CME Live: Anticoagulation

CME Live: Anticoagulation

Dr. Rupesh Raina

Curofy- India's largest community of verified doctors covered the CME-International Neonatal and Pediatric Nephrology Training Workshop live. This post was first published on the Curofy app. 

Heparin:

Commonly used
Easy to use and monitor
No evidence on dose
Systemic side effect
Contraindicated in bleeding patient

Citrate

Calcium dependent mechanism 
Binds to free calcium and inhibits binding
Has zero effect upon the patient 
Easy to monitor
Less clotted circuits
Less work of machinery

Problems:

Metabolic alkalosis
Electrolyte disorders
Cardiac toxicity

Complications: 
Seen with rising total calcium with dropping patient ionized calcium.
Citrate gap.

CME Live: Session One

Curofy- India's largest community of verified doctors covered the CME-International Neonatal and Pediatric Nephrology Training Workshop live. This post was first published on the Curofy app. 

Non Dialytic Management of AKI: 

Dr. Rupesh Raina

Modified RIFLE criteria doesn't help on bedside

Creatinins is not the only marker neither is it good.
Solute clearance
Risk assessment
Early intervention is critical in golden hour
Normal saline is the best for fluid replacement - gives them proteins, hypercatabolic state
Contrast induced neprotoxicity should be avoided. No contrast MRI

Nutrition in AKI 

Dr. Timothy buchman

Protein energy waste= increased morbidity & mortality

Hypoglycemis:
Altered substrate utilization in acute illness:
Inefficient oxidation, impaired glycogenesis, lipogenesis
Insulin resistance

Protein metablism:
Muscle efflux of amino acid to fuel gluconeogenesis
Liver protein synthesis shifts from anabolic to acute phase proteins. 
Net negetive nitrogen protein balance

Lipid metabolism:
Increased triglyceride
Decreased cholestrol
Impaired lipolysis

Water soluble vitamins:

Vit B1 def. altered energy metabolism
Vit B6 def: altered amino acid and lipid metabolism
Folate deficiency: anemia
Vit c def: potential for losses during CRRT

CME Live: Hyperammonaemia and CRRT in acute liver failure

CME Live: Hyperammonaemia and CRRT in acute liver failure

Dr. Timothy Buchman

Curofy- India's largest community of verified doctors covered the CME-International Neonatal and Pediatric Nephrology Training Workshop live. This post was first published on the Curofy app. 

Indication of RRT in ALF
Hepatic encephalopathy grade 3-4
Renal dysfunction
Metabolic abnormalities
No one indication is an absolute one in for initiation of RRT

RRT in CLD
Supportive therapy for kids who deteriorate
Volume overload, intractable metabolic acidosis, and hyperkalemia
Delay in RRT decreases mortality by 90% 
Serves as a bridge to transplant

Modalities:

CRRT-CVVH, CVVHD CVVHDF- no evidence which was bettter 
TPE- therapeutic plasma exchange 
MARS
SPAD: single pass albumin dialysis

No evidence for RRT in liver patients

Should we undertake CRRT in ALF?

Yes and review 
For neuroprotection, metabolic disarray, bridge for recovery or transplant
CRRT- unstable
TPE- the way to go

Dose: No evidence in pediatrics, High is gaining popularity

Anticoagulation: PGI2 and low dose heparin

CME Live: Hemolytic Uremic Syndrome

CME Live: Hemolytic Uremic Syndrome

Dr Siddhartha Sethi

Curofy- India's largest community of verified doctors covered the CME-International Neonatal and Pediatric Nephrology Training Workshop live. This post was first published on the Curofy app. 

Etiology
Infection: Shiga and verocytotoxin
Steptococcus Pneumoniae disorders: 

a) genetic disorders of complement regulation
b) Acquired disorders of complement regulation

VonWillebrand proteinase:

a) Genetic disorder
b) Acquired
HIV
Malignancy
Lupus

Complement studies should be a part of every HUS evaluation
Diarrhea+ HUS in young, severe, recurrent, family history
Early: plasma infusions, plasma exchange
Recurrence post renal transplant
Immunosuppression 
Eculizumab

Renal transplant in HUS
High rate of recurrence
Factor H & I mutation
Patients ideally not living related to non-Stx-HUS

Eculizumab: most expensive drug trial

CME Live: Pediatric Palliative Care: Chronic kidney disease

CME Live: Pediatric Palliative Care: Chronic kidney disease

Dr Mona Gupta

Curofy- India's largest community of verified doctors covered the CME-International Neonatal and Pediatric Nephrology Training Workshop live. This post was first published on the Curofy app. 

