1H, 13C and 15N backbone resonance assignments of hepatocyte nuclear factor-1-beta (HNF1β) POUS and POUHD

Hepatocyte nuclear factor 1β (HNF1β) is a transcription factor that plays a key role in the development and function of the liver, pancreas, and kidney. HNF1β plays a key role in early vertebrate development and the morphogenesis of these organs. In humans, heterozygous mutations in the HNF1B gene can result in organ dysplasia, making it the most common cause of developmental renal diseases, including renal cysts, renal malformations, and familial hypoplastic glomerular cystic kidney disease. Pathogenic variants in the HNF1B gene are known to cause various diseases, including maturity-onset diabetes of the young and developmental renal diseases. This study presents the backbone resonance assignments of HNF1β POUS and POUHD domains, which are highly conserved domains required for the recognition of double-stranded DNA. Our data will be useful for NMR studies to verify the altered structures and functions of mutant HNF1B proteins that can induce developmental renal diseases, including renal cysts, renal malformations, and familial hypoplastic glomerular cystic kidney disease. This study will provide the structural basis for future studies to elucidate the molecular mechanisms underlying how mutations in HNF1β cause diseases.

Adult survivors of childhood-onset steroid-dependent and steroid-resistant nephrotic syndrome treated with cyclosporine: a long-term single-center experience

BACKGROUND

Although evidence has confirmed that cyclosporine (CS) is efficacious against childhood-onset steroid-dependent and steroid-resistant nephrotic syndrome (SD/SRNS), some patients may continue to relapse during adulthood. However, predictive factors for adult active disease and kidney complications, such as chronic kidney disease (CKD) and hypertension, in this cohort remain unknown.

METHODS

We conducted a retrospective study on the long-term outcomes of 81 young adults with childhood-onset SD/SRNS treated with CS. The primary endpoint was the probability of active disease into adulthood. The secondary endpoint was the probability of developing kidney complications.

RESULTS

At the last follow-up (median age, 23.2 years; median disease duration, 15.8 years), 44 adult patients (54%) continued to have active disease, whereas 16 patients developed CKD or hypertension, respectively. The proportion of patients developing kidney complications was similar between the active disease and long-term remission groups. Young age at NS onset and history of relapse during the initial CS (median, 31 months) were independent predictive factors for active disease. Acute kidney injury at NS onset, focal segmental glomerulosclerosis, and irreversible CS nephrotoxicity were identified as risk factors for the development of CKD, whereas older age was identified as a risk factor for the development of CKD and hypertension.

CONCLUSIONS

More than 50% of adult survivors treated with CS continued to have active disease, and each 20% developed CKD or hypertension. A long-term follow-up is necessary for patients with SD/SRNS to identify the development of kidney complications later in adulthood that can be attributed to prior disease and CS treatment in childhood, irrespective of disease activity. A higher resolution version of the Graphical abstract is available as Supplementary information.

Association between earthquakes and perinatal outcomes: A systematic review and meta-analysis

BACKGROUND

Evidence for the association between earthquakes and adverse perinatal outcomes is limited.

OBJECTIVES

To evaluate the association between earthquakes and perinatal outcomes including preterm birth and low birth weight.

SEARCH STRATEGY

We searched studies using MEDLINE, Cochrane Central Register of Controlled Trials, EMBASE, World Health Organization International Clinical Trials Platform Search Portal, and ClinicalTrials.gov on February 9, 2023.

SELECTION CRITERIA

We included before-and-after studies that evaluated the associations between earthquakes and perinatal outcomes in women living in affected areas.

DATA COLLECTION AND ANALYSIS

Two independent reviewers extracted data. We calculated the pooled odds ratio (OR) with the random-effects model. We analyzed outcomes in subgroups of Asians and others. We evaluated the certainty of evidence with the Grading of Recommendations Assessment, Development and Evaluation system.

MAIN RESULTS

We included 2 607 405 women in 13 studies. Earthquakes may not increase preterm birth (nine studies, 1 761 760 participants: OR 1.10, 95% confidence interval [CI] 0.98-1.24, low certainty of evidence) or low birth weight (seven studies, 1 753 891 participants: OR 1.10, 95% CI 0.94-1.28, low certainty of evidence). Subgroup analyses showed that earthquakes may be associated with an increase of preterm birth among populations in Asia (OR 1.44, 95% CI 1.07-1.95), but this was not evident in others (OR 0.93, 95% CI 0.83-1.05).

CONCLUSIONS

Perinatal outcomes might not change after earthquakes. Further research on the association between earthquakes and perinatal outcomes, combined with an assessment of the characteristics of the region, is needed.

Predictive factors of long-term disease remission after rituximab administration in patients with childhood-onset complicated steroid-dependent nephrotic syndrome: a single-center retrospective study

BACKGROUND

Despite the fact that rituximab (RTX)-associated adverse events may be relatively frequent in younger patients, recent studies have reported RTX as a suitable first-line steroid-sparing agent for maintaining remission in children with steroid-dependent nephrotic syndrome (SDNS). However, the impact of age at RTX initiation on the long-term outcome remains unknown in this cohort.

METHODS

We retrospectively reviewed the clinical course of 61 patients with complicated SDNS who received a single dose of RTX (375 mg/m2) followed by maintenance immunosuppressive agents (IS) from January 2008 to March 2021. In patients who achieved > 12 months of prednisolone-free remission, IS tapering within 6 months was tried to achieve. The primary endpoint was the probability of achieving long-term treatment-free remission at the last follow-up.

RESULTS

After RTX initiation, 52 patients (85.2%) relapsed after a median of 665 days, and 44 patients (72.1%) received additional RTX doses (total, 226 infusions). At the last follow-up (median observation period, 8.3 years; median age, 18.3 years), 16 patients (26.2%) achieved long-term remission. Multivariate analysis showed that older age at RTX initiation was the independent predictive factor for achieving long-term remission (odds ratio, 1.25; p < 0.05). The proportion of those who achieved long-term remission was significantly higher in patients aged ≥ 13.5 years than in those aged < 13.5 years at RTX initiation (52.6 vs 14.3%, p < 0.05). Persistent severe hypogammaglobulinemia did not develop in older children (≥ 13.5 years) at RTX initiation.

CONCLUSION

For older children with complicated SDNS, RTX appeared to be a suitable disease-modifying therapy without persistent adverse events.

Utility of a rapid assay for prostaglandin E-major urinary metabolite as a biomarker in pediatric ulcerative colitis

Prostaglandin E-major urinary metabolite (PGE-MUM) is a urinary biomarker reflecting ulcerative colitis (UC) activity. This prospective observational study aimed to evaluate the usefulness of PGE-MUM via rapid chemiluminescent enzyme immunoassay in detecting endoscopic remission (ER) and histologic remission (HR) in pediatric UC (6-16 years) in comparison with fecal calprotectin (FCP). ER and HR were defined as Mayo endoscopic score (MES) of 0 and Matts' histological grades (Matts) of 1 or 2, respectively. A total of 104 UC and 39 functional gastrointestinal disorder (FGID) were analyzed. PGE-MUM levels were significantly higher in the UC group than in the FGID group (P < 0.001). FCP levels were significantly elevated in the group without ER and HR than in the group with ER and HR (P < 0.001 and P = 0.001), whereas PGE-MUM levels were significantly higher in the group without ER compared to the group with ER (P < 0.001). No significant differences were noted in the AUCs for PGE-MUM and FCP in detecting ER and HR. Although PGE-MUM was inferior to FCP for the detection of HR, it might have the potential for application as a biomarker of endoscopic activity in pediatric UC owing to its noninvasive and rapid method.

