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Now showing items 1 - 16 of 27

  • Assessment and management of fluid overload in children on dialysis

    Hayes, Wesley   Paglialonga, Fabio  

    Dysregulation of intravascular fluid leads to chronic volume overload in children with end-stage kidney disease (ESKD). Sequelae include left ventricular hypertrophy and remodeling and impaired cardiac function. As a result, cardiovascular complications are the commonest cause of mortality in the pediatric dialysis population. The clinical need to optimize intravascular volume in children with ESKD is clear; however, its assessment and management is the most challenging aspect of the pediatric dialysis prescription. Minimizing chronic fluid overload is a key priority; however, excessive ultrafiltration is toxic to the myocardium and can precipitate intradialytic symptoms. This review outlines emerging objective techniques to enhance the assessment of fluid overload in children on dialysis and outlines evidence for current management strategies to address this clinical problem.
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  • Measurement of iron status in chronic kidney disease

    Hayes, Wesley  

    Anemia is a common complication of chronic kidney disease (CKD) in children, and dysregulation of iron homeostasis plays a central role in its pathogenesis. Optimizing iron status is a prerequisite for effective treatment of anemia. Insufficient iron can lead to inappropriate escalation of the erythropoiesis-stimulating agent (ESA) dose, which is associated with adverse outcomes. Excess iron supplementation also has negative sequelae including free radical tissue damage and increased risk of systemic infection. Notwithstanding the importance of optimizing bioavailable iron for erythropoiesis for children with advanced CKD, achieving this remains challenging for pediatric nephrologists due to the historical lack of practical and robust measures of iron status. In recent years, novel techniques have come to the fore to facilitate accurate and practical assessment of iron balance. These measures are the focus of this review, with emphasis on their relevance to the pediatric CKD population.
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  • Acute dialysis in children: results of a European survey

    Guzzo, Isabella   de Galasso, Lara   Mir, Sevgi   Bulut, Ipek Kaplan   Jankauskiene, Augustina   Burokiene, Vilmanta   Cvetkovic, Mirjana   Kostic, Mirjana   Bayazit, Aysun Karabay   Yildizdas, Dincer   Schmitt, Claus Peter   Paglialonga, Fabio   Montini, Giovanni   Yilmaz, Ebru   Oh, Jun   Weber, Lutz   Taylan, Christina   Hayes, Wesley   Shroff, Rukshana   Vidal, Enrico   Murer, Luisa   Mencarelli, Francesca   Pasini, Andrea   Teixeira, Ana   Afonso, Alberto Caldas   Drozdz, Dorota   Schaefer, Franz   Picca, Stefano  

    The number of children with acute kidney injury (AKI) requiring dialysis is increasing. To date, systematic analysis has been largely limited to critically ill children treated with continuous renal replacement therapy (CRRT). We conducted a survey among 35 European Pediatric Nephrology Centers to investigate dialysis practices in European children with AKI. Altogether, the centers perform dialysis in more than 900 pediatric patients with AKI per year. PD and CRRT are the most frequently used dialysis modalities, accounting for 39.4% and 38.2% of treatments, followed by intermittent HD (22.4%). In units treating more than 25 cases per year and in those with cardiothoracic surgery programs, PD is the most commonly chosen dialysis modality. Also, nearly one quarter of centers, in countries with a gross domestic product below $35,000/year, do not utilize CRRT at all. Dialysis nurses are exclusively in charge of CRRT management in 45% of the cases and pediatric intensive care nurses in 25%, while shared management is practiced in 30%. In conclusion, this survey indicates that the choice of treatment modalities for dialysis in children with AKI in Europe is affected by the underlying ethiology of the disease, organization/set-up of centers and socioeconomic conditions. PD is utilized as often as CRRT, and also intermittent HD is a commonly applied treatment option. A prospective European AKI registry is planned to provide further insights on the epidemiology, management and outcomes of dialysis in pediatric AKI.
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  • Plasma electrolyte imbalance in pediatric kidney transplant recipients

    Hayes, Wesley   Longley, Catherine   Scanlon, Nicola   Bryant, William   Stojanovic, Jelena   Kessaris, Nicos   Van't Hoff, William   Bockenhauer, Detlef   Marks, Stephen D.  

