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Lack of efficacy and various toxicities: 2 case reports In a retrospective review, a male patient [age not stated] exhibited lack of efficacy during treatment with carnitine for dilated cardiomyopathy while a 15-month-old girl developed diarrhoea, reduced energy, cool peripheries and dry, itchy skin during treatment with carvedilol for cardiac failure [routes and dosages not stated]. Patient 1: A male patient had presented and diagnosed with an ulcerative colitis like inflammatory bowel disease. Later, he had presented for steroid resistant nephrotic syndrome. A collapsing variant focal segmental glomerulosclerosis confirmed upon biopsy examination. He had treated with unspecified immunosuppressants and liposorber apheresis; however, renal function deteriorated. Therefore, haemodialysis was started. However, he developed two episodes of posterior reversible encephalopathy syndrome, which was secondary to hypertension. Therefore, bilateral nephrectomy was performed. Post-operation, he became increasingly hypotensive. After eight months, an acute pulmonary oedema was noted. A severe dilated cardiomyopathy was diagnosed. He was started on carnitine and IV milrinone. However, he showed no effect to the carnitine treatment. His haemodialysis treatment was intensified. However, his cardiac function continued to deteriorate. He transitioned to a home haemodialysis (HHD) program. Additionally, spironolactone and carvedilol were started owing to intradialytic tachycardia. Eventually, he was switched to nocturnal HHD program of 10 hours, five times per week. Later, he was admitted for pulmonary oedema and chest infection. Enalapril and digoxin were started, and HHD program was increased to 8 hours, 7 times per week, nocturnally. His symptoms resolved within 12 months, and cardiac function gradually normalised with successful withdrawal of enalapril, digoxin and spironolactone. Patient 2: A 15-month-old girl had a history of bilateral Wilm’s tumour, which required bilateral nephrectomy. Eventually, she required haemodialysis. Every time the dialysis would get complicated with interdialytic hypertension with elevated systolic blood pressure. She became enteral feed dependent. She was started on HHD. Within weeks, her BP improved. Later, she developed upper respiratory tract infection, and her BP destabilised. She was diagnosed with moderate cardiac failure. She received treatment with carvedilol, spironolactone and digoxin. Her HHD program was intensified. Due to side effects of reduced energy, cool peripheries, diarrhoea and dry, itchy skin, her treatment with carvedilol was switched to ivabradine [duration of treatment to reactions onsets not stated]. Consequently, the side effects resolved. Her cardiac function normalised over the next six months. Hothi DK, et al. The impact of home hemodialysis in children with severe cardiac failure. Hemodialysis International 24: E61-E66, No. 4, Oct 2020. Available from: URL: 803518126 http://doi.org/10.1111/hdi.12872

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