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Biomedical subjects

D Geary

Publications and source records attributed to D Geary.

At least 19 recordsLinked to original sources
PubMed2001

Outcome analysis of vesicoamniotic shunting in a comprehensive population.

PURPOSE: Prenatal detection of obstructive uropathy is used widely and vesicoamniotic shunting is the accepted procedure in well-defined cases. We present outcomes of vesicoamniotic shunting in a consecutive series from a coordinated prenatal-postnatal treatment program. MATERIALS AND METHODS: From 1989 to 1998 bladder obstruction was identified in 89 fetuses at a multidisciplinary prenatal high risk clinic. Prenatal intervention was considered in cases of bilateral hydronephrosis associated with evidence of bladder outlet obstruction and oligohydramnios. RESULTS: Indications for prenatal shunting were present in 12 patients (13%), and 9 underwent vesicoamniotic shunt insertion between weeks 20 and 28 of gestation. None of the prenatal procedures was associated with preterm labor, chorioamnionitis or urine chemistry values greater than cutoff threshold on bladder tap. Shunts were extruded from 2 fetuses, which required sequential insertion. After prenatal intervention 1 patient elected pregnancy termination and the others proceeded to term. Two neonates died at birth, and 6 survived. The underlying urological diagnosis was posterior urethral valves in 4 newborns, urethral atresia in 1, and prune belly variant and urethral atresia in 1. Of the patients 3 had relatively normal renal function, 2 had severe renal insufficiency and 1 had mild renal impairment. Five newborns are voiding freely and 1 underwent bladder reconstruction and is on intermittent catheterization. None of the patients had pulmonary problems at last followup. CONCLUSIONS: Although vesicoamniotic shunting is effective in reversing oligohydramnios, its ability to achieve sustainable good renal function in infancy is variable. No specific prenatal parameters were effective in predicting eventual good renal function. Pulmonary function cannot be assured with restoration of amniotic fluid.

Amnion↗
PubMed2000

Multiple unilateral renal cysts in two children.

We report two children who presented with multiple renal cysts involving only one kidney and in whom there was no family history of renal disease and who did not have syndromes known to be associated with renal cystic disease. This unilateral involvement may represent a distinct entity, which has only been previously described in three cases; however, long-term follow-up will be needed to confirm this hypothesis. We illustrate the sonographic and computed tomographic findings, and the differential diagnosis is discussed.

Adolescent↗
PubMed2000

Polyuria and proteinuria in cystinosis have no impact on renal transplantation. A report of the North American Pediatric Renal Transplant Cooperative Study.

Because cystinotic patients are polyuric and may have severe proteinuria, each of which is a potential risk factor for graft thrombosis, preemptive transplantation for them is questionable. The objectives of this study were to characterize the changes in urine volume and protein excretion at various stages of cystinosis, determine whether there is serologic evidence of hypercoagulability, and review the clinical experience in renal transplantation in cystinotic children. The records of cystinotic patients followed at the Montreal Children's Hospital between 1992 and 1998 were reviewed. Urinary volume, protein excretion, and coagulation markers were collected to determine the glomerular filtration rate (GFR) >50 ml/min/1.73 m2, <20 ml/min/1.73 m2, before and after starting dialysis. In addition, graft failure and graft thrombosis rates were obtained from the North American Pediatric Renal Transplant Cooperative Study (NAPRTCS) database. Urinary volume and protein excretion remained elevated throughout different phases of the disease. Coagulation factors were within normal limits for all patients. In the NAPRTCS database there were four thromboses among the 114 patients transplanted cystinotic patients. All these occurred in cadaveric grafts and only one occurred after preemptive transplantation. Despite polyuria and severe proteinuria, children with cystinosis do not appear to be at an increased risk of graft failure or graft thrombosis.

Child↗
PubMed2000

The natural history of neonatal vesicoureteral reflux associated with antenatal hydronephrosis.

