Survival in children with ESRD has increased over the last 20 years, but the SMR remains high. Early transplantation and a more vigorous approach toward hypertension and infection may be mandatory in order to further reduce mortality.

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Abstract. Increased arterial stiffness is a risk factor for mortality in adults over 40 yr of age with end-stage renal disease (ESRD). As no data exist on vascular changes in young adults with ESRD since childhood, a long-term outcome study was performed. All living Dutch adult patients with onset of ESRD between 1972 and 1992 at age 0 to 14 yr were invited for carotid artery and cardiac ultrasound and BP measurements. Data on clinical characteristics were collected by review of all medical charts. Carotid ultrasound data were compared with those of 48 age-matched and gender-matched healthy controls. Carotid artery and cardiac ultrasound was performed in 130 out of 187 eligible patients. Mean age was 29.0 (20.7 to 40.6) yr. Compared with controls, patients had a similar intima media thickness but a reduced mean arterial wall distensibility DC (40.0 versus 45.0 kPa Ϫ1 · 10 Ϫ3 ; 95% CI, Ϫ9.1 to Ϫ0.8; P Ͻ 0.001), an increased stiffness parameter ␤ (4.2 versus 3.8; 95% CI, 0.05 to 0.68; P ϭ 0.02), an increased elastic incremental modulus E inc (0.35 versus 0.27 kPa · 10 3 ; 95% CI, 0.02 to 0.12; P Ͻ 0.001). Multiple regression analyses in all subjects revealed that ESRD was associated with an increase in ␤ and E inc . Arterial wall properties of patients currently on dialysis and transplanted patients were comparable. In all patients, current systolic hypertension was associated with increased E inc and decreased DC. In conclusion, carotid arterial wall stiffness is increased in young adult patients with pediatric ESRD. Hypertension is a main determinant and might be a target for treatment of these potentially lethal arterial wall changes.Cardiovascular disease is the main cause of death in adults with end-stage renal disease (ESRD) (1-4). Cardiovascular causes of death are relatively uncommon under the age of 40 yr in the general population. Yet, cardiovascular diseases also account for most deaths in patients with ESRD aged between 25 and 44 yr (1). There are indications that even in children and young adults with ESRD since childhood, cardiovascular disease is the main cause of death, similar to older ESRD patients. We performed a long-term follow up study on the somatic, social, and psychologic outcome of children with ESRD. Over 25% of all patients had died, all of them under the age of 36 yr. We found cardiovascular disease to be the most important cause of death in the whole group, and cardiac death most prominent in those patients who died more than 10 yr after beginning renal replacement therapy (RRT) (5).Clinical studies have shown that increased stiffness of the large arteries independently contributes to the high mortality in dialysis patients over 40 yr of age (6 -8). Recently, studies performed with electron beam CT have shown coronary calcifications in adolescents and young adults with ESRD (9 -11). However, these studies concern only a few patients; to date, no data exist on arterial wall distensibility in young adult patients with ESRD since childhood. The purpose of this study was to assess the pre...

Bone disease is a major clinical problem in young adults with pediatric ESRD. Further follow-up is needed to establish the impact of the low bone mineral densities found in these patients.

IntroductionExtracorporeal membrane oxygenation is a supportive cardiopulmonary bypass technique for patients with acute reversible cardiovascular or respiratory failure. Favourable effects of haemofiltration during cardiopulmonary bypass instigated the use of this technique in infants on extracorporeal membrane oxygenation. The current study aimed at comparing clinical outcomes of newborns on extracorporeal membrane oxygenation with and without continuous haemofiltration.MethodsDemographic data of newborns treated with haemofiltration during extracorporeal membrane oxygenation were compared with those of patients treated without haemofiltration in a retrospective 1:3 case-comparison study. Primary outcome parameters were time on extracorporeal membrane oxygenation, time until extubation after decannulation, mortality and potential cost reduction. Secondary outcome parameters were total and mean fluid balance, urine output in mL/kg/day, dose of vasopressors, blood products and fluid bolus infusions, serum creatinin, urea and albumin levels.ResultsFifteen patients with haemofiltration (HF group) were compared with 46 patients without haemofiltration (control group). Time on extracorporeal membrane oxygenation was significantly shorter in the HF group: 98 hours (interquartile range (IQR) = 48 to 187 hours) versus 126 hours (IQR = 24 to 403 hours) in the control group (P = 0.02). Time from decannulation until extubation was shorter as well: 2.5 days (IQR = 0 to 6.4 days) versus 4.8 days (IQR = 0 to 121.5 days; P = 0.04). The calculated cost reduction was €5000 per extracorporeal membrane oxygenation run. There were no significant differences in mortality. Patients in the HF group needed fewer blood transfusions: 0.9 mL/kg/day (IQR = 0.2 to 2.7 mL/kg/day) versus 1.8 mL/kg/day (IQR = 0.8 to 2.9 mL/kg/day) in the control group (P< 0.001). Consequently the number of blood units used was significantly lower in the HF group (P< 0.001). There was no significant difference in inotropic support or other fluid resuscitation.ConclusionsAdding continuous haemofiltration to the extracorporeal membrane oxygenation circuit in newborns improves outcome by significantly reducing time on extracorporeal membrane oxygenation and on mechanical ventilation, because of better fluid management and a possible reduction of capillary leakage syndrome. Fewer blood transfusions are needed. All in all, overall costs per extracorporeal membrane oxygenation run will be lower.

