin (r-HuEPO) in patients with end-stage renal failure. Information is limited, however, regarding the preferential route of iron administration in pediatric patients receiving hemodialysis. Therefore, we prospectively randomized 35 iron-replete patients (aged >1 to <20 years) to receive up to 16 weeks of maintenance i.v. ( n=17) or daily oral ( n=18) iron. Eligible patients had received hemodialysis for >2 months, had a baseline transferrin saturation [TSAT] >20%, and were receiving maintenance r-HuEPO. Treatment arms were evenly distributed with respect to baseline demographic and clinical characteristics, with no statistically significant differences in baseline hemoglobin (Hb), hematocrit (Hct), reticulocyte Hb content (CHr), serum ferritin (SF), TSAT, or r-HuEPO dose. In the 35 patients, i.v. iron dextran and not oral iron was associated with a significant increase (138.5 to 259.1 ng/ml, P=0.003) in SF. A comparison of the change in SF between the i.v. iron group and the oral iron group was also significant ( P=0.001). Whereas only i.v. iron was associated with a significant decrease in the dose of r-HuEPO (234.0 to 157.6 U/kg per week, P=0.046) and an increase of the CHr (29.2 to 30.1 pg, P=0.049), these changes were not significantly different from those experienced by patients in the oral iron group. In both groups, the Hct remained stable and in neither group was there a significant change in the TSAT. In summary, although both oral and i.v. iron maintained patients in an iron-replete state in this short-term study, only i.v. therapy allowed for a significant improvement in iron stores.
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http://dx.doi.org/10.1007/s00467-004-1457-5DOI Listing
June 2004

Blood volume monitoring to achieve target weight in pediatric hemodialysis patients.

Pediatr Nephrol 2004 Apr 26;19(4):432-7. Epub 2004 Feb 26.

Department of Pediatrics-Renal Section, Baylor College of Medicine, Houston, Texas, USA.

Achieving dry weight during hemodialysis (HD) while minimizing symptoms is critical for optimizing patient outcome by preventing chronic fluid overload, hypertension, and cardiomyopathy. Dry weight changes frequently in children because of growth and development and waxing and waning of appetite. We have previously shown non-invasive hematocrit monitoring (NIVM) helps to decrease intradialytic symptoms, while still achieving target dry weights in children receiving chronic HD. In the current study, we prospectively evaluated an NIVM-guided ultrafiltration (UF) management algorithm to determine target dry weight in nine pediatric patients (mean age 16.6+/-2.8 years, mean weight 41.6+/-11.1 kg). Use of NIVM could potentially lead to overly aggressive UF with increased interdialytic symptoms, post treatment thirst, and interdialytic weight gain (IDWG). To evaluate the effectiveness of our NIVM UF algorithm, we studied the effect of three different NIVM-guided UF models (100%, 90%, and 80% UF models) on intradialytic and interdialytic symptoms, pre-/post-treatment blood pressure (BP), and percentage IDWG. To assess interdialytic symptoms, patients completed two questionnaires, one for each day between treatments. No statistically significant difference was seen between the three UF models with respect to intradialytic or interdialytic symptoms, pre-/post-HD BP, or percentage IDWG. Only one of nine patients received non-ACEI chronic antihypertensive medication, yet all patients had pre- and post-HD BP <95th percentile for age and height. The current study suggests that routine determination of target dry weight using NIVM and aiming for 100% UF helps to achieve the target dry weight, reduces both the risk of chronic fluid overload and the need for antihypertensive medication, and does not lead to increased intra- or interdialytic symptomatology in pediatric patients treated with chronic HD.
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http://dx.doi.org/10.1007/s00467-003-1400-1DOI Listing
April 2004

"Flush before fill" in children receiving automated peritoneal dialysis.

Perit Dial Int 2003 Sep-Oct;23(5):493-8

Children's Mercy Hospital, Kansas City, Missouri 64108, USA.

Objective: To evaluate the impact of the "flush before fill" technique on the frequency of peritonitis in children receiving automated peritoneal dialysis (APD).

Design: Randomized prospective multicenter study.

Setting: Participating pediatric dialysis programs of the Pediatric Peritoneal Dialysis Study Consortium.

Patients: 121 pediatric (< 21 years of age) patients that had received peritoneal dialysis for > or = 2 months and that were currently receiving APD were randomized to use (flush group) or non-use (no flush group) of the "flush before fill" option. 66 patients were followed for > or = 12 months.