    Background In current practice, pediatric kidney transplant recipients receive large volumes of intravenous fluid intraoperatively to establish allograft perfusion, and further fluid to replace urinary and insensible losses postoperatively. Acute electrolyte imbalance can result, with potential for neurological sequelae. We aimed to determine the incidence and severity of postoperative plasma electrolyte imbalance in pediatric kidney transplant recipients managed with the current standard intravenous crystalloid regimen. Methods A retrospective analysis of plasma electrolytes in the first 72 hours post-kidney transplant in 76 children transplanted between January 1, 2015, and January 31, 2018, managed with a standard intravenous fluid strategy used in most UK pediatric transplant centers. Results Of 76 pediatric transplant recipients of median age 9.9 (range 2.2-17.9) years predominantly managed with 0.45% sodium chloride 5% glucose, 45 (59%) developed acute hyponatremia, 23 (30%) hyperkalemia, and 43 (57%) non-anion-gap acidosis in the postoperative period. Hyperglycemia occurred in 74 (97%) patients. Hyperkalemia was more prevalent in deceased than live donor recipients (P =3D 0.003) and was significantly associated with non-anion-gap acidosis (P < 0.001). Recipient weight was not associated with overt electrolyte imbalance. Conclusion Postoperative plasma electrolyte imbalance is common in pediatric kidney transplant recipients. Current clinical care strategies mitigate the associated risks of neurological sequelae to some degree. Further studies to optimize intravenous fluid therapy and minimize electrolyte disturbance in this group of patients are needed.
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  • Ab-normal saline in abnormal kidney function: risks and alternatives

    Hayes, Wesley  

    Intravenous 0.9% saline has saved countless lives since it was introduced over a century ago. It remains the most widespread crystalloid in both adult and pediatric practice. However, in recent years, evidence of deleterious effects is accruing. These include increased mortality, acute kidney injury (AKI), metabolic acidosis, and coagulopathy. The predominant cause for these sequelae appears to be the excess chloride concentration of 0.9% saline relative to plasma. This has led to development of balanced isotonic solutions such as PlasmaLyte. This review summarizes current evidence for adverse effects of chloride-rich intravenous fluid and considers whether 0.9% saline should still be used in 2018 or abandoned as a historical treatment in favor of balanced crystalloid solutions.
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  • Long-term outcome in inherited nephrogenic diabetes insipidus

    Sharma, Sonia   Ashton, Emma   Iancu, Daniela   Arthus, Marie-Francoise   Hayes, Wesley   van't Hoff, William   Kleta, Robert   Bichet, Daniel G.   Bockenhauer, Detlef  

    Background Inherited nephrogenic diabetes insipidus (NDI) is a rare disorder characterized by impaired urinary concentrating ability. Little clinical data on long-term outcome exists. Method This was a single-centre retrospective medical record review of patients with a diagnosis of NDI followed between 1985 and 2017. We collected available data on growth, weight, school performance, complications and comorbidities. Results We identified 36 patients with available data and a clinical diagnosis of NDI, which was genetically confirmed in 33 of them. Patients presented at a median age of 0.6years and median length of follow-up was 9.5years. Chief symptoms at presentation were faltering growth, vomiting/feeding concerns, polyuria/polydipsia, febrile illness and hypernatraemic dehydration. Median weight standard deviation scores (SDS) improved from -2.1 at presentation to 0.2 at last follow-up. In contrast, height SDS remained essentially unchanged at -1.1 at presentation and -0.9 at last follow-up. Most patients were treated with prostaglandin synthesis inhibitors and thiazides, yet weaned off during school age without an obvious change in urine output. Median estimated glomerular filtration rate at last follow-up was 81mL/min/1.73m(2). Urological complications were noted in 15 patients, constipation in 11 and learning difficulties in 5. Median age at resolution of nocturnal enuresis was 11years. Estimated median daily fluid intake at median age of 13years was 3800mL/m(2). Conclusion The overall prognosis in inherited NDI is favourable with regular treatment. As expected, most complications were related to polyuria. There is an apparent loss of efficacy of medications during school age. Our data inform the prognosis and management of patients with NDI.
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  • Acute dialysis in children: results of a European survey