In life threatening conditions Goals would be to:

Enhance quality of life

Minimize suffering

Optimize function

Interdisciplinary roles:

Pediatricians:

Initiate treatment

Decision making and future care

Care co-ordination

Nephrologist: 

- Replacing electrolytes

Psycologist:

-Family

Palliative care works towards 

Family bereavement

Support

Maximize quality of life

Minimize time

Benefits:

Attention to symptoms and quality of life

End of life preparation

Pain and symptom management

Early involvement beneficial to family, child, caregiver. 

CME LIVE: International Neonatal and Pediatric Nephrology Training Workshop

Curofy- India's largest community of verified doctors covered the CME-International Neonatal and Pediatric Nephrology Training Workshop live. This post was first published on the Curofy app. 

https://bnc.it/z53c/KW9zY4k0at

ACUTE KIDNEY INJURY

Most common cause: Post cardiac surgery
62% of neonates undergoing cardiac surgery develop AKI

1 in every 3 child in hospital contracts acute kidney injury

Children on ventilators: 36% of children on ventilators develop AKI
Inotrope score: increased postsurgery Inotrope, increased risks

AKI in non critically ill children:
Risk factors : longer treatment, AG treatment in previous months

How to prevent damage?

Decreased nephrotoxic drugs
Regulate hypotension

Fluid overload calculation 

Increased fluid overload means increased fatality
Fluid accumulation and fatality is independent of the critical condition of the patient, 

Survival rates fall down with increased fluid accumulation

Oxygenation is directly proportional to fluid overload

Renal Angina Index= risk of AKI*signs of injury

RAI predicts the survival and fluid overload. decreased RAI decreased risk of AKI

Invited to "Narayan Health" for "Symposium on Pediatric Liver Transplantation"

This weekend, I shall be at Narayan Health- Mazumdar Shah Medical Center, for taking a lecture on "Long term Kidney Issues in Pediatric Liver Transplantation".

It shall be interesting to have audience as Pediatric Liver transplant physicians and Pediatric Liver transplant surgeons, and trying to create awareness about renal issues in all kinds of Pediatric Transplantation.

It shall also be an honor to talk after well renowned Pediatric transplant physicians of the country!

What should be the dose of CRRT in patients with sepsis?

Continuous renal replacement therapy (CRRT) has been suggested to play a part in immunomodulation by cytokine removal. However, the effect of continuous venovenous hemodiafiltration (CVVHDF) dose on inflammatory cytokine removal and its influence on patient outcomes are not yet clear.

Randomised Controlled Trial published in American Journal of Kidney Diseases 2016

Intervention: Conventional (40 mL/kg/h) and high (80 mL/kg/h) doses of CVVHDF for the duration of CRRT
Results: High-dose CVVHDF, but not the conventional dose, significantly reduced interleukin 6 (IL-6), IL-8, IL-1b, and IL-10 levels.
Conclusions
High CVVHDF dose did not improve patient outcomes despite its significant influence on inflammatory cytokine removal. CRRT-induced immunomodulation may not be sufficient to influence clinical end points.
Personal view: These patients are so sick, that these studies usually fail to find a change in the hard clinical end points. 

Monitoring children for upper tract damage in Myelodysplasia

An interesting abstract from Turkey published in Journal of Urology 2009 on looking at the peak detrusor pressures and the risk of upper tract damage in these children. It challenges the McGuire study on leak point pressures published in 1981.
Detrusor leak point pressure evolved from the research of McGuire in the early 1980s (McGuire, Woodside, Borden, & Weiss, 1981). McGuire, Woodside, and Borden (1983) studied a population of myelodysplastic children and noted a correlation between the DLPP and the likelihood of upper-tract deterioration. Of the 42 patients studied, 22 had DLPP > 40 cm H2O. In that group, vesicoureteral reflux occurred in 68% and ureteral dilatation in 81%. In long-term followup, patients with the DLPP > 40 cm H2O developed upper-tract deterioration at a rate of 100% (McGuire et al., 1983).

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Lichen Planus and Nephrotic syndrom

Today one of my old nephrotic syndrome child presented with skin lesions bilaterally symmetrical violaceous polygonal pruritic papules present over both upper limbs, diagnostic of lichen planus.

Coincidence of lichen planus in nephrotic syndrome may reflect common immunological abnormalities, based on altered cell mediated immunity. It has already been reported from our friend Dr Sriram from JIPMER.  Lichen planus is a chronic inflammatory dermatological condition usually affecting adults, but rare in children. The diagnosis is essentially clinical.