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Biomedical subjects

A M Neu

Publications and source records attributed to A M Neu.

36 records · Page 2Linked to original sources
PubMed1997

Does greater pediatric experience influence treatment choices in chronic disease management? Dialysis modality choice for children with end-stage renal disease.

OBJECTIVE: To determine whether treatment choice for children with end-stage renal disease varies with greater pediatric experience at the dialysis facility. DESIGN: National cross-sectional study. SETTING: Outpatient dialysis facilities throughout the United States. PATIENTS: All children (age, < or = 19 years) undergoing dialysis in 1990, identified using the Medicare End-stage Renal Disease registry (1990 facility survey and quarterly dialysis records). OUTCOME MEASURES: The odds of receiving peritoneal dialysis vs hemodialysis according to the pediatric experience of the facility. "Pediatric experience" for dialysis facilities was defined as the number of patients 19 years old or younger divided by the total number of patients treated at that facility. Adjustment, using multiple logistic regression, was made for differences in age, sex, cause and duration of end-stage renal disease, income, education, and facility characteristics. RESULTS: In 1990, there were 1256 patients 19 years old or younger who underwent a single-treatment modality at a single facility for most of the year. Sixty-three percent (790/ 1256) were treated at facilities with fewer than 5% of patients younger than 19 years. Thirty-six percent were treated at centers with less than 1% of pediatric patients. In a multivariate analysis, pediatric experience in a facility was independently associated with the use of peritoneal dialysis in children. Children treated at facilities with more than 10% pediatric patients were 60% more likely to be treated with peritoneal dialysis rather than hemodialysis compared with children treated at facilities with fewer than 1% of pediatric patients, even after controlling for patient age, race, income, education, cause and duration of end-stage renal disease, and facility characteristics such as hospital-based vs independent unit and for-profit vs not-for-profit status (odds ratio, 1.6; 95% confidence interval, 1.1-2.3). CONCLUSIONS: Children receiving care at dialysis facilities that have greater experience with pediatric patients are more likely to receive peritoneal dialysis than hemodialysis, a therapy with recognized clinical benefits for children that is inherently less resource intensive than is hemodialysis.

Adolescent↗
PubMed1997

Immunization practices in children with renal disease: a report of the North American Pediatric Renal Transplant Cooperative Study.

To determine the current immunization recommendations of practicing pediatric nephrologists, a questionnaire was sent to the members of the North American Pediatric Renal Transplant Cooperative Society. Sixty-two percent of the centers responded. The results of the survey suggest that although consensus for approaching immunization does exist, recommendations do vary from center to center. Virtually all centers recommend standard vaccines [DTP, oral poliovirus (OPV), hepatitis B (Hep B), and Haemophilus influenzae B (Hib)] for their renal insufficiency and dialysis patients. Despite the fact that they are not infectious, standard killed vaccines (DTP, Hep B, Hib) are recommended less frequently for transplanted patients (86%) than their renal insufficiency (98%) and dialysis (near 100%) counterparts. Additionally, OPV and measles/mumps/rubella (MMR), both live viral vaccines, are rarely recommended post transplant. Almost 90% of centers recommend the use of influenza vaccine, while only 60% of centers recommend pneumococcal vaccine for children with renal disease. Over 70% of centers recommend the newly licensed varicella vaccine for patients on dialysis and those with renal insufficiency. Between 5% and 12% of centers recommend live viral vaccines, including OPV, MMR, and varicella vaccine, for immunosuppressed patients post renal transplant.

Child↗
PubMed1997

Racial differences in choice of dialysis modality for children with end-stage renal disease.

