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Stuart L Goldstein

Publications and source records attributed to Stuart L Goldstein.

14 recordsLinked to original sources
PubMed2004

Blood volume monitoring to achieve target weight in pediatric hemodialysis patients.

Achieving dry weight during hemodialysis (HD) while minimizing symptoms is critical for optimizing patient outcome by preventing chronic fluid overload, hypertension, and cardiomyopathy. Dry weight changes frequently in children because of growth and development and waxing and waning of appetite. We have previously shown non-invasive hematocrit monitoring (NIVM) helps to decrease intradialytic symptoms, while still achieving target dry weights in children receiving chronic HD. In the current study, we prospectively evaluated an NIVM-guided ultrafiltration (UF) management algorithm to determine target dry weight in nine pediatric patients (mean age 16.6+/-2.8 years, mean weight 41.6+/-11.1 kg). Use of NIVM could potentially lead to overly aggressive UF with increased interdialytic symptoms, post treatment thirst, and interdialytic weight gain (IDWG). To evaluate the effectiveness of our NIVM UF algorithm, we studied the effect of three different NIVM-guided UF models (100%, 90%, and 80% UF models) on intradialytic and interdialytic symptoms, pre-/post-treatment blood pressure (BP), and percentage IDWG. To assess interdialytic symptoms, patients completed two questionnaires, one for each day between treatments. No statistically significant difference was seen between the three UF models with respect to intradialytic or interdialytic symptoms, pre-/post-HD BP, or percentage IDWG. Only one of nine patients received non-ACEI chronic antihypertensive medication, yet all patients had pre- and post-HD BP <95th percentile for age and height. The current study suggests that routine determination of target dry weight using NIVM and aiming for 100% UF helps to achieve the target dry weight, reduces both the risk of chronic fluid overload and the need for antihypertensive medication, and does not lead to increased intra- or interdialytic symptomatology in pediatric patients treated with chronic HD.

Adolescent↗
PubMed2004

Management of a severe carbamazepine overdose using albumin-enhanced continuous venovenous hemodialysis.

Carbamazepine intoxication is common in the pediatric population. Highly protein-bound, carbamazepine is not removed efficiently through conventional hemodialysis. We describe the use of albumin-enhanced continuous venovenous hemodialysis (CVVHD) in a 10-year-old girl who developed coma and respiratory depression due to an intentional carbamazepine overdose (peak drug level of 44.8 microg/ml; therapeutic range: 8-12 microg/ml). Without intervention, the half-life of drug elimination is 25 to 60 hours in patients who are naive to carbamazepine and 12 to 20 hours in children on chronic carbamazepine therapy. In contrast, with albumin-enhanced CVVHD, we observed a half-life of 7 to 8 hours. The patient recovered rapidly and was discharged from hospital <4 days from the time of ingestion with no complications or neurologic impairment. Because the cost-benefit analysis was also favorable relative to other therapeutic options, albumin-enhanced CVVHD may be the optimal treatment of toxic-level ingestion of carbamazepine.

Anticonvulsants↗
PubMed2003

Fluid overload and acute renal failure in pediatric stem cell transplant patients.

Acute renal failure (ARF) with fluid overload (FO) occurs often in stem cell transplant (SCT) recipients. We have previously demonstrated that an increased percentage of FO prior to the initiation of continuous renal replacement therapy (CRRT) is associated with mortality in children with ARF. Based on these data, we devised a protocol for the prevention of FO in SCT patients with ARF. SCT patients with ARF and 5% FO were started on furosemide and low-dose dopamine. To allow for nutrition, medication, and blood product administration, RRT was initiated for patients with > or =10% FO. There were 272 patients who received allogeneic SCT from 1999 to 2002. Of these, medical records of 26 SCT patients with a first episode of oliguric ARF were reviewed. The mean patient age was 13+/-5 years (range 2-23.5 years). Mean days to ARF after SCT were 28+/-29 days (range 2-90 days). Of the 26 patients, 11 (42%) survived an initial ARF episode. All 11 survivors either maintained <10% FO during their course or re-attained <10% FO with RRT treatment. Of the 15 non-survivors, 6 had <10% FO at the time of death. Of 14 patients who received RRT, 4 (29%) survived. Mechanical ventilation and pediatric risk of mortality score > or =10 at the time of admission to the intensive care unit were associated with lower survival ( P<0.05). The use of one or more pressors, the presence of graft-versus-host disease, and septic shock were not correlated with survival. Our data demonstrate that maintenance of euvolemia ( <10% FO) is critical but not sufficient for survival in SCT patients with ARF, as all non-euvolemic patients died. We suggest that aggressive use of diuretics and early initiation of RRT to prevent worsening of FO may improve the survival of SCT patients.