    Guzzo, Isabella   de Galasso, Lara   Mir, Sevgi   Bulut, Ipek Kaplan   Jankauskiene, Augustina   Burokiene, Vilmanta   Cvetkovic, Mirjana   Kostic, Mirjana   Bayazit, Aysun Karabay   Yildizdas, Dincer   Schmitt, Claus Peter   Paglialonga, Fabio   Montini, Giovanni   Yilmaz, Ebru   Oh, Jun   Weber, Lutz   Taylan, Christina   Hayes, Wesley   Shroff, Rukshana   Vidal, Enrico   Murer, Luisa   Mencarelli, Francesca   Pasini, Andrea   Teixeira, Ana   Afonso, Alberto Caldas   Drozdz, Dorota   Schaefer, Franz   Picca, Stefano  

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  • Plasma electrolyte imbalance in pediatric kidney transplant recipients

    Hayes, Wesley   Longley, Catherine   Scanlon, Nicola   Bryant, William   Stojanovic, Jelena   Kessaris, Nicos   Van’t Hoff, William   Bockenhauer, Detlef   Marks, Stephen D.  

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  • Assessment and management of fluid overload in children on dialysis

    Hayes, Wesley   Paglialonga, Fabio  

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  • Line Detection as an Inverse Problem:Application to Lung Ultrasound Imaging

    Anantrasirichai, Nantheera   Hayes, Wesley   Allinovi, Marco   Bull, David   Achim, Alin  

    This paper presents a novel method for line restoration in speckle images. We address this as a sparse estimation problem using both convex and non-convex optimization techniques based on the Radon transform and sparsity regularization. This breaks into subproblems, which are solved using the alternating direction method of multipliers, thereby achieving line detection and deconvolution simultaneously. We include an additional deblurring step in the Radon domain via a total variation blind deconvolution to enhance line visualization and to improve line recognition. We evaluate our approach on a real clinical application: the identification of B-lines in lung ultrasound images. Thus, an automatic B-line identification method is proposed, using a simple local maxima technique in the Radon transform domain, associated with known clinical definitions of line artefacts. Using all initially detected lines as a starting point, our approach then differentiates between B-lines and other lines of no clinical significance, including Z-lines and A-lines. We evaluated our techniques using as ground truth lines identified visually by clinical experts. The proposed approach achieves the best B-line detection performance as measured by the F score when a non-convex l(p) regularization is employed for both line detection and deconvolution. The F scores as well as the receiver operating characteristic (ROC) curves show that the proposed approach outperforms the state-of-the-art methods with improvements in B-line detection performance of 54%, 40%, and 33% for F-0.5, F-1, and F-2, respectively, and of 24% based on ROC curve evaluations.
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  • Eculizumab hepatotoxicity in pediatric aHUS

    Hayes, Wesley   Tschumi, Sibylle   Ling, Simon C.   Feber, Janusz   Kirschfink, Michael   Licht, Christoph  