OBJECTIVE: Black-white disparities in the use of specific medical and surgical services have been reported in adult populations. Such disparities are not well documented in children. We sought to determine whether racial disparities in the use of medical services exist among children with chronic illness who have similar health insurance, specifically the choice of dialysis modality for individuals with end-stage renal disease. DESIGN: National cross-sectional study. SETTING: Outpatient dialysis facilities throughout the United States. PATIENTS AND PARTICIPANTS: All Medicare-eligible children (age, </=19 years) undergoing renal replacement therapy in 1990 in the United States, using data from the Medicare ESRD registry. OUTCOME MEASURES: The odds of receiving hemodialysis versus peritoneal dialysis according to race. Adjustment was made for differences in age, gender, cause, and duration of end-stage renal disease, income, education, and facility characteristics using multiple logistic regression. RESULTS: In 1990, 870 white and 368 black children received chronic (>1 year) renal replacement therapy in the United States. In bivariate analysis, blacks were two times (odds ratio [OR], 2.2; 95% confidence interval [CI], 1.7, 2.8) more likely than whites to receive hemodialysis versus peritoneal dialysis. After controlling for other patient and facility characteristics in multivariate analysis, black children were still significantly more likely than white children to receive hemodialysis (OR, 2.4; 95% CI, 1.7, 3.5). CONCLUSIONS: Black race is strongly associated with the use of hemodialysis in children. Family, patient, or provider preferences could account for the difference in choice of therapy by race.

Adolescent↗
PubMed1997

Varicella in the first year after renal transplantation: a report of the North American Pediatric Renal Transplant Cooperative Study (NAPRTCS).

Prior reports document that children with renal transplants are at risk of severe varicella, with a 5-25% mortality rate. We have examined the current incidence and mortality of varicella requiring hospitalization in pediatric patients in the first year after kidney transplantation through a multi-center retrospective cohort study. Data from the North American Pediatric Renal Transplant Cooperative Study (NAPRTCS) for 2320 pediatric patients who received renal transplants between 1987 and 1993 and were followed until 1995 were examined. Varicella requiring hospitalization in the first post-transplant year occurred in 44 children. Characteristics of the patients who developed varicella were compared to the rest of the NAPRTCS cohort using chi-square analysis. Kaplan-Meier estimates of graft survival were used to compare graft survival in varicella patients and other NAPRTCS patients. Varicella patients tended to be younger (p=0.09) and more often male (p=0.07, chi-square) than other NAPRTCS patients. None of the 44 patients with varicella in their first post-transplant year died from this infection. The number of episodes of acute rejection per transplant and the time to first rejection was not different in patients with varicella compared to the other NAPRTCS patients. Five-year graft survival was not different for varicella cases when compared to other NAPRTCS patients with grafts surviving at least 6 months post-transplant. We conclude that the mortality rate of patients hospitalized with varicella in the first post-transplant year and the risk of subsequent graft dysfunction may be significantly lower than previously described. However, varicella remains a significant cause of potentially avoidable hospitalization in the first post-transplant year. Further study of the safety and efficacy of varicella vaccination in children with renal insufficiency and those post-transplant is warranted.

Adolescent↗
PubMed1997

Evaluation of neurotoxicity in pediatric renal transplant recipients treated with tacrolimus (FK506).

The presence of severe and mild neurotoxicity in our pediatric renal transplant recipients treated with tacrolimus was determined by chart review (severe neurotoxicity) and patient survey (mild neurotoxicity). 14 patients were studied (mean age 15 yr, 5 month, +/- 4.4 yr). 1 patient experienced seizures, felt to be related to malignant hypertension. No other episode of severe neurotoxicity was documented. Most patients (12/14) reported at least one mild neurologic symptom, and half stated their symptoms were present at least 'most of the time'. The most frequent complaints were myalgias (7/14, 50%) and tremors (7/14, 50%) followed by fatigue (5/14, 38%). Severe neurotoxicity may be relatively infrequent in pediatric renal transplant patients treated with tacrolimus. Milder neurologic complaints may be commonly seen in this population, but in general are not severe enough to cause discontinuation of tacrolimus.

Adolescent↗
PubMed1997

Antibody levels to diphtheria, tetanus, and rubella in infants vaccinated while on PD: a Study of the Pediatric Peritoneal Dialysis Study Consortium.

