M. Isabel Roberti, M.D., Ph.D. was appointed Director of Pediatric Nephrology and Transplantation at Saint Barnabas Medical Center in 2003. Dr. Roberti has been with the program as its Associate Director since it was established in 1996. Dr. Roberti completed her medical degree, residency, and pediatric nephrology fellowship at the Escola Paulista de Medicina in Sao Paulo, Brazil, and an additional fellowship in pediatric nephrology at Mount Sinai Medical Center, New York. She received her Ph.D. in pediatrics at the Hospital Sao Paulo. Dr. Roberti is board certifi ed in both pediatrics and pediatric nephrology and is currently Clinical Associate Professor of Pediatrics in the Division of Pediatric Nephrology at Mount Sinai Medical Center.
Background: Dyslipidemia (DLP) is part of Nephrotic Syndrome (NS) but its prevalence after remission is unknown. Anedoctal reports questioned the impact of DLP in the early development of arteriosclerosis in children with NS. DLP after remission of NS has been suggested to be a predictor of relapse. Some authors observed that persistence and severity of dyslipidemia correlated with duration of NS and frequency of relapses. Objective: To determine the prevalence of DLP in children after remission of SDNS, FRNS and/or SRNS. Design/Methods: We reviewed all EHR of children with SDNS, FRNS and SRNS followed at our center. Secondary causes of NS, children with eGFR <80 % and/or with infrequent relapses of NS were all excluded. Steroid responsiveness, relapsing pattern, medications, biopsy and laboratory data were analysed. Kidney biopsy indications: age < 2 yrs or >7 yrs at presentation; SRNS; SDNS/FRNS that failed mycophenolate mofetil (mmf) prior of using calcineurin inhibitors. SDNS/FRNS received mmf and if no response tacrolimus, for steroid sparing. Non-compliant patients received IV cyclophosphamide. If relapse seen after lowering tacrolimus doses rituximab was given. SRNS received tacrolimus. Persistent DLP was defined by abnormal lipid panel after 3 mos of sustained remission of NS or if remission was never achieved. Results: Charts of 42 children were reviewed. Age at diagnosis: 8 mos to 17yrs (median=4yrs); 19 were males; 14 AA, 9 H, 19 C; 7 obese. F/u time: 1 to 16yrs (median=4yrs). Clinical pattern of NS: 28 had SDNS, 7 FRNS and 7 SRNS. Biopsy results: 15 MCNS, 11 IgMN, 8 FSGS. DLP was of long duration and recurrent associated with relapse pattern of the NS. Persistent DLP (all with LDH chol>150): 4/42 (ages: 3, 4, 5 and 15 yrs) - 2 MCNS, 2 FSGS (1 never remited); 1 was obese; none with positive FH. 31 children had normal lipid profile when in remission and 7 unknown. 1 case of DVT while in relapse. 1 case of carotid artery plaque (FSGS with LDL chol>300). Therapy: 32 tacrolimus, 9 cyclophosphamide, 29 mmf (22 after failing tacrolimus), 13 rituximab; Anti-lipid therapy: 1/42 (FSGS with persistant NS). ACEi were used if UProt/Cr >0.5. Conclusions: DLP can be long lasting and persistent DLP in children in remission of SDND/FRNS or SRNS was seen in 7.3 %. Anti-lipid therapy was only use in the child with persistent NS. Gaps in knowledge in how to treat dyslipidemia in children with NS remain and clear guidelines need to be established. Signs of early arteriosclerosis should be added to our routine monitoring of children with persistant dyslipidemia.
Lavinia Oltita Bratescu was graduated from University of Medicine and Pharmacy from Timisoara, Romania in 2000. She has completed her studies with specialization in Nephrology, in 2006. From 2007, she has worked as a Nephrologist in Sf Pantelimon International Healthcare Systems Nephrology and Dialysis Medical Center, Bucharest. From 2012, she has been a Chief Physician of the same medical center. She completed her PhD in 2013. She has participated in national and international nephrology conferences as a speaker and as poster presenter.
Introducere The ‘buttonhole’ technique has been used worldwide for about 25 years. The advantages are those related to pain relief at the puncture site, reducing the risk of hematoma and aneurysm at AVF level and performing hemodialysis at home. These benefits are offset by the increased risk of local infections or septic complications. Their causes are: poor technique, non-compliance with local hygiene conditions, the creation of "false channels" as the source of germs ‘localization. Materials and methods A 38-year-old female patient with IgA nephropathy, noncompliant to treatment, BCR stage 5, decides to start HD in 2010 (right jugular CVC jugular). From February 2016, the patient performs buttonhole technique at the left brachial-cephalic AVF. Inflamed puncture sites, without the appearance of any secretion highlighted in April 2017. The cultures at the puncture sites were Staphylococcus Aureus positive, initiating local and systemic oral treatment with Amoxicillin + Clavulanic Acid, according to laboratory results. After 4 days, the patient presents altered general condition and feverish syndrome. The clinical examination found: ulcerous injury at the left brachial-cephalic AVF; 2 left parasternal and thighs mobile and painful tumor masses of 2 cm. Paraclinically: marked inflammatory syndrome, positive Staphylococcus Aureus hemoculture ; radiographic – pneumatoceles in both lung fields. AVF ligation was performed with continued HD sessions on CVC. Antibiotic therapy was initiated according with antibiogram: Gentamicin 80mg/HD session - 5 administration; Linezolid 600mg/day - 14 days; Vancomicin 500mg/HD session - 6 weeks, with clinically and paraclinically favorable evolution. Discussions Characteristics of the case - the brutal evolution under initiated antibiotic treatment and the type of septic complications: pulmonary and muscular metastases. Making a "buttonhole workgroup" in every dialysis center is essential. Initial and periodic training of patients and nurses involved in this technique is essential for infection risk’ reducing.