    Eculizumab is a humanized anti-C5 antibody approved for the treatment of atypical hemolytic uremic syndrome (aHUS). Its use is increasing in children following reports of its safety and efficacy. We reviewed biochemical and clinical data related to possible drug-induced liver injury in 11 children treated with eculizumab for aHUS in a single center. Elevated aminotransferases were observed in 7 children aged 6 to 11 years following eculizumab treatment for aHUS. Internationally accepted liver enzyme thresholds for drug-induced liver injury were exceeded in 5 cases. In all cases, liver injury was classified as mixed hepatocellular and cholestatic. Infectious and other causes were excluded in each case. One patient with no pre-existing liver disease developed tender hepatomegaly and liver enzyme derangement exceeding 20 times the upper limit of normal following initiation of eculizumab. Recurrent liver injury following re-challenge with eculizumab necessitated its discontinuation and transition to plasma therapy. Hepatotoxicity in association with eculizumab is a potentially important yet previously unreported adverse event. We recommend monitoring liver enzymes in all patients receiving eculizumab. Further research is required to clarify the impact of this adverse event, to characterize the mechanism of potential hepatotoxicity, and to identify which patients are most at risk.
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  • Eculizumab hepatotoxicity in pediatric aHUS.

    Hayes, Wesley   Tschumi, Sibylle   Ling, Simon C   Feber, Janusz   Kirschfink, Michael   Licht, Christoph  

    BACKGROUND: Eculizumab is a humanized anti-C5 antibody approved for the treatment of atypical hemolytic uremic syndrome (aHUS). Its use is increasing in children following reports of its safety and efficacy.; METHODS: We reviewed biochemical and clinical data related to possible drug-induced liver injury in 11 children treated with eculizumab for aHUS in a single center.; RESULTS: Elevated aminotransferases were observed in 7 children aged 6 to 11 years following eculizumab treatment for aHUS. Internationally accepted liver enzyme thresholds for drug-induced liver injury were exceeded in 5 cases. In all cases, liver injury was classified as mixed hepatocellular and cholestatic. Infectious and other causes were excluded in each case. One patient with no pre-existing liver disease developed tender hepatomegaly and liver enzyme derangement exceeding 20 times the upper limit of normal following initiation of eculizumab. Recurrent liver injury following re-challenge with eculizumab necessitated its discontinuation and transition to plasma therapy.; CONCLUSIONS: Hepatotoxicity in association with eculizumab is a potentially important yet previously unreported adverse event. We recommend monitoring liver enzymes in all patients receiving eculizumab. Further research is required to clarify the impact of this adverse event, to characterize the mechanism of potential hepatotoxicity, and to identify which patients are most at risk.=20
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  • Finding covert fluid:methods for detecting volume overload in children on dialysis

    Allinovi, Marco   Saleem, Moin A.   Burgess, Owen   Armstrong, Catherine   Hayes, Wesley  

    Lung ultrasound is a novel technique for detecting generalized fluid overload in children and adults with end-stage renal disease (ESRD). Echocardiography and bioimpedance spectroscopy are established methods, albeit variably adopted in clinical practice. We compared the practicality and accuracy of lung ultrasound with current objective techniques for detecting fluid overload in children with ESRD. A prospective observational study was performed to compare lung ultrasound B-lines, echocardiographic measurement of inferior vena cava parameters and bioimpedance spectroscopy in the assessment of fluid overload in children with ESRD on dialysis. The utility of each technique in predicting fluid overload, based on short-term weight gain, was assessed. Multiple linear regression models to predict fluid overload by weight were explored. A total of 22 fluid assessments were performed in 13 children (8 on peritoneal dialysis, 5 on haemodialysis) with a median age of 4.0 (range 0.8-14.0) years. A significant linear correlation was observed between the number of B-lines detected by lung ultrasound and fluid overload by weight (r =3D 0.57, p =3D 0.005). A non-significant positive linear correlation was observed between fluid overload by weight and bioimpedance spectroscopy (r =3D 0.43, p =3D 0.2), systolic blood pressure (r =3D 0.19, p =3D 0.4) and physical examination measurements (r =3D 0.19, p =3D 0.4), while a non-significant negative linear relationship was found between the inferior vena cava collapsibility index and fluid overload by weight (r =3D -0.24, p =3D 0.3). In multiple linear regression models, a combination of three fluid parameters, namely lung ultrasound B-lines, clinical examination and systolic blood pressure, best predicted fluid overload (R (2) =3D 0.46, p =3D 0.05). Lung ultrasound may be superior to echocardiographic methods and bioimpedance spectroscopy in detecting volume overload in children with ESRD. Given the practicality and sensitivity of this new technique, it can be adopted alongside clinical examination and blood pressure in the routine assessment of fluid status in children with ESRD.
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  • Acute kidney injury

