Continous renal replacement therapy(CRRT) is becoming increasingly popular for the support of critically ill patients with acute renal failure, and the development of pump-driven volumetric-control CRRT machines with small extracorporeal volumes has lead to the widespread use of venovenous form of CRRT in pediatric field. Basic principles are diffusion and convection. CRRT is indicated in the hemodynamically unstable pediatric patients for hypervolemic anuric acute renal failure, electrolyte abnormalities, multiorgan failure, catabolic patients with increased nutritional needs and hyperammonemia, etc. To date, experiences are limited for pediatric CRRT, but current reports support that CRRT is feasible and useful in children and even infants, and the survival rate of the patients on CRRT is as same as adults. We describe the basic principles, equipments, methods and complications of CRRT, with special considerations on small children to meet the current need for CRRT.
Acute Kidney Injury ; Adult ; Child ; Convection ; Critical Illness ; Diffusion ; Humans ; Hyperammonemia ; Infant ; Pediatrics* ; Renal Replacement Therapy* ; Survival Rate

PURPOSE: Regional anticoagulation with trisodium citrate for continuous renal replacement therapy(CRRT) is an effective and safe method, with lower bleeding risk. However it is not widely used because of complex current protocols used to prevent anticipated metabolic derangements. We evaluated simplified regional anticoagulation protocols with ACD-A(R) solution and commercially available calcium-containing dialysis solution. METHODS: The medical records of twenty-eight patients who underwent CRRT were reviewed. Hemofilter life span according to the anticoagulation method used was compared, and laboratory findings at pre- and 48 hours post-CRRT initiation were compared in the citrate-based CRRT group. RESULTS: Of the twenty-eight patients, five patients underwent citrate-based CRRT. Hemofilter life span was 1.60+/-0.72 days, showing no significant differences with the hemofilter life span in the heparin based and LMWH based CRRT group. No patients experienced hemorrhagic complications. PT, aPTT, sodium, tCO2, iCa levels showed no difference in pre- and post-CRRT. Total calcium levels were increased. At the recommended postfilter iCa level, i.e., 0.25-0.39 mmol/L, all five patients needed increased amount of citrate infusion, and Ca infusion requirement was decreased. CONCLUSION: Simplified regional citrate anticoagulation with calcium-containing dialysate is an effective and safe method, and is not associated with increased hemofilter clotting. However, increased postfilter iCa level is recommended.
Calcium ; Child* ; Citric Acid* ; Dialysis ; Hemorrhage ; Heparin ; Heparin, Low-Molecular-Weight ; Humans ; Medical Records ; Renal Replacement Therapy* ; Sodium

Cytomegalovirus (CMV) is the single most common infection following kidney transplantation and despite prophylactic strategies and the development of new antiviral agents, it still remains a cause of considerable morbidity and mortality. Current literature suggests that CMV infection may trigger rejection. We report a case of late CMV disease in a preemptive seropositive recipient who did not receive CMV prophylaxis. Diarrhea and abdominal cramping persisted after the administration of mycophenolate mofetil (MMF) six months after transplantation and resulted in ileal perforation at eight months after transplantation. The boy recovered after six weeks of treatment with ganciclovir. MMF has been mooted as a risk factor for CMV infection since its introduction, and further investigations are required to confirm its role. More attention to infectious complications is necessary and serial monitoring of viral load is recommended when MMF is administered.
Antiviral Agents ; Colic ; Cytomegalovirus ; Diarrhea ; Ganciclovir ; Kidney ; Kidney Transplantation ; Mycophenolic Acid ; Risk Factors ; Transplants ; Viral Load

Objective: To investigate imaging biomarkers of microperfusion in contrast-induced nephropathy (CIN) using contrastenhanced ultrasound (CEUS). Materials and Methods: The CIN model was fabricated by administering indomethacin (10 mg/kg), L-NAME (15 mg/kg), and iopamidol (10 mL/kg) to Sprague-Dawley rats. After 24 hours, CEUS was performed on CIN (n = 6) and control (n = 6) rats with sulphur hexafluoride microbubbles (SonoVue). From time-intensity curves obtained from the kidney arriving time (AT), acceleration time (AC), time to peak (TTP), and peak enhancement (PE) were measured and compared between the groups. After CEUS, the rats were sacrificed, and cell apoptosis markers were evaluated to confirm the development of CIN. Results: Among CEUS parameters, AT (7.8 ± 1.6 vs. 4.2 ± 0.5 s, p = 0.002), AC (4.7 ± 1.4 vs. 2.0 ± 0.4 s, p = 0.002), and TTP (12.5 ± 2.9 vs. 6.2 ± 0.6 s, p = 0.002) were significantly prolonged in the CIN group compared to controls. PE was significantly higher in the control group than in the CIN group (17.1 ± 1.9 vs. 12.2 ± 2.0 dB, p = 0.004). In kidney tissue, mRNA and protein levels of the apoptotic makers were significantly higher in the CIN group than in the control group (p = 0.003 and p = 0.002). Conclusion CEUS parameters can be used as imaging biomarkers for microperfusion in CIN. In rats with CIN, AT, AC, and TTP were significantly prolonged, while PE was significantly lower compared to controls.