As in older adults, cardiovascular disease is the most important cause of death in adolescents and young adult patients with end-stage renal disease (ESRD) since childhood. This concerns patients on dialysis as well as transplant patients, despite the fact that a long duration of dialysis during childhood is an extra mortality risk factor. Left ventricular hypertrophy (LVH), aortic valve calcification, and increased arterial stiffness, but not increased arterial intima media thickening, are the most frequently observed alterations in young adult survivors with childhood ESRD. In transplanted patients a concentric LVH as a result of chronic hypertension is mostly observed; in dialysis patients a more asymmetric septal LVH is found as a result of chronic volume overload. These results suggest that in children and young adults with ESRD chronic pressure and volume overload, a high calcium-phosphate product, and chronic inflammation, but not dyslipidemia, play a role in the development of cardiovascular disease.

JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide range of content in a trusted digital archive. We use information technology and tools to increase productivity and facilitate new forms of scholarship. For more information about JSTOR, please contact support@jstor.org.. Wiley and American Finance Association are collaborating with JSTOR to digitize, preserve and extend access ABSTRACT This paper presents an aging analysis of 741 high yield bonds and finds default, exchange, and call percentages substantially higher than reported in earlier studies. By December 31, 1988, cumulative defaults are 34 percent for bonds issued in 1977 and 1978 and range from 19 to 27 percent for issue years 1979-1983 and from 3 to 9 percent for issue years [1984][1985][1986]. Exchanges are also a significant factor although they often are followed by default. Moreover, a significant percentage of high yield debt, 26-47 percent for 1977-1982, has been called. By December 31, 1988, approximately one third of the bonds issued in 1977-1982 has defaulted or been exchanged, and an additional one third had been called. On average, only 28 percent of these issues are still outstanding. There is no evidence that early results for more recent issue years differ markedly from issue years 1977 to 1982.THE DEVELOPMENT OF THE original issue high yield bond market represents one of the most successful innovations in recent financial history.1 From its inception, a major impetus behind the growth of the new issue high yield bond market has been the argument that risk-adjusted returns are high. Specifically, it is argued that defaults on high yield bonds, while higher than those on investment grade bonds, are low relative to their coupon rate, i.e., that their higher coupon rates more than compensate for the default risk. This apparent market inefficiency has been attributed to outdated conventions used by rating agencies and bond investors, both of whom supposedly fail to see the true risk/return characteristics of high yield bonds. the referee for this journal, as well as the participants at the University of Chicago and Harvard University Finance Seminars, for their comments. Finally, special thanks are due to Bruce MacLennan for his research assistance. 1 The growth in this market can be viewed as a process of securitization. Low rated firms previously borrowed from insurance companies and banks. Development of the public high yield market allowed the securitization of these private placements. 923 This content downloaded from 128.235.251.160 on Sun, 14 Dec 2014 11:19:05 AM All use subject to JSTOR Terms and Conditions 924The Journal of Finance Attempts to verify empirically the risk/return characteristics of the original issue high yield debt market are difficult because of data limitations. Since 1977 marks the beginning of the original issue high yield debt market,2 there is only a limited history of its performance through time and none through a full range of economic and ca...

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