PURPOSE: In an attempt to evaluate the natural history of neonatal vesicoureteral reflux, patients with antenatal history of hydronephrosis and documented reflux in the first 30 days of life were analyzed. MATERIALS AND METHODS: Between 1993 and 1998, 260 patients with a history of antenatal hydronephrosis were referred for evaluation. Of these patients 31 were diagnosed with unilateral or bilateral refluxing renal units (54 renal units). Patients were treated with a prospective plan of observational therapy and prophylactic antibiotics, and resolution rate was calculated in patients with adequate followup. Reflux grade was correlated with postnatal ultrasonographic findings, urinary tract infections and differential renal function. Outcome analysis of 34 high grade (III to V) refluxing renal units using the Kaplan-Meier survival curves was undertaken with the end point being complete resolution or improvement. Three patients with vesicostomy and 2 who underwent ureteral reimplantation were excluded from analysis. RESULTS: Reflux was grade I in 5% (33% males), II in 15% (62% males), III in 32% (71% males), IV in 18% (90% males) and V in 30% (100% males) of the patients. Postnatal ultrasound findings correlated poorly with the presence and degree of vesicoureteral reflux. Of 17 patients followed for at least 14 months (average followup 20) there was complete resolution in 60% with grade III, 50% with grade IV and 28% with grade V reflux. Using the Kaplan-Meier estimate there was a 50% chance of improvement (decrease in reflux grade by at least 2 grades) in high grade reflux by age 16 months. Urinary tract infections developed in 8 patients (26%) while on antibiotics. Of 46 renal units in 23 patients evaluated with a renal scan before urinary tract infection, 12 had less than 35% function. CONCLUSIONS: A normal postnatal ultrasound should not be a basis for excluding the use of cystography. Our Kaplan-Meier estimate shows that high grade reflux does improve and may resolve spontaneously. In addition, renal scarring may be seen with high and low grade reflux in the absence of urinary tract infection but high grade reflux is associated with a higher incidence of infection.

Female↗
PubMed1998

Non-mydriatic fundus photography: a viable alternative to fundoscopy for identification of diabetic retinopathy in an Aboriginal population in rural Western Australia?

PURPOSE: To evaluate the Canon CR5-45NM non-mydriatic fundus camera (Canon, Kanagawa, Japan) for identifying retinopathy and the need for laser treatment in a population of Aboriginal patients with diabetes mellitus in rural Western Australia. METHODS: Diabetic Aboriginal patients were photographed through undilated pupils using a Canon CR5-45NM non-mydriatic fundus camera, after which ophthalmoscopy was performed using indirect ophthalmoscopy through dilated pupils. The examining ophthalmologist recorded the presence of retinopathy and the need for laser treatment. A proportion of patients were rephotographed through dilated pupils. Photographs were reviewed by a second ophthalmologist who evaluated the quality of the image, the presence of retinopathy and the need for laser treatment. Results of fundus photographs and ophthalmoscopy were compared. RESULTS: Three hundred and twenty-eight eyes in 164 Aboriginal patients were examined. The mean patient age was 48.2 years (range 16-81 years) and the mean duration of diabetes was 7.5 years (range 1-35 years). Seventy-four eyes (22.6%) were diagnosed with retinopathy using combined examination techniques, 44 (59.5%) of which were identified by ophthalmoscopy and 55 (74.3%) by photography. Thirty-five eyes were deemed to need treatment, 18 (51.4%) of which were identified by ophthalmoscopy and 30 (85.7%) by photography. Kappa coefficient measurement for agreement for presence of retinopathy and need for referral was 0.41 and 0.53, respectively. Photograph quality was significantly improved following pupil dilation. CONCLUSIONS: The Canon CR5-45NM non-mydriatic fundus camera was relatively good at identifying diabetic retinopathy and could usefully be applied within a screening programme for treatable disease within this population.

Adolescent↗
PubMed1996

Ultrasound findings in juvenile nephronophthisis.

The ultrasound finding of renal medullary cysts associated with increased echogenicity has been suggested to be diagnostic of juvenile nephronophthisis. The lack of cysts in several of our patients with juvenile nephronophthisis lead us to review the ultrasound findings at presentation in our patient population. Of 11 children with the diagnosis of juvenile nephronophthisis, 10 demonstrated increased echogenicity with loss of corticomedullary differentiation on initial ultrasound. Only 2 children had a single cyst each. On follow-up ultrasound, 2, 4.5, and 7 years later, 3 patients developed visible renal cysts. We conclude that at presentation the ultrasound finding consistent with the diagnosis of juvenile nephronophthisis is most often that of hyperechogenic kidneys without cysts; namely the lack of cysts does not rule out the diagnosis of juvenile nephronophthisis.

Adolescent↗
PubMed1996

Peritoneal membrane transport function in children receiving long-term dialysis.