Main Outcome Measure: Peritonitis rates.

Results: Overall, patients enrolled in the flush group experienced a peritonitis rate of 1 infection every 16.8 patient months; patients in the no flush group experienced a rate of 1 infection every 12.6 patient months (p = 0.193). However, analysis by gender revealed the peritonitis rate of females in the flush group (1 infection every 44.7 patient months) to be significantly better than females in the no flush group (1 infection every 12.4 patient months) (p < or = 0.01). There was no difference noted in the male patients.

Conclusion: The use of the "flush before fill" option in pediatric patients receiving APD is associated with a marked improvement in the peritonitis rate of female but not male patients. Further study is indicated to explain the gender differences.
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March 2004

Permanent hemodialysis vascular access survival in children and adolescents with end-stage renal disease.

Kidney Int 2002 Nov;62(5):1864-9

Department of Pediatrics, and Michael E. DeBakey Department of Surgery, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas 77030, USA.

Background: Transplantation is the optimal therapy for pediatric end-stage renal disease (ESRD) patients, but in a subset of patients with peritoneal membrane failure, failed transplants or poor social situations, chronic hemodialysis (HD) remains the only option. Long-term survival of arteriovenous fistulas (AVFs) and arteriovenous grafts (AVGs) in pediatric patients has not been well described.

Methods: We studied the survival of permanent vascular access in 34 pediatric ESRD patients treated with chronic HD at our institution between 1/1/89 and 12/1/95 and followed to 12/31/2000.

Results: Twenty-four AVFs and 28 AVGs were created in 19 and 23 patients, respectively. Mean age and weight at insertion were 15.1 years (range 7.1 to 20.9) and 46 kg (18 to 81) for AVFs and 13.3 years (3.8 to 21.1) and 41.5 kg (10.5 to 145) for AVGs. Fifteen patients weighed <35 kg at the time of access creation (7 AVFs in 5 patients, 14 AVGs in 13 patients). Excluding primary failures, one-year, three-year and five-year patency rates for AVFs (74%, 59%, 59%) and AVGs (96%, 69%, 40%) were not significantly different. Patency did not correlate with patient weight or age at access creation. Primary access failure occurred more often (P < 0.01) in AVFs (8/24) compared to AVGs (1/28). Access thrombosis, stenosis and infection occurred more frequently in AVG (P = 0.02).

Conclusions: Both AVF and AVG function well even in small pediatric patients and have survival rates equivalent to adult series and longer than cuffed venous catheters in pediatric patients. Both AVFs and AVGs are preferable for long-term HD access in pediatrics.
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http://dx.doi.org/10.1046/j.1523-1755.2002.00630.xDOI Listing
November 2002

nPCR assessment and IDPN treatment of malnutrition in pediatric hemodialysis patients.

Pediatr Nephrol 2002 Jul 21;17(7):531-4. Epub 2002 Jun 21.

Renal Service, Texas Children's Hospital, 6621 Fannin Street, MC 3-2482, Houston 77030, USA.

Very few pediatric studies have monitored nutritional status using normalized protein catabolic rate (nPCR) or treating protein-energy malnutrition (PEM) with intradialytic parenteral nutrition (IDPN). The current study compares nPCR with serum albumin as a marker for nutritional status and examines the effectiveness of IDPN treatment in three malnourished adolescent patients receiving chronic hemodialysis in a pediatric dialysis unit. All patients demonstrated reversal of weight loss and initiation of weight gain within 6 weeks of IDPN initiation. Mean values of monthly percentage weight and percentage body mass index (BMI) change were significantly lower in the pre-IDPN era (-0.61+/-2.70 and -1.3+/-2.7) versus the IDPN treatment period (1.8+/-2.1 and 1.3+/-2.1) ( P<0.02). Two patients attained ideal body weight and IDPN was discontinued after 5 months. Patients required 150% recommended daily allowance to achieve weight and BMI gain. While mean monthly nPCR was significantly lower in the pre-IDPN period versus the IDPN period (1.05+/-0.36 versus 1.35+/-0.37, P<0.05), monthly serum albumin levels were no different before and after IDPN was initiated (3.7+/-0.8 versus 3.8+/-0.6). The current study demonstrates IDPN to be effective therapy for adolescent hemodialysis patients with PEM not correctable by enteral supplementation. nPCR was superior to serum albumin as a nutritional status marker in these malnourished pediatric patients receiving hemodialysis.
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http://dx.doi.org/10.1007/s00467-002-0925-zDOI Listing
July 2002

Invasive pneumococcal disease and hemolytic uremic syndrome.