Independent risk factors of rapid glomerular filtration rate decline in patients with type 2 diabetes with preserved kidney function and normoalbuminuria: A multicenter cohort study

AIMS/INTRODUCTION

Research on the incidence and underlying mechanisms of rapid renal function decline in patients with type 2 diabetes mellitus with preserved renal function and normoalbuminuria is limited. This study aimed to investigate the involvement of hemoglobin level as a risk factor for rapid decliners among patients with type 2 diabetes with preserved renal function and normoalbuminuria.

MATERIALS AND METHODS

This was a retrospective observational study of 242 patients with type 2 diabetes with a baseline estimated glomerular filtration rate of ≥60 mL/min/1.73 m² and normoalbuminuria (<30 mg/gCr), followed up for >1 year. The annual rate of estimated glomerular filtration rate decline during the follow-up period was calculated using least square regression analysis; rapid decliners defined at ≥3.3%/year. Risk factors associated with rapid decliners were identified using a logistic regression analysis of variables previously identified as risk factors of rapid decliners.

RESULTS

The median follow-up period was 6.7 years, and 34 patients showed rapid decliners. On multivariate analysis, lower baseline hemoglobin level was a risk factor of rapid decliners (odds ratio 0.69, 95% confidence interval 0.47-0.99; P = 0.045). Furthermore, the baseline hemoglobin levels were correlated positively with iron and ferritin levels, implying that an impaired iron metabolism might cause lower hemoglobin levels in rapid decliners.

CONCLUSIONS

In patients with type 2 diabetes with preserved renal function and normoalbuminuria, lower hemoglobin levels were a risk factor for rapid decliners, where disturbed iron metabolism might precede the development of diabetic kidney disease.

Early predictive factors for progression to kidney failure in infants with severe congenital anomalies of the kidney and urinary tract

BACKGROUND

Severe congenital anomalies of the kidney and urinary tract (CAKUT) progress to infantile kidney failure with replacement therapy (KFRT). Although prompt and precise prediction of kidney outcomes is important, early predictive factors for its progression remain incompletely defined.

METHODS

This retrospective cohort study included patients with CAKUT treated at 12 centers between 2009 and 2020. Patients with a maximum serum creatinine level ≤ 1.0 mg/dL during the first 3 days, patients who died of respiratory failure during the neonatal period, patients who progressed to KFRT within the first 3 days, and patients lacking sufficient data were excluded.

RESULTS

Of 2187 patients with CAKUT, 92 were finally analyzed. Twenty-five patients (27%) progressed to KFRT and 24 (26%) had stage 3-5 chronic kidney disease without replacement therapy during the median observation period of 52.0 (interquartile range, 22.0-87.8) months. Among these, 22 (24%) progressed to infantile KFRT. The kidney survival rate during the infantile period was significantly lower in patients with a maximum serum creatinine level during the first 3 days (Cr-day3-max) ≥ 2.5 mg/dL (21.8%) compared with those with a Cr-day3-max < 2.5 mg/dL (95.2%) (log-rank, P < 0.001). Multivariate analysis demonstrated Cr-day3-max (P < 0.001) and oligohydramnios (P = 0.025) were associated with higher risk of infantile KFRT. Eighty-two patients (89%) were alive at the last follow-up.

CONCLUSIONS

Neonatal kidney function, including Cr-day3-max, was associated with kidney outcomes in patients with severe CAKUT. Aggressive therapy for severe CAKUT may have good long-term life outcomes through infantile dialysis and kidney transplantation. A higher resolution version of the Graphical abstract is available as Supplementary information.

Comparison of the characteristics and factors influencing hospital visits among children with nocturnal enuresis in Japan: The Hirakata-Urayasu population-based cohort study

OBJECTIVES

The aim of this study was to compare the demographic characteristics of school-aged children with nocturnal enuresis and factors influencing hospital visits between two regions in Japan.

METHODS

A cross-sectional survey was conducted in Hirakata City, Osaka Prefecture, and Urayasu City, Chiba Prefecture. An anonymous online questionnaire was administered to all public elementary and junior high school students (aged 6-16 years) or their guardians. Questions included age, gender, perinatal history, frequency of nocturnal enuresis, frequency of bowel movements, comorbidities, and hospital visits for nocturnal enuresis.

RESULTS

The survey response rates were 15.4% in Hirakata City and 37.0% in Urayasu City. In total, 426 children with nocturnal enuresis in Hirakata City and 270 in Urayasu City were included in the final analysis. In both cities, the boy-girl ratio was approximately 2:1, and the prevalence of nocturnal enuresis gradually decreased with age. Multivariate analysis revealed that children aged ≥11 years had a significantly higher proportion of hospital visits (OR, 2.61; 95% CI: 1.49-4.56; p = 0.001; OR, 2.72; 95% CI: 1.12-6.64; p = 0.027, respectively). However, the frequency of nocturnal enuresis did not affect hospital visits.

CONCLUSIONS

The findings of this study suggest that parents with school-aged children have low awareness that nocturnal enuresis is a health problem and therefore subject to medical consultation. Although the proportion of hospital visits increases for children aged ≥11 years, children and families suffering from nocturnal enuresis should be encouraged to see a doctor instead of adopting a "wait and see attitude," even at a young age.

Effectiveness and safety of Tolvaptan in infants with congenital heart disease

BACKGROUND

Tolvaptan (TLV) is a selective vasopressin receptor 2 antagonist administered for congestive heart failure (CHF) after inadequate response to other diuretics. The effectiveness and safety of TLV have been evaluated well in adult patients. However, reports on its use in pediatric patients, especially infants, are scarce.

METHODS

We retrospectively evaluated 41 children younger than 1 year of age who received TLV for CHF for congenital heart disease (CHD) between January 2010 and August 2021. We monitored the occurrence of adverse events, including acute kidney injury and hypernatremia, as well as laboratory data trends.

RESULTS

Of the 41 infants included, 51.2% were male. The median age when TLV was initiated was 2 months, interquartile range (IQR) 1-4 months, and all infants had been administered other diuretics previously. The median dose of TLV was 0.1 mg/kg/day (IQR, 0.1-0.1). Urine output increased significantly after 48 h of treatment: baseline, 315 mL/day (IQR, 243-394); 48 h, 381 mL/day (IQR, 262-518) , p = 0.0004; 72 h, 385 mL/day (IQR, 301-569), p = 0.0013; 96 h, 425 mL/day (IQR, 272-524), p = 0.0006; and 144 h, 396 mL/day (IQR, 305-477), p = 0.0036. No adverse events were observed.

CONCLUSIONS

Tolvaptan can be used safely and efficiently in infants with CHD. From the perspective of adverse effects, initiating administration at a lower dosage is preferable because this was found to be sufficiently effective.

Survival analysis among pediatric patients receiving kidney replacement therapy: a Japanese nationwide cohort study

BACKGROUND

Limited data are available on the survival and causes of death in pediatric patients with chronic kidney disease (CKD) stage 5 receiving kidney replacement therapy (KRT) in Asia.

METHODS

Data were obtained from the Japanese nationwide cross-sectional CKD stage 5 survey on pediatric patients (<20 years of age) who started KRT from 2006 to 2013. The cohort was divided into three groups according to age at the start of KRT: <1, 1-5, and 6-19 years.

RESULTS

Among the 701 children who were included, 59.3% were boys. Peritoneal dialysis was the most common initial modality of KRT (60.3%). Median age at KRT initiation was 10.2 years. Infants (<1 year old) accounted for 16.0% of the total cohort. Overall survival at 1 and 5 years was 97.2% and 92.5%, respectively. Infants had significantly lower survival rates than the other groups (hazard ratio, 5.35; 95% CI, 2.60-11.03; P < 0.001). In contrast, after the age of 1 year, the survival rate improved and did not differ from that of other age groups. The most common causes of death were infection (35.9%) and sudden death (15.4%).

