The 1996 annual report of the Chronic Renal Insufficiency Arm of the North American Pediatric Renal Transplant Cooperative Study (NAPRTCS) summarizes descriptive data and highlights important features on 1,725 patients from 130 centers. This database contains information on patients with an estimated glomerular filtration rate (GFR) < or = 75 ml/min per 1.73 m2 as calculated by the Schwartz formula, who were treated on or after 1 January 1994. Thus this report reflects 2 years of data entry. Analysis of the data revealed that nearly two-thirds of patients registered had a structural anomaly. On average, patients were 1.5 standard deviations below age- and sex-specific norms for height, and 0.6 standard deviations below weight norms. Mean serum creatinine for the entire group was 2.4 mg/dl and 68% of patients had a baseline GFR of at least 25 ml/min per 1.73 m2. The mean hematocrit for all children at registration was 33.3 +/- 6.3%, and did not vary among age groups. Overall, 30.9% of patients had a hematocrit < 30%. Only 12.8% of patients were receiving Epoetin therapy. Although still in infancy, the Chronic Renal Insufficiency Arm of the NAPRTCS database in providing important insights into this disorder.

Venous catheters have become an indispensable form of hemodialysis access. We evaluated catheter performance as temporary and long-term access in children with end-stage renal disease (ESRD). We assessed the survival rates and causes of catheter failure in 78 catheters used for hemodialysis access in 23 pediatric patients (aged 10 months to 22 years) with ESRD over a 5-year period. Median survival was 31 days for 56 uncuffed catheters. One- and 2-month actuarial survival was 69% and 48%, respectively. Reasons for removal were: elective (39%), kinking (36%), trauma (11%), infection (7%), and other (5%). Smaller catheters (7 or 9 French) were more likely to be removed for kinking (P = 0.003). One-year actuarial survival for 22 cuffed catheters was 27%. Cuffed catheters were removed due to: infection (36%), kinking (14%), elective (9%), trauma (9%) and other (9%). Twelve catheters were removed for infection. Infection rates leading to removal were 0.58 and 0.71 per patient-year for uncuffed and cuffed catheters, respectively. Staphylococcus species were cultured most commonly. We conclude that uncuffed catheters function well for short-term hemodialysis access of up to 2 months' duration and cuffed catheters are successful for long-term access in children and adolescents with ESRD.

The records of 33 infants weighing 5 kg or less who received acute hemodialysis treatment at Children's Hospital between 1980 and 1991 were reviewed. Dialysis was initiated to treat hyperammonemia (8), primary renal or renovascular disease (7), and acute renal failure (18). The infants weighed 2.2 to 4.0 kg at birth and 27% were born prematurely. The infants were 2 to 120 days of age (median 10 days) and weighed 2.2 to 5.0 kg (median 3.5 kg) at the initiation of hemodialysis. Hemodialysis access was achieved via double-lumen 7 French catheters in 49% of the infants, the ECMO circuit in 24%, and the umbilical vessels in 27%. Thirty-three infants underwent a total of 216 hemodialysis treatments. Only nine treatments were discontinued prematurely: six for intractable hypotension and three for technical problems. Fifty-two percent (17 of 33) of the infants survived through the end of the hemodialysis treatment course. The survival rates for the infants with hyperammonemia (75%) and primary renal disease (71%) were better than those for infants with acute renal failure (33%). The survivors did not differ from those who died with respect to birthweight, weight when hemodialysis was initiated, or the number of hemodialysis treatments administered. We conclude that infants weighing less than 5 kg can be treated successfully with hemodialysis. Patient survival is related to underlying medical problems, not to complications of hemodialysis.

Data from the North American Pediatric Renal Transplant Cooperative Study were analyzed to determine the effects of alternate-day (QOD) steroid dosing on growth, graft survival, and graft function in children with functioning grafts 12 months after transplantation. At 12 months after transplantation, 16.8% (337/2001) of transplant recipients were receiving QOD dosing. The basis for the selection of a steroid dosing regimen cannot be determined from registry data; however, the frequency of QOD dosing differed by donor source, race, age at transplant, and the occurrence of rejection episodes in the first year. The effect of the steroid dosing pattern on growth was evaluated in children continuously on either QOD or daily (QD) steroid dosing. The mean change in the standardized height scores from 1 month to 24 months after transplantation was significantly greater in those on QOD dosing (+0.5 +/- 0.06) than in those on QD dosing (+0.1 +/- 0.03). Using multiple regression analyses, better growth was associated with QOD dosing, recipient age less than 13 years, lower total steroid dose over 48 hr, and lower serum creatinine (all P < 0.001). Graft survival did not differ on the basis of the steroid dosing pattern. In a proportional hazards model for survival of living donor grafts after 12 months, graft survival was negatively associated with the use of QD dosing, black race, rejection episodes in the first year, and a higher serum creatinine at 12 months. The survival of cadaver grafts was negatively associated with the use of QD steroid dosing, recipient age less than 2 years, rejection episodes in the first year, and a higher serum creatinine at 12 months. In addition, the decline in graft function did not differ between those on QOD steroid therapy and those on QD therapy. We conclude that selected pediatric renal transplant recipients receiving QOD dosing have better growth than those receiving QD dosing without compromising allograft survival or function.

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