Pediatrics 2002 Aug;110(2 Pt 1):371-6

Department of Pediatrics, Children's Hospital of New Mexico, Albuquerque, New Mexico 87131-5311, USA.

Objective: Severe pneumococcal infections have been associated with hemolytic uremic syndrome (HUS), usually with a poor clinical outcome when compared with Escherichia coli O157 gastroenteritis-associated (D+) HUS. We examined our experience with 12 cases of Streptococcus pneumoniae-associated HUS (SP-HUS) and compare it with a cohort of diarrhea-associated HUS (D+ HUS).

Methods: A retrospective case survey compared 2 unrelated groups of HUS patients. Demographic factors, clinical indices of disease severity, and outcome were used to compare the 2 groups of HUS patients.

Results: Twelve children with SP-HUS were studied. Pneumococcal pneumonia with empyema was the most common precipitating illness (67%), pneumococcal meningitis was present in 17% of children, pneumonia with bacteremia in 8%, and both pneumonia and meningitis in 8%. SP-HUS patients were younger than D+ HUS patients (22.1 vs 49 months) and had more severe renal and hematologic disease than D+ HUS patients. Compared with D+ HUS patients, SP-HUS patients were more likely to require dialysis (75% vs 59%) and had a longer duration of hospitalization (33.2 vs 16.1 days) and duration of thrombocytopenia (11.6 vs 6.8 days). SP-HUS patients were also more likely to require platelet transfusions (83% vs 47%) and needed more platelet (4.7 vs 0.5) and packed red blood cell transfusions (7.8 vs 2.0). The 2 groups did not differ significantly in the incidence of extrarenal HUS complications. There were no deaths in either group. Seven patients have been seen for long-term follow-up; 2 developed end-stage renal disease, and 5 have normal renal function.

Conclusions: HUS is a rare but severe complication of invasive pneumococcal infection. Although disseminated intravascular coagulation can also occur in these children, the treatment and follow-up may be different in the 2 conditions. Children with pneumococcal disease and severe hematologic or renal abnormalities should be investigated for evidence of HUS.
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http://dx.doi.org/10.1542/peds.110.2.371DOI Listing
August 2002

Response to recombinant hepatitis B vaccine in children and adolescents with chronic renal failure.

Am J Kidney Dis 2002 Aug;40(2):365-72

University of Washington and Division of Nephrology, Children's Hospital and Regional Medical Center, Seattle, WA 98105, USA.

Background: Diminished antibody responses to the dosage of hepatitis B (HB) vaccine indicated for healthy adults has led to a greater dosage recommendation (40 microg of HB surface antigen [HBsAg]) for adults with chronic renal failure (CRF), but an appropriate dosage for children with CRF has not been established.

Methods: Seventy-eight children and adolescents with CRF (22 patients, predialysis; 42 patients, chronic dialysis therapy; 14 renal transplant recipients) aged 1 to 19 years (mean, 10.1 years) were enrolled onto a study to test a three 20-microg dose course of the HB vaccine Recombivax HB (Merck & Co, Inc, West Point, PA).

Results: The vaccine was well tolerated; no patient had a serious adverse event attributable to vaccine, and no patient withdrew from the study because of an adverse event. Overall, 91% of 66 patients administered three doses had a protective titer of 10 mIU/mL or greater for antibody against HBsAg (anti-HBs) and a geometric mean titer (GMT) of 733 mIU/mL, with seroprotection rates and GMTs among predialysis, dialysis, and renal transplant patients of 100% (4,140 mIU/mL), 94% (419 mIU/mL), and 64% (152 mIU/mL), respectively. All (100%) predialysis patients had a 10-mIU/mL or greater anti-HBs titer after only two doses of vaccine compared with 64% of dialysis patients and 50% of transplant recipients. Eighty-eight percent of 57 fully vaccinated patients tested 12 months after the first dose retained a 10-mIU/mL or greater anti-HBs titer.

Conclusion: A regimen of three 20-microg doses of Recombivax HB is suitably immunogenic for children with CRF not administered immunosuppressive medication. When possible, at least two, and preferably all three, doses of vaccine should be administered before progression to end-stage renal disease.
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http://dx.doi.org/10.1053/ajkd.2002.34521DOI Listing
August 2002