To determine whether infants who receive routine childhood immunizations while on chronic peritoneal dialysis (CPD) develop protective antibody levels/titers, we measured antibody levels/titers in infants vaccinated with diphtheria/tetanus/pertussis (DTP) and measles/mumps/rubella (MMR) while on CPD. Eight CPD patients (median age 19 months, range 9-39 months) had measurement of antibody to diphtheria and tetanus toxoids. Seven of the 8 (88%) had protective levels of IgG antibody to both toxoids. The single patient who did not have protective antibody to either diphtheria or tetanus had a low total serum IgG. However, 3 other patients who had low IgG had protective antibody levels. Serial measurements of antibody to tetanus and diphtheria were obtained in 3 of the 8 patients. All maintained protective levels to both diphtheria and tetanus toxoids for as long as 24 months postvaccination. Antibody to rubella was also measured in 5 CPD patients (median 29 months, range 19-39 months), and all had protective antibody titers despite the fact that 3 had low total serum levels. In conclusion, most but not all infants immunized while on CPD have protective antibody levels/titers to diphtherial, tetanus, rubella. Alteration of the routine schedule for immunizations does not appear to be necessary. However, periodic measurements of antibody may be indicated, particularly to live vial vaccines, prior to transplantation.

Antibodies, Bacterial↗
PubMed1996

Haemophilus influenzae type b immunization in infants on peritoneal dialysis. Pediatric Peritoneal Dialysis Study Consortium.

As part of a multi-center collaborative study, we measured antibody levels to Haemophilus influenzae type b (Hib) in ten chronic peritoneal dialysis (CPD) patients, aged 39 months or less, who were immunized while on CPD. Nine of the ten developed protective antibody levels to Hib. Four patients had serial measurements of antibody and all maintained protective levels, although the levels did decrease in two patients. Thus most, but not all, infants immunized with Hib vaccine while on CPD develop protective antibody levels. The factors responsible for vaccine failure are not clear. Whether patients maintain protective antibody over time needs to be determined.

Antibodies, Bacterial↗
PubMed1996

Pneumococcal polysaccharide vaccine in children with chronic renal disease: a prospective study of antibody response and duration.

We studied the antibody response to pneumococcal serotypes 3 and 14 after pneumococcal polysaccharide vaccine was administered to 41 children with renal disease. One month after vaccination, 76% and 61% of patients achieved at least a twofold titer rise to serotypes 3 and 14, respectively; this finding was comparable to historic control values. One year after vaccination, the majority of patients retained protective antibody levels. Achieving a titer > or = 1.0 microgram/ml IgG at 1 month was highly predictive of retaining a protective antibody level > or = 0.15 microgram/ml at 1 year.

Adolescent↗
PubMed1996

Dialysis and renal transplantation in infants with irreversible renal failure.

Historically, infants with irreversible renal failure fared poorly, and aggressive medical intervention was considered futile. Although the care of this population clearly remains a challenge, technical advances and clinical experience have now made dialysis and transplantation reasonable and successful therapeutic options. This report provides a discussion of practical guidelines and patient care issues particular to the infant with end-stage renal disease. Topics addressed include nutritional requirements, neurodevelopmental abnormalities, and the possible contribution of alterations of the immune system to patient morbidity. Specific technical considerations for the performance of peritoneal dialysis, hemodialysis, and transplantation in the very small infant are also presented.

Humans↗
PubMed1995

IgG subclass levels in pediatric patients on chronic peritoneal dialysis.

Patients maintained on chronic peritoneal dialysis (CPD) have been reported to have a variety of abnormalities of humoral immunity, including hypogammaglobulinemia, altered response to vaccination, and selective absence of IgG2. We measured serum immunoglobulin and IgG subclass levels in 22 pediatric CPD patients followed at our institution; 8 patients had low total IgG; 4 of these had low levels of IgG2 and 3 also had low IgG1, but IgG2 levels were detected in all patients. Thus, many pediatric CPD patients may have low IgG, and some may have low IgG1 and IgG2 as a reflection of low total IgG. However, we did not demonstrate a selective absence of IgG2 in these patients.

Adolescent↗
PubMed1995

Immune response to influenza vaccination in children with renal disease.

Although immunization with influenza vaccine is recommended for children with chronic renal disease and after organ transplantation, the antibody response in these children has not been well described. We studied the response to the 1993-1994 trivalent influenza vaccine in children, aged 1-21 years, with chronic renal failure (n = 15), end-stage renal disease requiring dialysis (n = 10), and post renal transplantation (n = 17). Each group's antibody response was compared with that of a control group (n = 7). No significant differences were found in seroconversion rates, percentage of patients achieving protective hemagglutination-inhibition titers post vaccination or change in geometric mean titers from pre to post vaccination between study groups and controls. These results suggest that pediatric patients with renal disease will respond and therefore will benefit from currently recommended influenza immunization.