Acute Kidney Injury↗
PubMed2003

Adequacy of dialysis in children: does small solute clearance really matter?

Measurement of dialysis adequacy relies on an assessment of small molecule clearance during the dialysis procedure. However, recent adult studies (HEMO and ADEMEX) that pushed clearance to maximally achievable levels within practical constraints of thrice-weekly hemodialysis or four times daily continuous ambulatory peritoneal dialysis failed to demonstrate improvements in patient outcome above current guidelines. The relatively low incidence of pediatric compared with adult end-stage renal disease limits large-scale study of pediatric dialysis. Several single-center pediatric studies demonstrate a lack of association between small solute clearance alone and patient growth. The aim of the current article is to review the relevant pediatric and adult studies of small solute clearance and put them in the context of optimal dialysis provision. While small solute clearances do indeed matter, clearance is not all that matters. Our quest to provide optimal dialysis requires that we also focus our attention on patient nutritional status, increased dialysis delivery (daily/nocturnal hemodialysis), and adjunctive dialysis modalities (hemofiltration and renal tubular replacement therapy).

Child↗
PubMed2003

Cardiovascular calcifications in pediatric patients receiving maintenance dialysis.

Cardiovascular disease is a major cause of morbidity and mortality in adult patients with end-stage renal disease receiving maintenance dialysis. Coronary artery calcifications (CAC) contribute to the high prevalence of cardiac disease and are associated with hyperphosphatemia, an elevated calcium-phosphorus product (CaxP), and prolonged time on dialysis. Chronic inflammation and malnutrition are also associated with an increased risk for development of cardiac calcifications. Young adults receiving maintenance dialysis develop cardiac calcifications at a degree out of proportion to healthy adults of the same age and gender. Many of these young adults initiated dialysis as children or teenagers. Risk factors associated with the development of CAC are also seen in the pediatric dialysis population. To date, reports of cardiac calcifications in pediatric patients receiving maintenance dialysis are limited to post-mortem studies. We present two pediatric patients with ANCA-positive vasculitis diagnosed with cardiac calcifications while receiving maintenance dialysis. Hyperphosphatemia and an elevated CaxP product were seen in both patients and probably contributed to the development of extraskeletal calcifications. In addition, both patients had an underlying systemic inflammatory disease and significant weight loss/malnutrition that may have contributed to the early and rapid onset of cardiac calcifications.

Adolescent↗
PubMed2003

Adenovirus pyelonephritis in a pediatric renal transplant patient.

Gross hematuria, graft pain, and rising serum creatinine are classic signs of acute rejection, obstruction, or bacterial pyelonephritis for patients with renal transplants. This presentation often prompts percutaneous renal allograft biopsy. If subsequent evaluation fails to show evidence of acute rejection, obstruction, or bacterial infection, viral etiologies should be considered. We report a 14-year-old Hispanic female with a living-related renal transplant who had gross hematuria, graft tenderness, and increased serum creatinine, but did not have evidence of acute rejection, obstruction, or bacterial pyelonephritis. To our knowledge, this is the first report of adenovirus pyelonephritis in a transplanted kidney of a pediatric patient, with isolation of adenovirus in the urine and in the allograft using immunocytochemical techniques.