Objective: To investigate imaging biomarkers of microperfusion in contrast-induced nephropathy (CIN) using contrastenhanced ultrasound (CEUS). Materials and Methods: The CIN model was fabricated by administering indomethacin (10 mg/kg), L-NAME (15 mg/kg), and iopamidol (10 mL/kg) to Sprague-Dawley rats. After 24 hours, CEUS was performed on CIN (n = 6) and control (n = 6) rats with sulphur hexafluoride microbubbles (SonoVue). From time-intensity curves obtained from the kidney arriving time (AT), acceleration time (AC), time to peak (TTP), and peak enhancement (PE) were measured and compared between the groups. After CEUS, the rats were sacrificed, and cell apoptosis markers were evaluated to confirm the development of CIN. Results: Among CEUS parameters, AT (7.8 ± 1.6 vs. 4.2 ± 0.5 s, p = 0.002), AC (4.7 ± 1.4 vs. 2.0 ± 0.4 s, p = 0.002), and TTP (12.5 ± 2.9 vs. 6.2 ± 0.6 s, p = 0.002) were significantly prolonged in the CIN group compared to controls. PE was significantly higher in the control group than in the CIN group (17.1 ± 1.9 vs. 12.2 ± 2.0 dB, p = 0.004). In kidney tissue, mRNA and protein levels of the apoptotic makers were significantly higher in the CIN group than in the control group (p = 0.003 and p = 0.002). Conclusion CEUS parameters can be used as imaging biomarkers for microperfusion in CIN. In rats with CIN, AT, AC, and TTP were significantly prolonged, while PE was significantly lower compared to controls.

We report a 2-month-old boy who presented with severe hyponatremia and hyperkalemia secondary to ureteropelvic junction(UPJ) obstruction. By prenatal ultrasonography at 19 weeks of gestation, severe hydronephrosis was found which was confirmed postnatally. Pyeloplasty was done on the 45th day of life, and fifteen days after pyeloplasty, non-bilious vomiting, decreased activity and dehydration developed. Severe hyponatremia and hyperkalemia were observed, as a result of elevated serum aldosterone and plasma renin activity. The anterior posterior pelvic diameter(APPD) and Society for Fetal Urology(SFU) grade measured showed no interval change before and after pyeloplasty. Pseudohypoaldosteronism was diagnosed, and 2M NaCl was administrated orally for 7 days. The electrolyte imbalance was corrected, and 8 weeks later, the elevated levels of aldosterone and plasma renin activity were normalized. The left hydronephrosis was improved at 5 months of age. We hereby report a transient pseudohypoaldosteronism secondary to UPJ obstruction with a review of the literature.
Aldosterone ; Dehydration ; Humans ; Hydronephrosis ; Hyperkalemia ; Hyponatremia ; Infant ; Male ; Plasma ; Pregnancy ; Pseudohypoaldosteronism* ; Renin ; Ultrasonography, Prenatal ; Vomiting

Hypercalcemia in infancy is an uncommon disorder but has a potential of serious sequelae. Therefore, infants with hypercalcemia must be promptly investigated and need urgent management. We report three cases of infantile hypercalcemia caused by vitamin D intoxication, emphasizing diagnostic investigations and the course of treatment. The first and the second cases were thought to be vitamin D intoxication without doubt, and were presented with a low parathyoid hormone(PTH) level and increased 25-hydroxyvitamin D3(25(OH)D3). The third case, which was hypotonic and accompanied with chromosomal anomaly, showed relatively low PTH and elevated 25(OH)D3. The first and the third case presented with poor oral intake and a failure to thrive. The second case was asymptomatic and founded incidentally by routine laboratory tests during treatment of the underlying disease. The hypercalcemia of three patients improved after a change of the formula milk with short term medication, lowering serum calcium. Thus we suspect that infants with hypercalcemia have a vitamin D intoxication caused by formula milk. This report describes three cases of hypercalcemia in infancy induced by vitamin D intoxication, a with review of the literature.
Calcium ; Failure to Thrive ; Humans ; Hypercalcemia* ; Infant ; Milk ; Poisoning ; Vitamin D* ; Vitamins*