CONCLUSIONS

The overall survival rate of pediatric patients with CKD stage 5 in Japan is like that in other high-income countries. Age at initiation of KRT is an important factor affecting survival since the poorest survival rate was observed in infants. Further improvement in infant dialysis therapy is still needed to improve survival of the youngest children. A higher resolution version of the Graphical abstract is available as Supplementary information.

MO426: Elucidation of Mechanism of Low-Birth-Weight-Related Fsgs in Rats by Rna-Seq Analysis of Cultured Podocytes From Low-Birth-Weight Rats

BACKGROUND AND AIMS

The pathogenesis of low-birth-weight (LBW)-related nephropathy has been considered to be the result of intra-glomerular hyperfiltration during growth due to the presence of low nephron numbers. On the other hand, we hypothesized that there may be pathogenic factor(s) other than low nephron number in LBW individuals [1]. We reported the results of proteomic analysis of the renal cortex of LBW rats to show that metabolic abnormalities should exist in the kidneys of LBW individuals [2]. However, our result of the previous study was obtained by analysis using the renal cortex, which did not allow us to interpret the mechanism of focal segmental glomerulosclerosis (FSGS) formation, the most typical pathological picture of LBW-related nephropathy.

METHOD

A total of 5 LBW rats (birth weight 4.38±0.08) were obtained by 55% caloric restriction to pregnant maternal rats. The normal-birth-weight (NBW) rats (birth weight 6.48±0.18) were obtained by feeding normal diets to pregnant maternal rats. Kidneys were removed at 4 weeks of age, and after isolation of the glomeruli by sieving of kidneys, primary culture of glomerular epithelial cells (podocytes) was performed. Then, mRNAs were extracted from the cultured podocytes after 7 days and RNA-seq analysis was performed using these mRNAs from LBW podocytes and NBW podocytes.

RESULTS

Gene expression of Nphs1 (nephrin), Nphs2 (podocin) Podxl (podocalyxin) was detected in all samples of both groups, confirming that podocytes were cultured. The number of transcripts detected was 17 967 genes. In addition, by comparison of mRNA expression levels between LBW podocytes and NBW podocytes, 107 genes (102 genes decreased in the LBW group and 5 genes increased in the LBW group) showed a False Discovery Rate (FDR) P -value (q-value) &lt; 0.05 between the two groups. Furthermore, IPA (Ingenuity® Pathway Analysis) by using these 107 genes was performed. As a result, five candidates for the upstream master regulator were identified: TNF, SIRT1, SH2B1, C5 and GDF15 as shown in the Figure. The downstream of all these pathways contain TCS2. This gene has been implicated in FSGS formation, as we recently reported [3].

CONCLUSION

It is possible that TCS2 is involved in the mechanism of FSGS formation in LBW-related nephropathy.

Telemedicine in epilepsy management during the coronavirus disease 2019 pandemic

BACKGROUND

Telemedicine has spread rapidly during the coronavirus disease 2019 (COVID-19) pandemic and shown its usefulness, particularly for patients with epilepsy, compared to face-to-face visits. We sought to evaluate the clinical features of patients with childhood onset epilepsy associated with consultations by telephone call during the COVID-19 pandemic.

METHODS

We retrospectively investigated the medical records of patients with childhood onset epilepsy who visited an outpatient clinic in Saitama Children's Medical Center, Saitama, Japan, from 1 March 2020 to 30 September 2020. To find the clinical features of patients who utilized telemedicine consultation (by telephone call), we divided the patients into the telemedicine group and the face-to-face group. We then reviewed the clinical features. Telemedicine consultation was not implemented for new patients.

RESULTS

We enrolled 776 outpatients in total, and 294 patients (37.9%) utilized telemedicine consultations. The total number of visits was 2,299 and the total number of telemedicine consultations was 373 (16.2%). No clinical feature was associated with telemedicine consultations except for age at onset of epilepsy. The number of oral antiepileptic drugs prescriptions decreased in 23 of 776 (3.0%) of the patients who did not experience seizure deterioration, including status epilepticus, or who visited the emergency room.

CONCLUSION

Telemedicine consultations were successfully utilized for epilepsy treatment at our outpatient clinic, regardless of epilepsy type, etiology, seizure frequency, comorbidities, and patients' residential areas. Thus, telemedicine by telephone call may be a useful resource in the management of patients with childhood onset epilepsy during the pandemic.

Experience with enteral sulfonylurea monotherapy for extremely low birth weight infants with hyperglycemia

Limited data are available on the effects of enteral sulfonylurea (SU) monotherapy in extremely low birth weight infants (ELBWIs) with hyperglycemia. Therefore, we report our experience with enteral SU monotherapy for hyperglycemic ELBWIs. We retrospectively evaluated 11 hyperglycemic ELBWIs (seven male infants, median gestational age = 24.9 wk) who received SU between January 2016 and December 2019. Blood glucose (BG) levels were monitored before and after SU initiation and evaluated for the occurrence of adverse effects. We administered SU at a median of 15 d (interquartile range [IQR]: 12–20 d) after birth, with the median maximum dose of 0.2 mg/kg/d (IQR: 0.125–0.3 mg/kg/d). Hyperglycemia improved in all patients, and the target BG levels were achieved without severe side effects at a median of 6 d (IQR: 4–8.5 d) after initiation of treatment. The incidence of hypoglycemia during SU treatment was observed in 18 events per 1000 patient hours; however, the patients were asymptomatic. Based on these results, enteral SU monotherapy may be considered as an option for hyperglycemic ELBWIs.

YouTube videos in Japanese as a source of information on nocturnal enuresis: A content-quality and reliability analysis

BACKGROUND

This study aimed to evaluate the quality and reliability of Japanese YouTube videos pertaining to nocturnal enuresis (NE).

METHODS

In this cross-sectional study, we performed a YouTube search using the keyword "Ya-nyou-shou" ('nocturnal enuresis' in Japanese). We considered the first 200 videos listed based on the YouTube default option. Videos that were irrelevant, concerned personal experiences or adult NE, had non-Japanese content, were advertisements, were duplicated, and those without audio were excluded. Video features and upload source were recorded. The Modified DISCERN, Journal of the American Medical Association (JAMA), and Global Quality Scale (GQS) scoring systems were used for analysis. Two independent pediatricians, specialists in nephrology and urology, completed the scoring. Correlation analysis was performed between video features and the three quality analysis scores.

RESULTS

In total, 72 videos were analyzed. The most common upload sources were physicians (40.3%) and non-physician health personnel (40.3%). The median modified DISCERN, JAMA, and GQS scores for the videos were 1 (lowest: 0; highest: 4), 2 (lowest: 1; highest: 3), and 2 (lowest: 1; highest: 4), respectively. The highest scores for video power index (VPI) were for independent users (6.43 points) and physicians (3.05 points). There were positive correlations between the VPI and video length and modified DISCERN and GQS scores. No video presenter disclosed conflicts of interest.

CONCLUSIONS

Most Japanese YouTube videos about NE were low quality. Healthcare experts should be encouraged to upload better quality content.

Body temperature predicts recurrent febrile seizures in the same febrile illness

BACKGROUND

The incidence of recurrent febrile seizures during the same febrile illness (RFS) is 14-24%. A pilot study found that body temperature and male sex were predictors of RFS. This study sought to validate body temperature as a predictor of RFS, calculate the optimal cut-off body temperature for predicting RFS, and identify the other predictors of RFS.

METHODS

This prospective cohort study enrolled children with febrile seizures aged 6-60 months who visited the emergency department at Atsugi City Hospital, Japan, between March 1, 2019, and February 29, 2020. Children who had multiple seizures, diazepam administration before the emergency department visit, seizures lasting >15 min, underlying diseases, or who could not be followed up were excluded. The optimal cut-off body temperature was determined using a receiver-operating characteristic curve.

