CKD staged by level of eGFR and proteinuria characterizes the timeline of progression and can guide management strategies in children.

Objective Our purpose was to identify the main food contributors to energy and nutrient intake in children with chronic kidney disease (CKD). Methods In this cross-sectional study of dietary intake assessed using Food Frequency Questionnaires (FFQ) in the Chronic Kidney Disease in Children (CKiD) cohort study, we estimated energy and nutrient intake and identified the primary contributing foods within this population. Results Completed FFQs were available for analysis in 658 children. Of those, 69.9% were boys, median age 12 years (interquartile range (IQR): 8, 15 years). The average daily energy intake was 1968 kcal/day (IQR: 1523 – 2574 kcal/day). Milk was the largest contributor to total energy, protein, potassium, and phosphorus intake. Fast foods were the largest contributors to fat and sodium intake, the second largest contributors to energy intake, and the third largest contributors to potassium and phosphorus intake. Fruit contributed 12.0%, 8.7% and 6.7% to potassium intake for children aged 2–5, 6–13 and 14–18 years old, respectively. Conclusions Children with CKD consumed more sodium, protein, and calories but less potassium than recommended by the National Kidney Foundation guidelines for pediatric CKD. Energy, protein, and sodium intake is heavily driven by consumption of milk and fast foods. Limiting the contribution of fast foods to diet in patients with good appetite may be particularly important for maintaining recommended energy and sodium intake, as overconsumption can increase the risk of obesity and cardiovascular complications in this population.

Objective Our aim was to characterize the nutrient intake of children with chronic kidney disease (CKD) relative to recommended intake levels. Methods We conducted a cross-sectional study of dietary intake assessed by food frequency questionnaire (FFQ) in The North American Chronic Kidney Disease in Children (CKiD) prospective cohort study. Nutrient intake was analyzed to estimate the daily consumption levels of various nutrients and compared to national guidelines for intake. Results There were 658 FFQs available for analysis; 69.9% of respondents were boys, with a median age (Interquartile range [IQR]) of 11 years (8–15). Median daily sodium, potassium and phosphorus intake of the cohort was 3089 mg (2294–4243), 2384 mg (1804–3076) and 1206 mg (894–1612) respectively. Sodium and phosphorus consumptions were higher than recommended in all age groups. Caloric intake decreased with dropping glomerular filtration rate (p=0.003). Median daily caloric intakes were 1307 kcal in male children 2–3 years old, 1875 kcal in 4–8 year old, 1923 kcal in those 9–13 years old, and 2427 kcal in those 14–18 years old. Respective levels for girls were 1467 kcal, 1736 kcal, 1803 kcal, and 2281 kcal. Median protein intake exceeded recommended levels in all age groups, particularly among younger participants. Younger children were more likely than older children to exceed the recommended intakes for phosphorus (p<0.001) and the age-specific recommended caloric intake (p<0.001). Macronutrient distribution (carbohydrate: fat: protein) was consistent with recommendation. Conclusions Children in the CKiD cohort consumed more sodium, phosphorus, protein and calories than recommended. The gap between actual consumption and recommendations indicates a need for improved nutritional counseling and monitoring.

CHP and SPAD are effective extracorporeal methods of removing methotrexate. They provide alternative treatment options for critical care nephrologists in the management of methotrexate toxicity.

A 6-year-old boy developed acute liver failure with hepatic coma due to drug rash with eosinophilia and systemic symptoms (DRESS) after multiple antibiotics exposure. He had hyperbilirubinemia, elevated serum bile acids and hyperammonemia with peak serum levels of total bilirubin, direct bilirubin, bile acids and ammonia measuring 418, 328, 174, and 172 μmol/L respectively. In addition to the use of systemic steroid and other supportive therapy, he also received three sessions of hemoadsorption using the Cytosorb® column incorporated into the continuous renal replacement therapy circuit as extracorporeal liver support for a total duration of 75 h, which brought down his serum levels of total bilirubin to 119 μmol/L, bile acids to 58 μmol/L, and ammonia to 55 μmol/L. His conscious level gradually regained coupling an improvement of liver function. Except for mild thrombocytopenia and electrolyte disturbances, the therapy was well tolerated with no major complication encountered. Our case demonstrated that hemoadsorption can be safely employed as an adjunctive extracorporeal liver support modality in children with acute liver failure. The potential role and technical concerns of applying such technique in pediatric patients requires further evaluation in future studies.

We report two children with rhabdomyolysis-associated acute kidney injury who were successfully treated with a haemoadsorption column CytoSorb® in addition to continuous renal replacement therapy (CRRT). A 14-year-old girl with multiorgan failure requiring extracorporeal membrane oxygenation developed rhabdomyolysis due to reperfusion injury. Her creatine kinase (CK) and lactate levels continued to escalate despite high-dose CRRT. A haemoadsorption column was therefore added post-CRRT filter, which brought down the CK level from 264,500 IU/L to 97,436 IU/L after 8 hours of therapy. Another 4-year-old boy with epilepsy and cerebral palsy who was admitted for gastroenteritis with dehydration developed acute kidney injury and rhabdomyolysis with a peak CK level of 946,060 IU/L. He was initially treated with CRRT for 40 hours, which reduced his CK level to 147,580 IU/L. Two sessions of haemoadsorption were then performed in addition to the CRRT, which further lowered his CK level to 32,306 IU/L in 48 hours. Both patients demonstrated enhanced reduction of CK levels when the haemoadsorption column was used in addition to the CRRT, and no specific complication related to the haemoadsorption therapy was reported. Our cases showed that haemoadsorption can be considered as an adjunctive therapy for children with severe rhabdomyolysis-associated acute kidney injury.

Background: Poisoning is one of the leading causes of childhood morbidity and mortality worldwide. Despite the advancement of poison detection by modern investigation methods, the clinical skill of toxidrome recognition by combining the findings from a detailed history, thorough physical examination, and the results of basic investigations is still indispensable for the management of children with suspected poisoning. Objective : To review pediatric toxidromes and poisoning management. Methods: A literature search was conducted on PubMed (between February 1 and 15, 2020) with keywords of "toxidrome" "poisoning" "intoxication” “children” and "pediatric". The search was customized by applying the appropriate filters so as to get the most relevant articles to meet the objective of this review article. Results: Toxidrome recognition may help to offer a rapid guide to possible toxicology diagnosis, so that specific antidote can be administered in a timely manner. This article discusses a few commonly encountered toxidromes in pediatric poisoning, with an emphasis on the symptomatology and source of exposure. The antidote and specific management for each toxidrome are also discussed. Although most patients with intoxication can be managed with close observation, supportive measures and antidote treatment, it is unfortunate that antidotes are only available for a limited number of poisons responsible for intoxication. Extracorporeal toxin removal is being increasingly recognized as a mode of treatment in patients with rapid deterioration of the clinical condition who are unresponsive to conventional management. The decision of applying such technique and the choice of removal modality are frequently individualized due to the paucity of high-level evidence. Various patient and toxin/medication factors involved in the decision-making process are discussed. Conclusion: Poisoning is a common cause of pediatric accident and injury. Physicians should be familiar with common toxidromes and poisoning management.

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