Adenovirus Infections, Human↗
PubMed2003

Continuous renal replacement therapy in children up to 10 kg.

BACKGROUND: There is growing use of continuous renal replacement therapy (CRRT) for pediatric patients, but no large studies reporting CRRT use and outcome in young children. We describe a cohort of patients weighing 10 kg or less who underwent CRRT at five US children's hospitals between 1993 and 2001. METHODS: We reviewed records of 85 patients weighing 10 kg or less who underwent at least 24 hours of CRRT. We evaluated weight, diagnosis, pressor number, CRRT characteristics, days on CRRT, and outcome (survival to leave intensive care unit versus death). RESULTS: Patients weighed 1.5 to 10 kg (mean, 5.3 +/- 2.8 kg; 16 patients < or = 3 kg). Sixty-nine percent of patients were being administered pressors at the time of CRRT initiation, 88% of patients were administered heparin, and the others were administered citrate or no anticoagulation. Mean blood flow was 48 +/- 24 mL/min (range, 15 to 106 mL/min) or 9.5 +/- 4.2 mL/min/kg. Six hundred fifty-five patient-days of therapy were studied (mean, 7.6 +/- 8.6 d/patient; range, 1 to 46 d/patient). Thirty-two patients (38%) survived; 4 of 16 patients (25%) weighing 3 kg or less survived. The smallest survivor weighed 2.3 kg. Overall, survivors and nonsurvivors showed no significant difference in weight, days on CRRT, or pressor number. However, for patients weighing more than 3 kg, 28 of 69 patients (41%) survived, and mean pressor number was lower for survivors versus nonsurvivors (0.96 +/- 1.1 versus 1.6 +/- 1.0 pressors; P < 0.03). CONCLUSION: CRRT is feasible and useful in children weighing 10 kg or less. Hemodynamic instability requiring pressor support neither precludes successful CRRT nor adversely affects survival. After CRRT, the survival rate in children who weigh 3 to 10 kg is similar to that in older children and adolescents.

Acute Kidney Injury↗
PubMed2003

Overview of pediatric renal replacement therapy in acute renal failure.

The disease spectrum leading to pediatric renal replacement therapy (RRT) provision has broadened over the last decade. In the 1980s, intrinsic renal disease and burns constituted the most common pediatric acute renal failure etiologies. More recent data demonstrate that pediatric acute renal failure (ARF) most often results from complications of other systemic diseases, resulting from advancements in congenital heart surgery, neonatal care, and bone marrow and solid organ transplantation. In addition, RRT modality preferences to treat critically ill children have shifted from peritoneal dialysis to continuous renal replacement therapy (CRRT) as a result of improvements in CRRT technologies. Currently, multicenter prospective outcome studies for critically ill children with ARF are sorely lacking. The aims of this article are to review the pediatric specific causes necessitating renal replacement therapy provision, with an emphasis on emerging practice patterns with respect to modality and the timing of treatment, and to focus upon the application of the different renal replacement therapy modalities and assessment of the outcome of children with ARF who receive renal replacement therapy.

Acute Kidney Injury↗
PubMed2003

Acute and chronic inflammation in pediatric patients receiving hemodialysis.