Adolescent↗
PubMed1995

Cytokine production by peripheral blood mononuclear cells from pediatric chronic peritoneal dialysis patients.

Previous reports have documented impaired cytokine production by peritoneal macrophages in chronic peritoneal dialysis (CPD) patients. To determine if this observed defect was a reflection of systemic mononuclear cell dysfunction, the function of peripheral blood mononuclear cells obtained from pediatric patients on CPD was assessed after stimulation with lipopolysaccharide (LPS). Levels of interleukin-1 beta (IL-1 beta) and tumor necrosis factor-alpha (TNF-alpha) mRNA and protein were measured before and after stimulation with LPS. There was no significant difference in the response of mononuclear cells from CPD patients and normal controls in terms of increase in TNF-alpha mRNA [median stimulation index (SI) = 6.6 vs. 3.7, P = 0.35] or IL-1 beta mRNA (median SI = 6.2 vs. 6.5, P = 1.0). There was also no significant difference between the median increase in TNF-alpha protein secretion (median 372 pg/ml vs. 373 pg/ml, P = 0.60). These results suggest that systemic mononuclear cell function may be intact in CPD patients, and therefore this does not account for the dysfunction of peritoneal macrophages that has been previously reported.

Adolescent↗
PubMed1995

Immunizations in children on PD: current guidelines and recommendations.

Antibody responses to currently recommended immunizations in pediatric patients on chronic peritoneal dialysis (CPD) have been measured and the results have been variable. Although the incidence of vaccine-preventable disease in pediatric CPD patients is not known, it appears that protection from these diseases may be reduced. The explanation for the abnormal response to vaccines might include lower seroconversion rates in these patients, with lower antibody titers or levels. Also a rapid decline of antibody levels or titers may occur as a consequence of continuous peritoneal dialysis. Specific vaccines that may result in a less than optimal response in pediatric CPD patients include hepatitis B virus, hemophilus influenza type b, measles, mumps, rubella and pneumococcal vaccine. Patients who receive these immunizations should be monitored closely. Increased vaccine dosage, reinforced vaccination schedules, as well as concomitantly administered adjuvant immuno-modulators may play an important role in more effective vaccination of pediatric CPD patients. It is important that vaccine response be monitored in these patients by measuring specific antibody titers or levels to ensure adequate protection from vaccine-preventable illness.

Adolescent↗
PubMed1995

Current approach to peritoneal access in North American children: a report of the Pediatric Peritoneal Dialysis Study Consortium.

To determine standard peritoneal access practices in North American children, a questionnaire was distributed to the 18 participating centers of the Pediatric Peritoneal Dialysis Study Consortium. The survey covered areas including catheter placement, postoperative catheter break-in, chronic catheter care, and treatment of exit-site and tunnel infection.

Bacterial Infections↗
PubMed1994

Neisseria sicca peritonitis in a patient maintained on chronic peritoneal dialysis.

Neisseria sicca, previously classified as a "nonpathogenic" organism, has now been recognized as a cause of many infections, including endocarditis and meningitis. However, it has not been reported as a cause of peritonitis. We present a case of documented N. sicca peritonitis immediately following an episode of Staphylococcus aureus peritonitis in a pediatric chronic peritoneal dialysis (CPD) patient. N. sicca should be considered as a possible pathogen in CPD-associated peritonitis.

Anti-Bacterial Agents↗
PubMed1993

Hypogammaglobulinemia and fatal sepsis in an infant maintained on peritoneal dialysis.

Chronic peritoneal dialysis (CPD) is a common form of renal replacement therapy in children. Recent studies suggest that immunological abnormalities, in particular hypogammaglobulinemia, may develop in children and infants on peritoneal dialysis. We report an infant maintained on CPD who died of gram-negative sepsis. At post-mortem examination, he was noted to have severe panhypogammaglobulinemia.

Agammaglobulinemia↗