Accurate characterization of peritoneal solute transport capacity in children has been hampered by a lack of standardized test mechanics and small patient numbers. A standardized peritoneal equilibration test was used to study 95 pediatric patients (mean age, 9.9 +/- 5.6 yr) receiving chronic peritoneal dialysis at 14 centers. Patients were divided into four age groups (< 1, 1 to 3, 4 to 11, 12 to 19 yr) for analysis. Each patient received a 4-h peritoneal equilibration test with an exchange volume of 1100 mL/m2 per body surface area. Dialysate to plasma (D/P) ratios for creatinine (C) and urea (U) and the ratio of dialysate glucose (G) to initial dialysate glucose concentration (D/D0) were determined. Mass transfer area coefficients (MTAC) were calculated for the three solutes and potassium (P). The mean (+/- SD) 4-h D/P ratios for C and U were 0.64 +/- 0.13 and 0.82 +/- 0.09, respectively. The mean 4-h D/D0 for G was 0.33 +/- 0.10. D/P and D/D0 ratio results were similar across age groups. Normalized (for body surface area) mean MTAC (+/- SD) values were as follows: C, 10.66 +/- 3.74; G, 12.93 +/- 5.02; U, 18.43 +/- 4.02; and P, 14.02 +/- 3.94. Whereas a comparison of the normalized MTAC values across age groups with an analysis of variance showed significant age group differences only for glucose (P = 0.001) and potassium (P = 0.036), analysis by quadratic regression demonstrated a nonlinear decrease with age for C (P = 0.016), G (P < 0.001), and P (P = 0.034). In summary, evaluation of D/P and D/D0 ratios obtained from a large group of children in a standardized manner reveals values that are similar across the pediatric age range and not unlike the results obtained in adults. In contrast, normalized MTAC values of young children are greater than the values of older children, possibly as a result of maturational changes in the peritoneal membrane or differences in the effective peritoneal membrane surface area.

Adolescent↗
PubMed1995

Renal replacement therapy after repair of congenital heart disease in children. A comparison of hemofiltration and peritoneal dialysis.

The development of renal failure necessitating peritoneal dialysis after cardiac operations is associated with a reported mortality greater than 50%. Improved fluid removal and nutritional support have been reported with the use of continuous arteriovenous hemofiltration and continuous venovenous hemofiltration techniques. We have compared our experience with all three techniques in managing children who required renal replacement therapy after cardiac operations in terms of efficacy (fluid removal, calorie intake, and clearance of urea and creatinine), complications, and outcome. Over a 5-year period renal replacement therapy was initiated in 42 children, and in 34 of them it was successfully established for more than a 24-hour period: 17 were managed with peritoneal dialysis, 8 with continuous arteriovenous hemofiltration, and 9 with continuous venovenous hemofiltration. A net negative fluid balance was achieved in only 6 (35%) patients treated with peritoneal dialysis compared with 50% of those treated with continuous venovenous hemofiltration and 89% of those treated with continuous venovenous hemofiltration. In terms of nutritional support, calorie intake increased by 43% after peritoneal dialysis was started compared with 515% and 409% in the arteriovenous and venovenous hemofiltration groups, respectively, (p < 0.005). The serum urea levels fell by 36% (p = 0.02) and 39% (p = 0.005) compared with pre-therapy levels with arteriovenous and venovenous hemofiltration, respectively, and the creatinine content was reduced by 19% and 33% (p = 0.003). Neither parameter was reduced in the peritoneal dialysis group. We conclude that the use of hemofiltration as a renal replacement therapy after surgical correction of congenital heart disease offers significant advantages over the more traditional approach of peritoneal dialysis. In addition, we suggest that a more aggressive approach to the management of fluid overload and nutritional depletion with hemofiltration may result in a decrease in the very high mortality seen in renal failure after cardiac operations.

Acute Kidney Injury↗
PubMed1995

The relationship between intraperitoneal volume and solute transport in pediatric patients. Pediatric Peritoneal Dialysis Study Consortium.

A multicenter study was conducted to determine the relationship between intraperitoneal volume and solute (e.g., urea, creatinine) transport as determined by the dialysate to plasma (D/P) ratio and mass transfer area coefficient (MTAC). Two 4-h peritoneal equilibration tests were conducted on each of 12 pediatric peritoneal dialysis patients (mean age, 10.8 yr; range, 0.2 to 19.2 yr). One test exchange volume was 900 mL/m2 body surface area (BSA), and the other was 1,100 mL/m2 BSA. Dialysate samples were collected at 0, 30, 60, 120, 180, and 240 min. Blood samples were drawn at 0 and 240 min. Solute equilibration was significantly more rapid with the 900 mL/m2 BSA exchange volume than with the 1,100 mL/m2 exchange volume when evaluated by the D/P ratio. In contrast, no differences in solute transport were noted with either exchange volume when assessed with the MTAC. In conclusion, solute D/P ratios vary with changes in the intraperitoneal volume, necessitating the use of a standardized exchange volume for the reliable interpretation of evaluations such as the peritoneal equilibration tests. In contrast, the use of the MTAC allows for an accurate assessment of solute transport over a wide range of exchange volumes.