PURPOSE: Acute poststreptococcal glomerulonephritis (APSGN) is a common form of glomerulonephritis in children. Most patients recover completely after the acute phase but a few patients have acute complications or progress to chronic renal disease. In recent years, the frequency of APSGN has been was decreasing but is still common in children. So we studied the clinical characteristics of APSGN from 1994 to 2003 and compared it with past studies. METHODS: We studied 105 patients who were diagnosed with APSGN in the Department of Pediatrics, Asan Medical Center between January 1994 and December 2003, with a retrospective chart review. RESULTS: The mean age was 8.5+/-2.6 years. The male to female ratio was 2: 1. Average annual incidence was 10.5+/-4.9 most patients (60.0 percent) occurred from October to January. Edema was seen in 82 cases (78.1 percent), gross hematuria in 70 cases (66.7 percent), hypertension in 50 cases (47.6 percent) and oliguria in 22 cases (20.9 percent). Microscopic hematuria was seen in 105 cases (100 percent), positive ASO in 99 cases (94.2 percent), proteinuria in 67 cases (63.8 percent) and azotemia in 38 cases (36.2 percent). Serum complement 3 (C3) level decreased in 96 cases and returned to normal within eight weeks in 70 patients (75.3 percent). Kidney biopsy was carried out in 22 cases. Most acute symptoms subsided within 2 weeks of onset. CONCLUSION: We concluded that there was no significant difference between clinical features of recent and past APSGN in children, and short term prognoses were excellent.
Azotemia ; Biopsy ; Child* ; Chungcheongnam-do ; Complement C3 ; Edema ; Female ; Glomerulonephritis* ; Hematuria ; Humans ; Hypertension ; Incidence ; Kidney ; Male ; Oliguria ; Pediatrics ; Prognosis ; Proteinuria ; Renal Insufficiency, Chronic ; Retrospective Studies

With the advent of hemodialysis, the success of renal transplants in the 1960s and the wide use of continuous ambulatory peritoneal dialysis at the end of the 1970s, children with renal failure now enjoy an extended life span. As a result, several children experience renal osteodystrophy and growth retardation. Renal osteodystrophy is induced by phosphorus retention, hypocalcemia, low vitamin D levels and hyperparathyroidism. The pharmacologic interventions are used to prevent bone deformities and to normalize growth velocity. But surgical intervention is required sometimes when osteodystrophy is severe and poorly controlled. We report an eight-year-old boy with chronic renal failure who developed severe bone deformities and needed osteotomy.
Child ; Congenital Abnormalities* ; Humans ; Hyperparathyroidism ; Hypocalcemia ; Kidney Failure, Chronic ; Male ; Osteotomy ; Peritoneal Dialysis, Continuous Ambulatory ; Phosphorus ; Renal Dialysis ; Renal Insufficiency ; Renal Osteodystrophy* ; Vitamin D

PURPOSE: Renal transplantation for the management of end-stage renal disease(ESRD) in children is now the optimal treatment. We analyzed the clinical courses and characteristics of pediatric renal transplantation in Asan Medical Center. METHODS: We reviewed the charts of 60 cases of renal transplantation under the age of 18, admitted to Asan Medical Center, from Oct. 1990 to May 2003. We analyzed retrospectively to clarify the clinical courses, risk factors affecting graft survival, recurrence of the original disease, complications and growth. RESULTS: Graft was taken from 48 living donors, and 12 cadaveric donors. The mean age at transplantation was 13.1 years. The overall graft survival rates were 96.3% at one year, 84.4% at five year, 47.6% at 10 years. The overall patient survival rates were 98.1% at one year, 95.1% at five years, 95.1% at 10 years. A total of 13 grafts were lost(21.7%). The presence of acute rejection within one year after graft(P=0.0045) and recipient less than five years old(P=0.0027) were significant risk factors for poor graft survival. The recurrence rate of original disease was 8.3% and the most common complication was infection(50%). In the group less than 3 percentile of pretransplantation height, there were much longer duration of ESRD and much greater growth after transplantation(P=0.002). CONCLUSION: The graft survival rate for pediatric renal transplantation has been greatly increased, similar to those of adult renal transplantation with the development of operation techniques and immunosuppressants. Further studies into the factors improving graft survival and new immunosuppressants to reduce the rate of rejection, and efforts to reduce the incidence of infection, are needed at this time.
Adult ; Cadaver ; Child ; Chungcheongnam-do ; Graft Survival ; Humans ; Immunosuppressive Agents ; Incidence ; Kidney Failure, Chronic ; Kidney Transplantation* ; Living Donors ; Recurrence ; Retrospective Studies ; Risk Factors ; Survival Rate ; Tissue Donors ; Transplants