Uric acid, the end product of purine metabolism, is excreted predominantly by the proximal tubules. Abnormal serum levels of uric acid are due to alterations in production or excretion. Fractional excretion of uric acid is helpful in determining the underlying etiology of hypouricemia or hyperuricemia in children. Abnormalities in the molecular mechanisms that control renal uric acid tubular transport are implicated in various disorders associated with abnormal uric acid levels. Gout is rare in children; yet its presence necessitates evaluation for enzymatic defects in purine metabolism. Well-known effects of uric acid on the kidney include nephrolithiasis and acute kidney injury (AKI) in the setting of tumor lysis. However, recent data suggest that uric acid may be an important factor in the pathogenesis of AKI in general, as well as of chronic kidney disease (CKD) and hypertension. Hence, uric acid may not only be a marker but also a potential therapeutic target in kidney disease. Nonetheless, because of confounders, more studies are needed to clarify the association between uric acid and multifactorial disorders of the kidney.
Women surgeons have a small but growing presence on surgical editorial boards, and gender-based qualification differences are likely attributable to practice length. Men's longer tenure on editorial boards may drive some of the observed disparity by limiting new appointment opportunities. Strategies such as imposing term limits or instituting merit-based performance reviews may help editorial boards capture the field's changing demographics.
Background
Providing renal support for small children is very challenging using the machinery currently available in the United States. As the extra-corporeal volume (ECV) relative to blood volume increases, and the state of critical illness worsens, the chance for instability during continuous renal replacement therapy (CRRT) initiation rises. CRRT machines with smaller ECV could reduce the risks and improve outcomes.
Methods
1) Case series of small children (n = 12) who received continuous veno-venous hemofiltration (CVVH) via Aquadex™ machine (ECV = 33 mL) with 30 mL/kg/h of pre-replacement fluids at Children’s of Alabama between December 2013 and April 2015. 2) In vitro assessment of fluid precision using the adapted CVVH system.
Results
We utilized 101 circuits over 261 days to provide CVVH for 12 children (median age = 30 days; median weight 3.4 kg). Median CVVH duration = 14.5 days (IQR = 10, 22.8 days). Most circuits were routinely stopped for change after 72 h. Only 5/101 (5 %) initiations were associated with mild transient change in vital signs. Complications were infrequent (three transient hypothermia; three puncture-site bleeding, one systemic bleeding, and one right atrial thrombus). Most patients (7/12, 58 %) were discharged from ICU, and 6/12 (50 %) were discharged home.
Conclusions
CRRT machines with low ECV can enable clinicians to provide adequate, timely, safe and efficient renal support to small critically ill infants.
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