RESULTS

A total of 109 children were enrolled, of whom 13 (11.9%) had RFS. A lower body temperature was significantly associated with RFS (P = 0.02). The optimal cut-off body temperature for predicting RFS was 39.2 °C. Children with RFS also had significantly lower C-reactive protein and blood glucose levels (P = 0.01 and 0.047, respectively), but none of the other factors considered were significantly associated with RFS.

CONCLUSIONS

This large prospective study confirmed that body temperature is a predictor of RFS. The optimal cut-off body temperature for predicting RFS was 39.2 °C. Low C-reactive protein level and blood glucose level might be predictors of RFS, but this needs to be confirmed in prospective multicenter studies.

Utility of the Global Respiratory Severity Score for predicting the need for respiratory support in infants with respiratory syncytial virus infection

Background

Respiratory syncytial virus (RSV) is a common cause of acute respiratory infection in children. One of the most important strategies for treatment of an RSV infection is to decide whether the patient needs respiratory support. This study aimed to assess the validity and clinical benefit of the Global Respiratory Severity Score (GRSS) and the Wang bronchiolitis severity score (WBSS) for clinical decision-making regarding providing respiratory support (high-flow nasal cannula, nasal continuous positive airway pressure, or ventilator) in infants with an RSV infection.

Study design and methods

This retrospective cohort study enrolled 250 infants aged under 10 months who were admitted to Atsugi City Hospital with an RSV infection between January 2012 and December 2019. The utility of these scores was evaluated for assessing the need for respiratory support through decision curve analysis by calculating the optimal GRSS and WBSS cut-offs for predicting the need for respiratory support.

Results

Twenty-six infants (10.4%) received respiratory support. The optimal cut-offs for the GRSS and the WBSS were 4.52 and 7, respectively. Decision curve analysis suggested that the GRSS was a better predictive tool than the WBSS if the probability of needing respiratory support was 10–40%.

Conclusions

The GRSS was clinically useful in determining the need for respiratory support in infants aged under 10 months with an RSV infection.

Impact of acute kidney injury in patients prescribed angiotensin-converting enzyme inhibitors over the first two years of life

BACKGROUND

The association of long-term acute kidney injury (AKI) risk with angiotensin-converting enzyme (ACE) inhibitor use in neonates/infants is poorly understood. We examined this association to identify potential AKI risk factors.

METHODS

We retrospectively evaluated 119 children aged < 2 years (72 boys; median age, 5.0 months) who received ACE inhibitors for congenital heart disease for ≥ 6 months between January 2009 and June 2019. We monitored the occurrence of AKI, defined according to the Kidney Disease Improving Global Outcomes guidelines. Demographic and clinical data were extracted from medical records. Risk factors associated with AKI onset were identified by a Cox proportional hazards regression analysis of variables previously identified as risk factors of AKI and those significant in a univariate analysis.

RESULTS

Thirty-three of 119 patients (28%) developed AKI at a median follow-up of 1.3 years (interquartile range, 0.8-3.2 years). AKI incidence was 1257 events per 10,000 patient-years. Concomitant tolvaptan use (hazard ratio [HR], 3.81; 95% confidence interval [CI], 1.82-7.97; P < 0.01) and Down syndrome (HR, 3.22; 95% CI, 1.43-7.29; P < 0.01) were identified as independent risk factors of AKI onset.

CONCLUSIONS

AKI was strongly associated with concomitant tolvaptan use and Down syndrome in our study population. Physicians should consider these factors when prescribing ACE inhibitors for neonates/infants. Low-dose ACE inhibitors slow CKD progression because of their antifibrotic properties. ACE inhibitors may be beneficial for patients with Down syndrome who have underlying CKD in a non-acute setting. Therefore, they should be administered to such patients with caution.

Clinical assessment of upper airway and its complications in Hunter syndrome

BACKGROUND

Hunter syndrome (HS) is an X-linked, recessive, lysosomal storage disease caused by a deficiency of the lysosomal enzyme, iduronate sulfatase (IDS). It is characterized by multisystem accumulations of glycosaminoglycans and upper airway obstruction is one of the major causes of death. While the current disease severity classifications for HS are mainly based on the degree of neurocognitive impairment, its association with the level of upper airway obstruction has not been assessed.

METHODS

A retrospective chart review of HS patients who were followed at the Jikei University School of Medicine was performed. Association between the degree of airway obstruction and the currently used disease severity scores was evaluated.

RESULTS

We identified eight HS patients and they were enrolled in the study. The Modified Mallampati classification (MMC) score, used to predict difficulties for oropharyngeal procedures, was significantly correlated with the HS severity. It was also correlated with the Apnea-Hypopnea Index (AHI). No significant correlation between IDS enzymatic activity and the severity of HS disease was identified.

CONCLUSIONS

Variable clinical expressivities exist in HS, but the risk of respiratory complications is likely to be associated with disease severity, assessed by the previously recognized neurocognitive function-based severity scoring systems. MMC can be a simple supplementary tool to evaluate disease severity as well as predict difficulties for oropharyngeal procedures and respiratory function complications in HS, such as sleep apnea.

Pectus carinatum as the key to early diagnosis of Morquio A syndrome: a case report

Background

A 20-month-old Asian boy with normal growth presented with genu valgum, kyphosis, and pectus carinatum, with no neurological symptoms. No other symptoms suggestive of mucopolysaccharidoses, for example joint contracture and peculiar facies, were present.

Case presentation

As part of our differential diagnosis we found elevated urine glycosaminoglycans, which triggered further investigation. Detailed examination showed flattening of the ribs, kyphoscoliosis and ovalization of the thoracolumbar vertebral body, strikingly short metacarpals, and very slight cardiac regurgitation. N-Acetylgalactosamine-6-sulfatase levels in the blood and dermal fibroblasts were very low, thus confirming diagnosis of Morquio A within 2 months of presentation. The patient was placed on elosulfase alfa enzyme replacement therapy and followed for 3 years.

Conclusions

This case exemplifies the importance of considering mucopolysaccharidoses as part of the initial differential diagnosis of pediatric patients with skeletal deformities; urine glycosaminoglycan levels and a blood enzyme mucopolysaccharidoses panel are simple screening tests that could lead to early definitive diagnosis.

Perinatal factors contributing to chronic kidney disease in a cohort of Japanese children with very low birth weight

BACKGROUND

Developmental programming of chronic kidney disease (CKD) in young adults is linked to preterm birth and intrauterine growth restriction (IUGR). Which confers a higher risk of progression to chronic kidney damage in children with very low birth weight (VLBW; born weighing < 1500 g): prematurity or IUGR?

METHODS

This is a national historical cohort study of children with VLBW cared for in perinatal medical centers in Japan. Predictive factors included three latent variables (prematurity, IUGR, stress during neonatal period) and eight observed variables (gestational age, birth weight Z-score, maternal age, duration of treatment with antibiotics and diuretics, maternal smoking, late-onset circulatory collapse, kidney dysfunction) during the perinatal period. The primary endpoint was estimated glomerular filtration rate (eGFR) at age ≥ 3 years. A structural equation model was used to examine the pathologic constitution.

RESULTS

The 446 children with VLBW included 253 boys and 193 girls, of mean age 5.8 ± 2.6 years and mean eGFR 111.7 ml/min/1.73 m² at last encounter. Pathway analyses showed intrauterine malnutrition (β = 0.85) contributed more to chronic kidney damage than stress during the neonatal period (β = - 0.19) and prematurity (β = 0.12), and kidney dysfunction and late-onset circulatory collapse were important observed variables in stress during the neonatal period.

