The pattern of early multiorgan system failure and death, minimal relative cost of CVVH/D provision, and potential for improved outcome with initiation of CVVH/D at lesser degrees of fluid overload are factors that may support early initiation of CVVH/D in critically ill children with acute renal failure.

Patient ratings on global health and physical activity, emotional, and social and disease-specific worry and communication domains were higher (i.e., better) than parent-proxy ratings, confirming the importance of obtaining both sources of information. Patients on dialysis longer, particularly females, reported worse emotional functioning; females also reported more physical appearance concerns. Parents rated older children and those on dialysis longer as functioning worse on multiple global and disease-specific (e.g., fatigue, relationship) domains. Parents also rated children as functioning increasingly worse in school over time. Further, patient ESRD history (acute onset vs. medically managed) impacted how parents viewed the burden of ESRD on their child over time.

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Abstract. 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 ac-

Rationale and Objective: Chronic kidney disease (CKD) has wide-ranging and long-term consequences for young people and their families. The omission of outcomes that are important to young people with CKD and their caregivers limits knowledge to guide shared decision-making. We aimed to identify the outcomes that are important to young people with CKD and their caregivers. Study Design: We used the nominal group technique whereby participants identified and ranked outcomes and explained their priorities. Settings and participants: Young people with CKD (stage 1-5, dialysis or transplant) and their caregivers were purposively sampled from six centers across Australia, the United States and Canada. Analytical Approach: Importance scores were calculated (scale of 0 to 1), and qualitative data were analyzed thematically. Results: Thirty-four patients (aged 8-21 years) and 62 caregivers participated in 16 groups, and identified 48 outcomes. The five highest ranked outcomes for patients were survival (importance score = 0.25), physical activity (0.24), fatigue (0.20), lifestyle restrictions (0.20) and growth (0.20), and for caregivers, kidney function (0.53), survival (0.28), infection (0.22), anemia (0.20) and growth (0.17). Twelve themes were identified reflecting their immediate and current priorities (wanting to feel normal, strengthening resilience, minimizing intrusion into daily life, imminent threats to life, devastating family burdens, and seeking control over health) and considerations regarding future impacts (protecting health/development, remaining hopeful, concern for limited opportunities, prognostic uncertainty, dreading painful and invasive procedures and managing expectations). Limitations: Only English-speaking participants were recruited. 4 Conclusions: Kidney function, infection, survival and growth were the highest priorities for patients with CKD and their caregivers. Young people with CKD also prioritized highly the outcomes that directly affected their lifestyle and sense of normality, while caregiver's highest priorities concerned the long-term health of their child, current health problems, and the financial and family burdens of caring for a child with CKD.

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.

Accurate dry weight assessment is difficult in pediatric hemodialysis patients but is essential to prevent chronic fluid overload, hypertension, and cardiovascular morbidity. A noninvasive monitoring (NIVM) of hematocrit-guided ultrafiltration algorithm was studied prospectively in 20 pediatric hemodialysis patients. The algorithm targeted the first 50% of total goal ultrafiltration to be removed during the first hour of dialysis with a maximum blood volume change of 8 to 12% per hour. The second 50% was removed during the remaining treatment time with a maximum blood volume change of 5% per hour. Data that were collected at baseline and 6 mo included weight, BP, number of antihypertensive medications, 24-h ambulatory BP monitoring (ABPM), echocardiogram, and ultrafiltration-associated symptoms. Sixteen of 20 enrolled patients completed the study. No difference was seen between baseline and 6-mo weight, predialysis casual BP, nighttime ABPM, or left ventricular mass index. There was a decrease in postdialysis casual systolic BP, daytime ABPM, number of antihypertensive medications prescribed, and rate of intradialytic events related to ultrafiltration (all P < 0.05). Adoption of a standardized NIVM-guided algorithm led to (1) improved ABPM profiles, (2) decreased antihypertensive medication burden, and (3) decreased ultrafiltration-associated symptoms. Wider use of NIVM-guided ultrafiltration may decrease cardiovascular morbidity in pediatric hemodialysis patients.

Parents value partnership with clinicians and consider long-term and quality-of-life implications of their child's illness. Children with CKD want more involvement in treatment decision making but are limited by vulnerability, fear, and uncertainty. There is a need to support the child to better enable him or her to become a partner in decision making and prepare him or her for adulthood. Collaborative and informed decision making that addresses the priorities and concerns of both children and parents is needed.