Adolescent↗
PubMed1992

Iphosphamide-induced nephrotoxicity in children.

The nephrotoxic potential of iphosphamide was evaluated in a retrospective analysis of all children receiving the drug at The Hospital for Sick Children in Toronto. The 25 children exhibiting nephrotoxicity did not receive more cycles or higher doses per square metre than the 78 with normal renal function. Similarly, the two groups received comparable doses and number of cycles of sodium 2-mercaptoethanesulphonate, and had similar rates of exposure to nephrotoxic drugs (except for cis-platinum). Children exhibiting nephrotoxicity were significantly younger (78.1 +/- 64.1 months) than those having normal kidney function (103.8 +/- 66.6 months) (P less than 0.05). Children exhibiting nephrotoxicity were more likely to have received cis-platinum prior to the iphosphamide (10/25, 40%) than those with normal renal function (14/73, 18%) (P less than 0.05). Nephrotoxicity was associated with a significant effect on growth. Careful follow-up of renal function should take place in children receiving iphosphamide, with special attention paid to children younger than 5 years of age and those who have received cis-platinum.

Antineoplastic Combined Chemotherapy Protocols↗
PubMed1992

Continuous arteriovenous hemofiltration after cardiac operations in infants and children.

Acute renal insufficiency after cardiopulmonary bypass can lead to a significant morbidity from fluid overload and electrolyte disturbance, impede pulmonary gas exchange, and postpone weaning from mechanical ventilation. The limitations placed on free water intake result in severe restriction of nutrition while diuretic therapy causes electrolyte imbalance. Artificial renal support either in the form of peritoneal dialysis or hemodialysis may be complicated by sepsis and hemodynamic instability. We reviewed our experience with the use of continuous arteriovenous hemofiltration, an extracorporeal technique for removal of solutes, toxins, and water in critically ill patients with cardiac failure complicated by acute renal insufficiency and hemodynamic instability after cardiopulmonary bypass. Ten infants and children with renal insufficiency caused by low cardiac output had continuous arteriovenous hemofiltration instituted for indications including sepsis, volume overload, oliguria for more than 24 hours nonresponsive to diuretic therapy, and the need for hyperalimentation. All were supported by mechanical ventilation and receiving high-dose inotropic support. Arterial and venous vascular access was successfully obtained by cannulation of the femoral artery and vein in nine patients. Anticoagulation of the circuit was achieved with heparin infusion (6 to 20 micrograms/kg/hr) and monitored by measurement of activated clotting time. The continuous arteriovenous hemofiltration circuit was replaced if there was clot formation, or at 3 days after placement. Dialysis solution (Dianeal) 1.5% or 0.5% was infused as prefilter dilution. With the use of continuous arteriovenous hemofiltration, 20 to 100 m/hr of ultrafiltrate was removed, which allowed correction of hypervolemia, and caloric intake increased from 13.5 kcal/kg/day to 79.5 kcal/kg/day. Continuous arteriovenous hemofiltration was maintained between 5 hours and 8 days and was well tolerated in all patients. Serum urea and creatinine levels declined during continuous arteriovenous hemofiltration. We conclude that continuous arteriovenous hemofiltration is a safe and effective method for fluid and electrolyte homeostasis and that it thus allows hyperalimentation in infants and children after cardiac operations.

Acute Kidney Injury↗
PubMed1990

Exit-site infection during continuous and cycling peritoneal dialysis in children.

A 10-year retrospective review of pediatric patients on peritoneal dialysis showed that 50 of 83 had 132 episodes of exit-site infection (ESI). Thirty-nine episodes were purulent. The most prevalent organism was Staphylococcus aureus. Staphylococcus epidermidis was also common, usually occurring in purulent infections. Gram-negative organisms were responsible for 23 ESIs, with Pseudomonas species being the most common. Age, sex, concomitant primary disease type, length of training, dressing techniques, quality of daily dialysis technique, use of diapers, and pyelostomies did not affect the incidence of ESI. However, 40% of children with a skin infection from other sites had associated peritoneal catheter ESI. Thirty-eight episodes of ESI in 28 patients resulted in peritonitis; the main organisms involved were Staphylococcus and Pseudomonas species. Catheters were replaced in 13 patients with peritonitis, but there was no difference in the incidence of ESI before and after catheter replacement.