CONCLUSIONS

IUGR was more harmful to future kidneys of VLBW neonates. Neonatal kidney dysfunction and late-onset circulatory collapse were important risk factors for subsequent CKD development. This emphasizes the need for obstetricians to monitor for fetal growth restriction and neonatologists to minimize neonatal stress to prevent CKD in later life.

The role of inflammatory markers and calculated osmotic pressure in the classification of febrile seizures

OBJECTIVE

Systemic inflammatory response may contribute to the onset of febrile seizures (FSs). The neutrophil-to-lymphocyte ratio (NLR) has been reported to be useful for differentiating simple and complex FSs in children with a first FS. This study aimed to determine whether easily measurable inflammatory markers were useful for distinguishing between the types of FSs in children with FSs not limited to the first FS.

PATIENTS AND METHODS

We conducted a retrospective study of children aged 6-60 months who were presented to the Atsugi City Hospital in Japan for the treatment of FSs between December 2018 and February 2020. A complex FS was defined as a seizure with multiple seizures during the same febrile illness, prolonged seizures and/or focal seizures. A simple FS was defined as a seizure without the characteristics of complex FS. We assessed complete blood count, C-reactive protein, and calculated osmotic pressure.

RESULTS

A total of 205 children with FSs (simple, 139; complex, 66) fulfilled the inclusion criteria. None of the inflammatory markers, including NLR, could predict the FS type. The median osmotic pressure was 279.0, 278.8, 283.3, and 278.3 mOsm/kg H2O for children with simple, multiple, prolonged, and focal seizures, respectively. Children with prolonged seizures had a significantly higher calculated osmotic pressure than those with simple FSs (p<0.001) and multiple seizures during the same febrile illness (p=0.004).

CONCLUSIONS

Easily measurable inflammatory markers, including NLR, were not useful for distinguishing between types of FSs in children. Large multicenter studies are needed to evaluate the association between osmotic pressure and FS.

Effect of Avoiding Cow's Milk Formula at Birth on Prevention of Asthma or Recurrent Wheeze Among Young Children: Extended Follow-up From the ABC Randomized Clinical Trial

IMPORTANCE

Children with food allergies may develop asthma or recurrent wheeze.

OBJECTIVE

To evaluate whether asthma or recurrent wheeze among children were changed by avoiding supplementing breastfeeding (BF) with cow's milk formula (CMF) in the first 3 days of life.

DESIGN, SETTING, AND PARTICIPANTS

This randomized, unmasked, clinical trial was conducted at 1 university hospital in Japan beginning October 2013 with follow-up examinations occurring until January 2020. A total of 312 newborns at risk for atopy were randomized and assigned to either BF with or without amino acid-based elemental formula (EF) or BF with CMF, with follow-up examinations for participants showing signs of atopy conducted at 24 months. Follow-up examinations ran through January 2020.

INTERVENTIONS

Immediately after birth, newborns were randomly assigned (1:1 ratio) to either breastfeeding with or without amino acid-based elemental formula for at least the first 3 days of life (no CMF group) or breastfeeding supplemented with CMF (≥5 mL/d) from the first day of life to 5 months of age (CMF group).

MAIN OUTCOMES AND MEASURES

Asthma or recurrent wheeze diagnosed by the pediatric allergy specialists of this trial; subgroups were stratified by serum levels of 25-hydroxyvitamin D and IgE.

RESULTS

Of 312 infants (156 [50.0%] randomized to the no CMF group), 302 (96.8%) were followed up at their second birthday: 77 of 151 (51.0%) in the no CMF group and 81 of 151 (53.6%) in the CMF group underwent extended follow-up because of having atopic conditions. Asthma or recurrent wheeze developed in 15 (9.9%) of the children in the no CMF group, significantly less than the children in the CMF group (27 [17.9%]; risk difference, -0.079; 95% CI, -0.157 to -0.002). In participants with vitamin D levels above the median at 5 months of age, asthma or recurrent wheeze developled in 5 (6.4%) children in the no CMF group, significantly less than in the children in the CMF group (17 [24.6%]; risk difference, -0.182; 95% CI, -0.298 to -0.067; P for interaction = .04). In the highest quartile group of total IgE at age 24 months, asthma or recurrent wheeze developed in 2 children (5.3%) in the no CMF group, significantly less than the children in the CMF group (14 [43.8%]; risk difference, -0.385; 95% CI, -0.571 to -0.199; P for interaction = .004).

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that avoiding CMF supplementation in the first 3 days of life has the potential to reduce the risk of asthma or recurrent wheeze in young children, especially among those with high vitamin D or high IgE levels.

TRIAL REGISTRATION

umin.ac.jp/ctr Identifier: UMIN000011577.

Preventive Effect of Tonsillectomy on Recurrence of Henoch-Schönlein Purpura Nephritis after Intravenous Methylprednisolone Pulse Therapy

Henoch-Schönlein purpura (HSP) is regarded as a benign and self-limiting vasculitis characterized by purpura, arthritis, and gastrointestinal symptoms; however, about one third of the patients develop HSP nephritis (HSPN), the most serious long-term complication. Since 2013, we have proposed that tonsillectomy in addition to intravenous methylprednisolone pulse therapy (IVMP) be performed in all patients with HSPN, similar to immunoglobulin A nephropathy (IgAN) patients because both diseases are considered to a share common pathogenesis. Herein, we retrospectively reviewed the clinical courses of 71 Japanese children with HSPN (34 boys; median age at diagnosis, 6.7 years; median follow-up period, 5.6 years) who had received initial treatment with IVMP (15-20 mg/kg; on 3 consecutive days/week for 3 weeks) followed by oral prednisolone (initially 1 mg/kg; tapered off within 12 months) and achieved clinical remission (i.e., disappearance of both proteinuria and hematuria). The patients were divided into two groups: 31 patients receiving tonsillectomy after IVMP between 2013 and 2017 (tonsillectomy group) and 40 patients receiving IVMP monotherapy between 2003 and 2012 (IVMP group). For the 2 years after IVMP therapy, the rate of HSPN recurrence (i.e., persistent proteinuria combined with hematuria requiring additional treatments) after clinical remission was significantly lower in the tonsillectomy group than the IVMP group (0% vs. 19%, P < 0.05). Despite the short follow-up period in the tonsillectomy group, this study provides the evidence that tonsillectomy may be beneficial for preventing recurrence of HSPN from clinical remission with IVMP therapy in Japanese children.

Independent risk factors and long-term outcomes for acute kidney injury in pediatric patients undergoing hematopoietic stem cell transplantation: a retrospective cohort study

BACKGROUND

Acute kidney injury (AKI) remains a frequent complication in children undergoing hematopoietic stem cell transplantation (HSCT) and an independent risk factor of the patient's survival and a prognostic factor of progression to chronic kidney disease (CKD). However, the causes of these complications are diverse, usually overlapping, and less well understood.

METHODS

This retrospective analysis was performed in 43 patients (28 boys, 15 girls; median age, 5.5 years) undergoing HSCT between April 2006 and March 2019. The main outcome was the development of AKI defined according to the Pediatric Risk, Injury, Failure, Loss, End-stage Renal Disease (pRIFLE) criteria as ≥ 25% decrease in estimated creatinine clearance. The secondary outcome was the development of CKD after a 2-year follow-up.

RESULTS

AKI developed in 21 patients (49%) within 100 days after HSCT. After adjusting for possible confounders, posttransplant AKI was associated with matched unrelated donor (MUD) (HR, 6.26; P = 0.042), but not total body irradiation (TBI). Of 37 patients who were able to follow-up for 2 years, 7 patients died, but none had reached CKD during the 2 years after transplantation.