OBJECTIVES: To assess chronic and acute inflammation in children receiving maintenance hemodialysis. STUDY DESIGN: To assess markers of acute inflammation, serum levels (ELISA) of the cytokines tumor necrosis factor (TNF)-alpha, interleukin (IL)-1beta, IL-10, and IL-6, 3 to 5 mL of serum was obtained from 13 pediatric patients (mean patient weight, 37.0+/-15.2 kg; mean age, 14.6+/-4.6 years) before and 30 minutes and 24 hours after a routine midweek hemodialysis treatment session. Chronic inflammation was assessed by serum C-reactive protein (CRP) levels. RESULTS: Early-response cytokines TNF-alpha at 30 minutes (5.84+/-0.94 to 9.67+/-0.92 pg/mL; P=.002) and 24 hours (5.84+/-0.94 to 9.54+/-1.05 pg/mL; P=.008) and IL-1beta at 30 minutes (17.19+/-2.00 to 26.17+/-1.12 pg/mL; P=.001) and 24 hours (17.19+/-2.00 to 23.01+/-1.13 pg/mL; P=.02) increased significantly after hemodialysis. Later-response cytokines IL-10 and IL-6 activation was not significant. CRP levels were elevated in 10 of 13 patients (mean, 14.7+/-9.5mg/L; range, 7.2-38.8 mg/L) and correlated with dialysis vintage. Baseline IL-6 and IL-10 levels correlated with dialysis vintage and correlated negatively with eqKt/V. CONCLUSIONS: We observed a chronic inflammatory state in pediatric hemodialysis patients not related to the hemodialysis treatment but rather dialysis vintage and hemodialysis adequacy. We suggest that either more frequent dialysis or enhanced cytokine clearance may ameliorate the chronic inflammatory state observed in pediatric patients receiving hemodialysis.

Acute Disease↗
PubMed2003

Noninvasive interventions to decrease hospitalization and associated costs for pediatric patients receiving hemodialysis.

Minimal pediatric data describe hospitalization causes and associated costs for children who receive maintenance hemodialysis, and no data exist to evaluate methods to decrease hospitalization. In 1999, two common causes of hemodialysis patient hospitalization at Texas Children's Hospital were fluid overload/hypertension (FO/HTN) and vascular access thrombosis (VAT). Evaluated is the effect of two noninvasive monitoring programs, monitoring of hematocrit-guided ultrafiltration algorithm and vascular access flow using ultrasound dilution vascular access flow technology, on FO/HTN and VAT in the pediatric maintenance hemodialysis population. This prospective observational study reviewed all hospitalization data for all 51 patients who received maintenance hemodialysis from January 1999 through December 2001 obtained from unit monthly performance improvement meeting records. Hospitalization rates and related costs for FO/HTN and VAT were tracked before and after institution of the noninvasive monitoring programs. Application of the noninvasive monitoring of hematocrit-guided ultrafiltration algorithm since January 2000 significantly decreased hospitalization for FO/HTN (64 total days in 1999, 4 total days in 2000 and 2001 combined) while maintaining acceptable patient BP control and minimizing antihypertensive medication requirements. The vascular access monitoring program using ultrasound dilution vascular access flow technology to direct referral for angioplasty instituted in January 2001 led to a significant decrease in hospitalization for VAT (45 d in 2000 and 21 d in 2001). It is suggested that application of noninvasive technologies to assess patient target dry weight and access flow can significantly decrease pediatric maintenance dialysis patient morbidity and health care cost.

Adolescent↗
PubMed2002

nPCR assessment and IDPN treatment of malnutrition in pediatric hemodialysis patients.

Very few pediatric studies have monitored nutritional status using normalized protein catabolic rate (nPCR) or treating protein-energy malnutrition (PEM) with intradialytic parenteral nutrition (IDPN). The current study compares nPCR with serum albumin as a marker for nutritional status and examines the effectiveness of IDPN treatment in three malnourished adolescent patients receiving chronic hemodialysis in a pediatric dialysis unit. All patients demonstrated reversal of weight loss and initiation of weight gain within 6 weeks of IDPN initiation. Mean values of monthly percentage weight and percentage body mass index (BMI) change were significantly lower in the pre-IDPN era (-0.61+/-2.70 and -1.3+/-2.7) versus the IDPN treatment period (1.8+/-2.1 and 1.3+/-2.1) ( P<0.02). Two patients attained ideal body weight and IDPN was discontinued after 5 months. Patients required 150% recommended daily allowance to achieve weight and BMI gain. While mean monthly nPCR was significantly lower in the pre-IDPN period versus the IDPN period (1.05+/-0.36 versus 1.35+/-0.37, P<0.05), monthly serum albumin levels were no different before and after IDPN was initiated (3.7+/-0.8 versus 3.8+/-0.6). The current study demonstrates IDPN to be effective therapy for adolescent hemodialysis patients with PEM not correctable by enteral supplementation. nPCR was superior to serum albumin as a nutritional status marker in these malnourished pediatric patients receiving hemodialysis.