    Hayes, Wesley   Christian, Martin  

    The definition and classification of acute kidney injury (AKI) in children has become clearer over the last decade. The paediatric RIFLE criteria stratify AKI in children into five groups (R = risk, I = injury, F = failure, L = loss of kidney function, E = end stage renal disease) enabling earlier recognition and intervention. This article reviews the definition, classification, causes and management of AKI as relevant to the general paediatrician. Common causes of AKI in neonates and children are reviewed including E. Coli associated haemolytic uraemic syndrome, hypoxic ischaemic insults and medication related kidney injury. Initial management of acute kidney injury and its complications is outlined in the context of the role of the general paediatrician and factors which should prompt discussion with a tertiary paediatric nephrologist. The outcome and complications of kidney injury are discussed and future directions in the field considered.
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  • Intradialytic hypotension

    Hayes, Wesley   Hothi, Daljit K.  

    Intradialytic hypotension (IDH) is common in children during conventional, 4 hour haemodialysis (HD) sessions. The declining blood pressure (BP) was originally believed to be caused by ultrafiltration (UF) and priming of the HD circuit, however emerging data now supports a multifactorial aetiology. Therefore strategies to improve haemodynamic stability need to be diverse and address specific patient requirements or risks. In the treatment of IDH immediate action is required to stop or reduce the severity of symptoms that may precede or follow. Typically UF is slowed or stopped, a fluid bolus is given and in resistant cases the HD session is prematurely discontinued. Patients complete their treatment under-dialysed and volume expanded. Chronically, repeated episodes of IDH cause devastating, multi-system morbidity with an increased risk of mortality. This had provided the impetus for more haemodynamically friendly dialysis prescriptions that attenuate the risk of IDH. During pediatric HD several preventative strategies have been tested but with variable success. Of these, dialysate sodium profiling, UF guided by relative blood volume (RBV) algorithms, cooling and intradialytic mannitol appear to be the most effective. However in refractory cases one may be left with no option but to switch dialysis modality to haemodiafiltration (HDF) or more frequent or prolonged HD regimens.
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  • Lung ultrasound:a novel technique for detecting fluid overload in children on dialysis

    Allinovi, Marco   Saleem, Moin   Romagnani, Paola   Nazerian, Peiman   Hayes, Wesley  

    Background: Optimizing the target weight of infants and children on dialysis remains an important clinical challenge. The use of ultrasound to detect fluid overload in adult patients on dialysis is receiving growing attention. We hypothesized that fluid overload can be quantified in infants and children receiving dialysis using lung ultrasound. Methods: In this prospective observational study, infants and children receiving dialysis for end-stage renal disease (ESRD) or acute kidney injury (AKI) in a regional paediatric nephrology centre were eligible. Lung ultrasound examinations were performed during in-centre dialysis, on home visits or in an outpatient clinic. Fluid overload was assessed by quantifying B-lines on ultrasound and compared with proportional (%) increase in patient weight from the target weight. Results: A total of 142 ultrasound assessments were performed in 23 children. In children with AKI, median B-line score reduced from 5 (range 0-22) at presentation to 1.5 (0-4) at recovery (P =3D 0.04) with concurrent improvement in fluid overload judged by weight from 7.2 (- 1.9 to 15.2)% to 0%. A linear correlation between lung ultrasound B-line score and fluid overload judged by weight was observed in children with AKI (r =3D 0.83) and ESRD (r =3D 0.61). Inter-observer variability was acceptable. Conclusions: Lung ultrasound is a practical and sensitive method of quantifying subclinical fluid overload in infants and children on dialysis. Interventional studies to determine the benefits of using lung ultrasound to optimize the target weight for children with ESRD are merited.
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