CONCLUSIONS

Posttransplant AKI was strongly associated with HSCT from MUD. Although the incidence of AKI was high in our cohort, that of posttransplant CKD was lower than reported previously in adults. TBI dose reduced, GVHD minimized, and infection prevented are required to avoid late renal dysfunction after HSCT in children since their combinations may contribute to the occurrence of AKI.

AB0619 PROGNOSTIC FACTORS OF PATIENTS WITH ANTI-MDA5 ANTIBODY-POSITIVE DERMATOMYOSITIS COMPLICATED WITH INTERSTITIAL PNEUMONIA -A JAPANESE SINGLE CENTER STUDY-

Background:

Anti-melanoma differentiation-associated gene 5 antibody (anti-MDA5 Ab)-positive dermatomyositis (DM) is frequently associated with rapidly progressive interstitial pneumonia (RPIP), whose prognosis is assumed to be poor[1]. Although outcome of DM-RPIP has been reported to be improved by early immunosuppressive therapy, we still experience the cases with severe outcome. Only several reports mentioned the prognostic factors and they have not been fully elucidated.

Objectives:

To identify the predictors of prognosis in patients with anti-MDA5 Ab-positive DM associated with interstitial pneumonia (DM-IP).

Methods:

Anti-MDA5 Ab-positive DM-IP patients admitted to Fujita Health University Hospital between January 2010 and October 2019 were consecutively included and stratified into 2 groups, the survived and the deceased groups. DM was diagnosed according to the criteria proposed by Bohan and Peter[2]. Clinically amyopathic DM was diagnosed according to the criteria proposed by Sontheimer [3]. Diagnosis of IP was based on findings of high resolution CT scan (HRCT). The definition of RPIP was rapid exacerbation of hypoxemia or HRCT findings in a period of days to one month after the onset. Clinical features and prognosis of the patients were collected retrospectively and compared between groups. Candidates of predictors are extracted by the univariable analysis using Fisher’s exact test for dichotic parameters and Wilcoxon signed-rank test for continuous parameters and multivariable analysis using logistic regression analysis. Receiver operating characteristic (ROC) curve analysis was examined to obtain the cut-off level. Survival was examined using Kaplan-Meier method and Log-rank test.

Results:

Twenty-one patients were involved. Eight were deceased and 13 were survived. The deceased group had a higher ratio of male (75% versus 25%, p= 0.018). All deceased cases were with RPIP and 67 % in the survived cases. Levels of serum ferritin (4490 versus 646 ng/mL, p = 0.0026), CRP (2.1 versus 0.9 mg/dL, p = 0.0490), CK (1150 versus 290 U/L, p = 0.017), AST (194 versus 108 U/L, p = 0.025) and LDH (674 versus 368 U/L, p = 0.011) were higher in the deceased group. Interestingly, skin ulcers were tended to be more frequent (12.5% versus 87.5%, p= 0.0587), and anti-SS-A antibody was also more frequently detected (14.3% versus 85.7%, p=0.0072) in the survived group. Using ROC analysis cut-off values were 963 ng/mL for serum ferritin level (sensitivity 100%, specificity 83%), 0.7 mg/dL for CRP (sensitivity 75%, specificity 69%), 308 U/L for CK (sensitivity 88%, specificity 77%), 62 U/L for ALT (sensitivity 100%, specificity 62%), and 454 U/L for LDH (sensitivity 88%, specificity 77%). Patients were divided into two groups based on these cut-offs or based on dichotic parameters and survival was examined between 2 groups. Except CRP and anti-SS-A antibody, survival was significantly worse in parameter-positive or higher groups. Interestingly, anti-SS-A antibody-positive group had better outcome compared with those without.

Conclusion:

In our analysis, novel candidates such as serum CK, AST, and LDH levels were newly extracted and parameters previously reported was also included and those were also associated with the clinical outcome. In addition, anti-SS-A antibody was identified as a novel protective factor associated with a good outcome.

References:

[1]Nakashima R, Hosono Y, Mimori T. Clinical significance and new detection system of autoantibodies in myositis with interstitial lung disease. Lupus 2016;25:925-33.

[2]Bohan A, Peter JB. Polymyositis and dermatomyositis. N Eng J Med 1975;292:344-7.

[3]Sontheimer RD. Dermatomyositis: an overview of recent progress with emphasis on dermatologic aspects. Dermatol Clin 2000;20:387-408.

Disclosure of Interests:

None declared

Predictors of recurrent febrile seizures during the same febrile illness in children with febrile seizures

Febrile seizures (FS) are common in childhood. Of children who experience an FS, 14-24% experience recurrence within 24 h, during the same febrile illness (RFS). The aim of this pilot study was to identify the predictors of RFS among children who experience FS. We conducted a retrospective cohort study of children aged 6-60 months, who visited the emergency department (ED) at Atsugi City Hospital in Japan for treatment of an FS between December 1, 2018 and February 28, 2019. Exclusion criteria included multiple seizures before visiting the ED, diazepam administration before visiting the ED or on departure, seizures lasting >15 min, underlying diseases such as epilepsy, and absence of laboratory test results. The primary outcome was RFS. Fifty-one patients fulfilled the inclusion criteria, of whom nine (17.6%) had RFS. The incidence of RFS was significantly higher in children with a body temperature ≤ 39.8 °C during the ED visit (P = .01). The combination of male sex and a body temperature ≤ 39.8 °C had a sensitivity, specificity and negative predictive value of 88.9%, 76.2%, and 97.0%, respectively. In conclusion, the incidence of RFS was 17.6%. The major predictors of RFS were male sex and a body temperature ≤ 39.8 °C.

Molecular mechanisms determining severity in patients with Pierson syndrome

Null variants in LAMB2 cause Pierson syndrome (PS), a severe congenital nephrotic syndrome with ocular and neurological defects. Patients' kidney specimens show complete negativity for laminin β2 expression on glomerular basement membrane (GBM). In contrast, missense variants outside the laminin N-terminal (LN) domain in LAMB2 lead to milder phenotypes. However, we experienced cases not showing these typical genotype-phenotype correlations. In this paper, we report six PS patients: four with mild phenotypes and two with severe phenotypes. We conducted molecular studies including protein expression and transcript analyses. The results revealed that three of the four cases with milder phenotypes had missense variants located outside the LN domain and one of the two severe PS cases had a homozygous missense variant located in the LN domain; these variant positions could explain their phenotypes. However, one mild case possessed a splicing site variant (c.3797 + 5G>A) that should be associated with a severe phenotype. Upon transcript analysis, this variant generated some differently sized transcripts, including completely normal transcript, which could have conferred the milder phenotype. In one severe case, we detected the single-nucleotide substitution of c.4616G>A located outside the LN domain, which should be associated with a milder phenotype. However, we detected aberrant splicing caused by the creation of a novel splice site by this single-base substitution. These are novel mechanisms leading to an atypical genotype-phenotype correlation. In addition, all four cases with milder phenotypes showed laminin β2 expression on GBM. We identified novel mechanisms leading to atypical genotype-phenotype correlation in PS.

Predictive factors of first dosage intravenous immunoglobulin-related adverse effects in children

BACKGROUND

Intravenous immunoglobulin (IVIG) therapy is used in the treatment of various diseases, and IVIG-related adverse effects (IVIG-AEs) vary from mild to severe. However, the mechanisms underlying IVIG-AEs and the potential predictive factors are not clear. This study investigated whether certain IVIG-AEs can be predicted before IVIG administration.

STUDY DESIGN AND METHODS

This retrospective cohort study at the Division of Neurology, Saitama Children's Medical Center included patients enrolled from 2008 to 2018 who were < 18 years old and received IVIG for the first time. IVIG-AEs were classified according to the Common Terminology Criteria for Adverse Events version 5.0.