Adolescent↗
PubMed2002

Proactive monitoring of pediatric hemodialysis vascular access: effects of ultrasound dilution on thrombosis rates.

BACKGROUND: Hemodialysis vascular access thrombosis (VAT) is a significant cause of morbidity for hemodialysis patients and results, in part, from decreased access flow potentially caused by venous outflow stenosis. We have previously shown ultrasound dilution (UD) to be a practical and reliable predictor of venous outflow in children receiving hemodialysis. METHODS: The current study is the first to our knowledge to assess the impact of a proactive UD monitoring program upon VAT in pediatric patients. Nine patients experienced 18 VAT over the two-year study. Mean values for variables potentially associated with VAT were compared to values from a size-matched seven patient group without VAT during the study period. VAT rates were compared between the year-before (pre-UD era) and year-after (UD era) UD was initiated. During the latter half of the UD era (rapid referral period), patients with VA flow rate (QAcorr) <650 mL/min/1.73 m2 were referred for balloon angioplasty within 48 hours. RESULTS: Mean QAcorr was lower for patients with subsequent VAT (562 +/- 290 mL/min/1.73 m2) versus patients without VAT (1005 +/- 372 mL/min/1.73 m2; P = 0.02). The VAT rate was significantly lower in the UD era (4.1 VAT/100 patient-months) versus the pre-UD era (11.0 VAT/100 patient-months; P = 0.03). The decrease in VAT rates was caused predominantly in the rapid referral period, where the VAT rate dropped to 0.96 VAT/100 patient-months (P < 0.001). Cost of vascular access management was 65% higher ($1264 vs. $765/patient-month) in the pre-UD era, reflecting the increased cost for treatment of VAT. CONCLUSIONS: Monthly QAcorr <650 mL/min/1.73 m2 is predictive of imminent VAT in children receiving hemodialysis. Prompt referral for angioplasty of VA with QAcorr <650 mL/min/1.73 m2 leads to decreased VAT rates in children.

Angioplasty, Balloon↗
PubMed2002

Permanent hemodialysis vascular access survival in children and adolescents with end-stage renal disease.

BACKGROUND: Transplantation is the optimal therapy for pediatric end-stage renal disease (ESRD) patients, but in a subset of patients with peritoneal membrane failure, failed transplants or poor social situations, chronic hemodialysis (HD) remains the only option. Long-term survival of arteriovenous fistulas (AVFs) and arteriovenous grafts (AVGs) in pediatric patients has not been well described. METHODS: We studied the survival of permanent vascular access in 34 pediatric ESRD patients treated with chronic HD at our institution between 1/1/89 and 12/1/95 and followed to 12/31/2000. RESULTS: Twenty-four AVFs and 28 AVGs were created in 19 and 23 patients, respectively. Mean age and weight at insertion were 15.1 years (range 7.1 to 20.9) and 46 kg (18 to 81) for AVFs and 13.3 years (3.8 to 21.1) and 41.5 kg (10.5 to 145) for AVGs. Fifteen patients weighed <35 kg at the time of access creation (7 AVFs in 5 patients, 14 AVGs in 13 patients). Excluding primary failures, one-year, three-year and five-year patency rates for AVFs (74%, 59%, 59%) and AVGs (96%, 69%, 40%) were not significantly different. Patency did not correlate with patient weight or age at access creation. Primary access failure occurred more often (P < 0.01) in AVFs (8/24) compared to AVGs (1/28). Access thrombosis, stenosis and infection occurred more frequently in AVG (P = 0.02). CONCLUSIONS: Both AVF and AVG function well even in small pediatric patients and have survival rates equivalent to adult series and longer than cuffed venous catheters in pediatric patients. Both AVFs and AVGs are preferable for long-term HD access in pediatrics.

Adolescent↗