Catheters, Indwelling↗
PubMed1990

Factors predisposing and contributing to peritonitis during chronic peritoneal dialysis in children: a ten-year experience.

Factors contributing and predisposing to peritonitis were studied retrospectively in 83 children treated with continuous ambulatory (CAPD) or continuous cycling peritoneal dialysis (CCPD) from 1978 to 1988. Recurrent peritonitis was the most frequent complication and the major reason for peritoneal dialysis failure. Fifty patients had 171 episodes of peritonitis during the ten years and 33 remained peritonitis-free. The duration of dialysis was significantly shorter in the peritonitis-free group. The incidence of peritonitis was lower with CCPD than with CAPD. Leucopenia was not a predisposing factor nor was blood leucocytosis helpful in diagnosing peritonitis. Serum IgG was low in 33% of patients with episodes of peritonitis, but there was no correlation or predictive value in this finding. The C3 component of complement was relatively lower than the C4 but both components was relatively lower than the C4 but both components were usually in the normal range. Serum albumin was low in all patients, but lower in those with peritonitis episodes. Age, sex, primary disease, diapers, pyelostomies, dialysis training, and living conditions were not significantly associated risk factors. Sterile dressings gave no benefit over the shower technique. Patient noncompliance, upper respiratory tract infection, skin infections, and dental treatment were potential risk factors. However, peritonitis seemed to be distributed randomly among the patients.

Adolescent↗
PubMed1986

Personalized versus usual care of previously uncontrolled hypertensive patients: an exploratory analysis.

This study was conducted to explore whether the quality of provider care may contribute to blood pressure reduction and whether other factors related to the treatment of hypertension may explain decline in blood pressure. In the study, 46 uncontrolled (greater than or equal to 140/90 mm Hg), medically treated hypertensive patients who received more personalized care differed significantly in the magnitude of blood pressure reduction from 36 usual-care patients (10/7 vs 2/2 mm Hg means for systolic and diastolic blood pressure reduction, respectively). About twice as many experimental patients as controls were reclassified as having "controlled" blood pressure, and this difference reached statistical significance. A multiple regression analysis for personalized-care subjects showed that no dynamic variables were related to blood pressure changes. It was postulated that more personalized care may have accounted for the significant difference between groups in blood pressure reduction. Similar personalized monitoring services might be important additions to usual medical care in order to control blood pressure more fully in high-risk hypertensive patients.

Biofeedback, Psychology↗
PubMed1985

Minimal lesion disease followed by membranous glomerulonephropathy in two children with nephrotic syndrome.

Two children with nephrotic syndrome are described whose clinical course, initial response to steroids, and renal biopsies were consistent with a diagnosis of minimal lesion disease (MLD). Both children subsequently became resistant to steroids and repeat renal biopsies 7 and 8 years after initial biopsies showed membranous glomerulonephropathy (MGN). Explanations are suggested which may account for the occurrence of MLD followed by MGN in a single patient. These cases illustrate the necessity of performing repeat renal biopsies in patients with nephrotic syndrome if the clinical behavior and response to steroids are not typical for MLD.

Basement Membrane↗
PubMed1983

Nephrotic syndrome and diffuse mesangial proliferative glomerulonephritis in children.

The clinical course, response to therapy, and outcome were analyzed in 25 children with nephrotic syndrome associated with moderate to severe mesangial cell proliferation. The conditions of more than two thirds of the patients (16/23) failed to respond to prednisone therapy, and renal insufficiency or failure developed in 13. Our data suggest an association between response to therapy and degree of mesangial cell proliferation. Persistent nephrotic syndrome was associated with slow deterioration of renal function.

Adolescent↗
PubMed1980

Evaluation of an educational program on compliance with medication regimens in pediatric patients with renal transplants.

An educational program was initiated in an attempt to improve compliance in taking medications among pediatric renal transplant patients. Compliance was assessed by pill counts and by knowledge about medications by interview and questionnaire before, during, and after a six-month study period. Forty-three percent of the population was initially found to be in some way noncompliant with medication regimens, and 19% remained so after extensive counseling and instruction. Factors associated with noncompliance were adolescence, female sex, and family instability. Compliance was associated with direct parental involvement and voluntary maintenance of medication calendars. Although knowledge about drugs significantly improved, there was no correlation with compliance; motivational factors appeared to be of greater importance.

Adolescent↗