Continuous renal replacement therapy (CRRT) is used to treat renal failure in children. Despite widespread use of the technique, little research has evaluated how variations in dose of replacement fluid or degree of fluid overload at initiation relate to outcomes. We conducted a retrospective review of patients treated with convective CRRT at our institution, using a multivariable Cox regression model. Children with high fluid overload (>10%) at CRRT initiation were at 3.02 times greater risk of mortality than those with low or no fluid overload [95% confidence interval (CI) 1.50-6.10, P=0.002]. The hazard ratio for death in children treated with high-dose convective clearance was not statistically significant. Our data support previous findings that volume overload in excess of 10% is strongly correlated with poor outcome. We favor early institution of CRRT, before excessive fluid overload occurs. In contrast to findings in adults, we find no advantage to higher rates of convective clearance. Given the risks and increased complexity associated with high-volume hemofiltration, we recommend further study prior to widespread adoption of high-level convection in children treated with continuous veno-venous hemofiltration.

The following two cases are examples of nephrolithiasis in children recently observed in the Hospital for Sick Children, Toronto. Case 1. J. C., a boy aged thirteen years, was previously in hospital in December, 1939, with two days' history of frequency and haematuria. The urine showed a cloud of albumin and was loaded with red blood cells. The non-protein nitrogen was 67 mgm. per cent., the creatinine 1-8 mgm. per cent. A diagnosis of acute haemorrhagic nephritis was made. His condition cleared up on the usual treatment and he was discharged in six weeks. He was followed in the outpatient department, and the urine remained clear for two months; he then had dysuria and passed two stones. He was readmitted April 1, 1940, for investigation. Analysis of the stones showed calcium oxalate and magnesium and calcium phosphate. X-ray showed many small bilateral calculi in the calices and bilateral hydronephrosis, especially the left side. The non-protein nitrogen, creatinine and cholesterol were normal, but the urine concentrated to a specific gravity of only 1010 (volume 70 c.c.). Urine culture gave no growth from bladder or ureters. Blood calcium on admission was 13-2 mgm. per cent., phosphorus 4-1 mgm. per cent. Subsequent estimations were normal and below normal. Phosphatase was 26 units. X-ray examination of the long bones was negative. Calcium balance was negative with two-thirds excreted in the urine. Following an unsuccessful attempt to dissolve the stones by medical treatment, a left pyelolithotomy was done on May 30, 1940, to be followed by a similar operation on the right side at a later date. Case 2. The second case was treated surgically. B. M., a girl, was aged two-and-a-half years when first admitted in October, 1937, with bilateral renal calculi. Kidney function tests were normal. The urine cultured bacillus coli. Right nephrolithotomy was performed and three calcium phosphate stones removed. She returned in November, 1937, with a right ureteral calculus as well as those in the left kidney pelvis. The urine concentrated to a specific gravity of 1015. B. coli were found in the urine on culture. In January, 1938, a left nephrolithotomy was done and three calcium carbonate stones removed. During that year she passed stones on three occasions and returned in December, 1938, with a stricture of the left ureter, which was dilated, and left pyelonephritis; new stones were present on the right side. She remained moderately well for three months and then returned in March, 1940, with severe pain in the left side and a soft fluctuant mass-an infected hydronephrosis. X-ray showed bilateral calculi. Non-protein nitrogen was 109 mgm. per cent. and creatinine 3.45 mgm. per cent. The haemoglobin was 43 per cent. Despite transfusion, fluids and irrigations by indwelling ureteral catheters, she died suddenly April 12, 1940, at five years of age. No autopsy was obtained.

Dialysis guidelines recommend aggressive management of anemia, including the use of intravenous iron (i.v.Fe) when indicated. However, few published data are available to guide the use of i.v.Fe in children, and studies are difficult to compare. In this meta-analysis we sought to combine evidence by pooling clinical trial data to determine if i.v.Fe therapy helped increase hematocrit, serum levels of hemoglobin, ferritin, and transferrin saturation (TSAT), and reduce erythropoietin use. We searched MEDLINE and other databases, publications, and other sources to identify as many published and unpublished trials as possible. Of 379 possible studies, nine met the criteria for inclusion and analysis. Across all nine studies, 141 patients were studied, for durations of 2 weeks to 12 months. Pooled results identified an increase in hemoglobin, hematocrit, ferritin, and TSAT levels, and reduced use of erythropoietin, with effect sizes (in standardized weighted mean differences) ranging from 0.62 (95% confidence interval 0.11-1.13) to 1.86 (1.58-2.15) standard deviation improvements. Current practice is based largely on extrapolation from adult data and a few small pediatric trials. The pooled pediatric data suggest that i.v.Fe is effective and produces moderate to large effects on the reported outcomes. Prospective, multi-center trials are needed to determine the optimal utilization of i.v.Fe in children.

Leuconostoc species are rarely pathogenic in humans, but may cause infection in patients at risk. A 7-year-old girl with p-ANCA-positive crescentic glomerulonephritis, treated with peritoneal dialysis, developed peritonitis due to Leuconostoc species. She had a history of treatment with vancomycin and a brief course of immunosuppressive therapy. The peritonitis responded well to ampicillin therapy. To date, only 47 cases of Leuconostoc infection, including our patient, have been reported in the medical literature; 25 of the cases occurred in children. Only 1 prior case has been reported in the setting of peritoneal dialysis. The risk factors for Leuconostoc infections are not clear, but commonly associated conditions include immunocompromised status and indwelling medical devices. Leuconostoc species are easily misidentified as streptococci in culture, but they possess inherent resistance to vancomycin despite sensitivity to most other antibiotics. In patients with gram-positive peritonitis, Leuconostoc should be considered as a possible etiological agent, particularly if vancomycin resistance is noted in an organism thought to be a Streptococcus species.

Post-transplant anemia is a widespread problem among pediatric renal transplant recipients. Many clinicians treat post-transplant anemia in a manner similar to treatment of anemia in dialysis patients, including the use of intravenous iron, such as sodium ferric gluconate (SFG). Data on pediatric dosing of SFG are limited to rare small series containing few or no renal transplant recipients. We conducted a retrospective chart review of practice patterns at our institution to evaluate doses used, hemoglobin response and adverse events. We identified 15 renal transplant recipients who received SFG during the 28-month study period. Data from 14 of these patients were available for analysis. Patients received between one and six doses of SFG to yield a total dose of 100-1000 mg or 2.7-23.7 mg/kg. The largest doses given during a single infusion ranged from 1.9 to 6.4 mg/kg. The mean hemoglobin level increased from 101 +/- 16 to 114 +/- 21 g/L (p = 0.0092) following SFG therapy. Adverse events were recorded for three patients. Treatment with SFG appears to yield some improvement in anemia in renal transplant recipients, but the paucity of published information on this topic highlights the need for stronger data, particularly with respect to pediatric patients.