RESULTS

A total of 104 patients fulfilled the inclusion criteria. The rate of IVIG-AEs was 37.5% (39/104). The most frequent IVIG-AEs were fever (41.0% [16/39]) and headache (38.5% [15/39]). AEs were below grade 2 in all except one patient and there were no grade 4 AEs. High serum total protein (TP) level was significantly related to the occurrence of IVIG-AEs (odds ratio, 14.8; 95% confidence interval, 2.4-90.5; P < 0.01). The optimal cutoff TP level was 6.7 g/dL. Although low WBC count and immunoglobulin G level may be predictive risk factors of IVIG-AEs, it was not confirmed in this study.

CONCLUSION

IVIG-AEs occurred in 37.5% of cases, and most were mild. TP was the best predictive risk factor of IVIG-AEs before IVIG administration. These results may aid in elucidating the mechanism underlying IVIG-AEs.

Primary Prevention of Cow's Milk Sensitization and Food Allergy by Avoiding Supplementation With Cow's Milk Formula at Birth: A Randomized Clinical Trial

IMPORTANCE

Cow's milk formula (CMF) is used to supplement breastfeeding (BF) at birth without clear clinical evidence to support the practice.

OBJECTIVE

To determine whether avoiding supplementation with CMF at birth can decrease risks of sensitization to cow's milk protein and/or clinical food allergy, including cow's milk allergy (CMA), overall and in subgroups stratified by 25-hydroxyvitamin D (25[OH]D) levels.

DESIGN, SETTING, AND PARTICIPANTS

The Atopy Induced by Breastfeeding or Cow's Milk Formula (ABC) trial, a randomized, nonblinded clinical trial, began enrollment October 1, 2013, and completed follow-up May 31, 2018, at a single university hospital in Japan. Participants included 330 newborns at risk for atopy; of these, 312 were included in the analysis. Data were analyzed from September 1 through October 31, 2018.

INTERVENTIONS

Immediately after birth, newborns were randomized (1:1 ratio) to BF with or without amino acid-based elemental formula (EF) for at least the first 3 days of life (BF/EF group) or BF supplemented with CMF (≥5 mL/d) from the first day of life to 5 months of age (BF plus CMF group).

MAIN OUTCOMES AND MEASURES

The primary outcome was sensitization to cow's milk (IgE level, ≥0.35 allergen units [UA]/mL) at the infant's second birthday. Secondary outcomes were immediate and anaphylactic types of food allergy, including CMA, diagnosed by oral food challenge test or triggered by food ingestion, with food-specific IgE levels of at least 0.35 UA/mL. Subgroup analysis was prespecified by tertiles of serum 25(OH)D levels at 5 months of age.

RESULTS

Of the 312 infants included in the analysis (160 female [51.3%] and 152 male [48.7%]), 151 of 156 (96.8%) in the BF/EF and BF plus CMF groups were followed up until their second birthday. The primary outcome occurred in 24 infants (16.8%) in the BF/EF group, which was significantly fewer than the 46 infants (32.2%) in the BF plus CMF group (relative risk [RR], 0.52; 95% CI, 0.34-0.81). The middle tertile of the 25(OH)D subgroup, but not the low and high tertiles, had a significant interaction with the intervention (RR, 0.19; 95% CI, 0.07-0.50; P = .02). The prevalence of food allergy at the second birthday was significantly lower in the BF/EF than in the BF plus CMF groups for immediate (4 [2.6%] vs 20 [13.2%]; RR, 0.20; 95% CI, 0.07-0.57) and anaphylactic (1 [0.7%] vs 13 [8.6%]; RR, 0.08; 95% CI, 0.01-0.58) types.

CONCLUSIONS AND RELEVANCE

The evidence suggests that sensitization to cow's milk and food allergy, including CMA and anaphylaxis, are primarily preventable by avoiding CMF supplementation for at least the first 3 days of life.

TRIAL REGISTRATION

http://umin.ac.jp Identifier: UMIN000011577.

Clinical characteristics at the renal replacement therapy initiation of Japanese pediatric patients: a nationwide cross-sectional study

BACKGROUND

Although there is debate regarding the timing of initiation of renal replacement therapy (RRT) in adults with end-stage renal disease, there is a paucity of reliable epidemiological data on pediatric patients. The present study was performed to investigate current practice in Japan with regard to the timing of initiation of RRT in children based on estimated glomerular filtration rate (eGFR).

METHODS

A total of 649 pediatric patients < 20 years old with eGFR at the initiation of RRT between 1 January 2006 and 31 December 2013 were included in the study. Baseline eGFR was calculated for each patient using the Schwartz formula.

RESULTS

eGFR at the start of RRT was 12.1 mL/min/1.73 m² [interquartile range (IQR) 8.4-16.3]. A total of 209 children (32.2%) had high eGFR (eGFR > 15 mL/min/1.73 m²) at the initiation of RRT. Initiation of RRT was more likely in those undergoing preemptive transplantation (PEKT) with high eGFR [odds ratio (OR) 4.16; 95% confidence interval (CI) 1.95-8.90, P < 0.001]. There were 31 deaths of various causes during follow-up, with infections representing the leading causes of death.

CONCLUSIONS

The median eGFR at the initiation of RRT in children showed a wide range of variation. Further studies are needed to investigate the impact of the decision regarding when to initiate RRT in individual pediatric patients.

Epidemiology and clinical features of childhood-onset anti-neutrophil cytoplasmic antibody-associated vasculitis: a clinicopathological analysis

BACKGROUND

This study was performed to determine the clinical features and outcomes of childhood-onset anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV), particularly microscopic polyangiitis (MPA).

METHODS

A retrospective Japanese multicenter study was performed in patients diagnosed with AAV before 16 years of age.

RESULTS

Of 49 patients with AAV, 36 were female. The diagnoses were as follows: MPA (n = 38, 78%), granulomatosis with polyangiitis (GPA; n = 9, 18%), eosinophilic granulomatosis with polyangiitis (EGPA; n = 1, 2%), and other (n = 1, 2%). The median age at onset was 10.7 years, and median time to diagnosis was 2.0 months. Twenty-seven (55%) patients were identified through a school urinary screening program. Initial symptoms included fever and fatigue (45%), and renal (71%), pulmonary (29%), ocular (20%), and mucocutaneous involvement (22%). Although 27 (55%) patients achieved remission and none had died at the last follow-up, at least one recurrence occurred in 13 (48%) patients after a median of 48 months and was more common in patients with GPA (P < 0.01). After a median follow-up of 43 months, seven (14%) patients (all with MPA) progressed to end-stage renal disease (ESRD).

CONCLUSIONS

Childhood-onset AAV has an estimated prevalence of 3.41-4.28 per million children and is characterized by female predominance and high frequency of detection in school urinary screening programs. More than 10% of patients with childhood-onset AAV still progress to ESRD without achieving remission. Histological chronicity is a factor associated with ESRD.

Skin injuries and joint contractures of the upper extremities in Rett syndrome

OBJECTIVES

The purpose of this study was to investigate the incidence and type of skin injuries and joint contractures of the upper extremities in individuals with Rett syndrome.

METHODS

In 2016, a questionnaire regarding skin injuries and joint contractures was sent to 1016 directors of schools for special needs education and 204 directors of departments of rehabilitation [consisting of 130 facilities for persons with severe motor and intellectual disabilities (SMID), 73 wards for patients with SMID, and the National Hospital Organisation and National Centre Hospital, National Centre of Neurology and Psychiatry] in Japan. Descriptive statistics were used to indicate frequency in each question.

RESULTS

Information was acquired from 216 cases (3-53 years old) with Rett syndrome. Skin injuries and joint contractures of the upper extremities were observed in 41% and 49% of individuals with Rett syndrome, respectively. Most of the skin injuries were observed on the hands (19%) and fingers (29%). The incidence of skin injuries was not affected by age or disease severity. Many joint contractures were observed in the shoulder (33%) and elbow (29%) joints. Joint contractures tended to occur in individuals aged over 10 years or with severe locomotor impairment.

CONCLUSION

Almost half of the Rett syndrome subjects assessed in the present study had skin injuries and joint contractures. Especially, the incidence of joint contractures was affected by age and disease severity. Thus, it is important that medical staff attempt to prevent the occurrence of skin injuries and joint contractures in this patient population.

Independent Risk Factors and 2-Year Outcomes of Acute Kidney Injury after Surgery for Congenital Heart Disease

BACKGROUND

Data are limited regarding risk factors for acute kidney injury (AKI) following cardiac surgery in children with congenital heart disease (CHD). This observational study was performed to examine temporal trends in AKI incidence according to the Pediatric Risk, Injury, Failure, Loss, End-Stage Renal Disease (pRIFLE) criteria, identify independent risk factors for AKI after cardiac surgery, and examine associations between AKI and long-term mortality.

METHODS

We retrospectively evaluated 418 patients (259 males, 159 females; median age, 5 months) who underwent cardiac surgery for CHD between April 2007 and August 2013. Patients were followed up for 2 years. AKI was defined according to the pRIFLE criteria as ≥25% decrease in estimated creatinine clearance.

RESULTS

AKI developed postoperatively in 104 cases (24.9%). Approximately 80% belonged to the "Risk" category according to the pRIFLE criteria, and only 21 cases (5%) required renal replacement therapy (peritoneal dialysis in all cases). Multivariate analysis revealed 3 independent risk factors for onset of AKI: young age (<1 year), surgery in Risk Adjustment in Congenital Heart Surgery (RACHS-1) category ≥4, and long cardiopulmonary bypass (CPB) time (≥90 min). Twenty-three patients (22%) with AKI died during the 2-year follow-up. In multivariate cox hazard regression analysis, the most significant contributor to risk of mortality was AKI.

CONCLUSIONS

Postoperative AKI was strongly associated with young age, high RACHS-1 category, and prolonged CPB time. In addition, mortality rate was higher in patients who survived after recovery from AKI than in those without AKI, even among the lower pRIFLE categories.

Azithromycin suppressed relapses of idiopathic nephrotic syndrome in a child

Long-term immunosuppressive therapy with severe adverse effects is indispensable to maintain disease remission in frequently relapsing nephrotic syndrome (NS) in children. Hence, development of new therapy with less toxicity for relapses of NS is required. We demonstrated a case of a 2-year-old boy with frequently relapsing NS, whose frequent relapses were successfully treated with azithromycin. Azithromycin treatment prevented the need for long-term immunosuppressive therapy in this case. Azithromycin could be a new treatment option for relapse of NS, with few adverse effects, in selected cases.

Impaired nephrogenesis in neonatal rats with oxygen-induced retinopathy

BACKGROUND

Preterm neonates are born while nephrogenesis is ongoing, and are commonly exposed to factors in a hyperoxic environment that can impair renal development. Oxidative stress has also been implicated in the development of retinopathy of prematurity (ROP). The rat model of oxygen-induced retinopathy (OIR) is the most clinically relevant model of ROP because its biologic features closely resemble those of ROP in preterm infants. We investigated impaired renal development in a rat model of OIR.

METHODS

Newborn Sprague-Dawley rats were maintained in either a normoxic (room air, 21% O₂ ; control group) or a controlled hyperoxic (80% O₂ ; OIR group) environment from birth to postnatal day (P) 12. All pups were then raised in room air from P12 to P19.

RESULTS

The hyperoxic environment led to significantly higher urinary excretion of 8-hydroxy-2'-deoxyguanosine, a marker of oxidative DNA damage, and a reduction in nephrogenic zone width at P5 in OIR pups. Additionally, glomerular count was significantly reduced by 20% in the OIR group, and avascular and neovascular changes in the retina were observed only in the OIR group at P19. Messenger RNA levels of vascular endothelial growth factor-A (VEGF-A) and platelet-derived growth factor-β, essential angiogenic cytokines for glomerulogenesis, in the renal cortex were significantly lower at P5 and significantly higher at P19 in the OIR group compared with controls.

CONCLUSION

Renal impairment was caused by exposure to a hyperoxic environment during nephrogenesis, and the pathology of the impaired nephrogenesis in this OIR model reflects the characteristics of ROP observed in preterm infants.

Oral alendronate in pediatric chronic recurrent multifocal osteomyelitis

Chronic recurrent multifocal osteomyelitis (CRMO) primarily affects children and adolescents, and is characterized by episodic sterile osteomyelitis over several years. No definitive treatment is available. Non-steroidal anti-inflammatory drugs (NSAID) are common first-line agents, but provide limited improvement in bone pain and do not affect disease duration. Several agents are utilized in the case of non-response to NSAID, including corticosteroids, methotrexate, and tumor necrosis factor-blocking agents. Bisphosphonates are increasingly being used. Most case series involve cyclic i.v. pamidronate, but this restricts the social lives of children and their families. Although oral medication has advantages over cyclic i.v. infusion because it does not require repeated hospital admissions, there have been no reports on treatment with oral bisphosphonates, such as alendronate, in pediatric CRMO patients. This case report describes the use of oral bisphosphonate as an alternative treatment in CRMO patients in whom standard therapy has failed.

Evaluation of kidney dysfunction and angiotensinogen as an early novel biomarker of intrauterine growth restricted offspring rats

BACKGROUND

Few studies have addressed the growing concerns of chronic kidney diseases in children with intrauterine growth restriction (IUGR). Therefore, the purpose of this study was to evaluate long-term kidney dysfunction and determine if urinary angiotensinogen (AGT) was suitable as a novel early biomarker for kidney dysfunction in IUGR offspring.

METHODS

Pregnant rats underwent bilateral uterine artery ligation, and as a control group, sham surgeries were performed.

RESULTS

The birth weight was reduced, the urinary AGT to creatinine ratio was significantly higher at week 20, and urinary protein levels were significantly higher at week 32 in IUGR rats than in control rats. On the other hand, the histological findings at week 32 revealed long-term kidney dysfunction, more severe glomerulosclerosis, and greater glomerular diameters in IUGR rats. Moreover, AGT mRNA expression and immunohistological staining were significantly increased in IUGR rats; this suggests that the intrarenal renin-angiotensin system (RAS) contributes to renal dysfunction of IUGR offspring.

CONCLUSION

Urinary AGT elevation prior to urinary protein levels suggests that AGT is an early biomarker. At week 32, kidney dysfunction was severe in IUGR rats and intrarenal RAS appeared to be one of the causes.

Tolvaptan in a pediatric patient with diuretic-resistant heart and kidney failure

Despite conventional diuretic therapy, volume overload persists in many patients with decompensated heart failure. Adverse effects of diuretics are common, including worsening kidney function and electrolyte disturbance. Furthermore, decreased kidney function also affects the response to diuretics and is associated with an increased risk of mortality. A 10-year-old boy with congestive heart failure (CHF) complicated by advanced chronic kidney disease (CKD) presented with oliguria and generalized edema. He was being treated with furosemide and spironolactone, and these doses were increased to 3 mg/kg/day after admission. Although edema decreased temporarily, the symptoms worsened and furosemide resistance developed 2 months later. Tolvaptan (0.1 mg/kg/day) was started, resulting in a gradual increase in the plasma sodium level and adequate decongestion of the volume overload state. Cardiac function also improved. The use of tolvaptan should be considered in pediatric cases of conventional diuretic-resistant CHF, even when complicated by advanced CKD.