Pediatric chronic kidney disease: blood cell count indexes as inflammation markers

INTRODUCTION

Chronic kidney disease (CKD) is defined as a progressive decline of kidney functions. In childhood, the main triggering factors are congenital anomalies of the kidneys and urinary tract (CAKUT) and glomerulopathies. Inflammatory responses present challenges for diagnosis and staging, which justifies studies on biomarkers/indexes.

AIM

To define blood cell count indexes and verify their association with pediatric CKD etiology and staging. The included indexes were: Neutrophil-Lymphocyte Ratio (NLR), Derived Neutrophil-Lymphocyte Ratio (dNLR), Lymphocyte-Monocyte Ratio (LMR), Systemic Inflammation Response Index (SIRI), Aggregate Index of Systemic Inflammation (AISI), and Systemic Immune-Inflammation Index (SII).

METHODS

We determined the indexes in 52 pediatric CKD patients and 33 healthy controls by mathematical calculation. CKD patients were separated in five groups based on the etiology and staging: Group IA: glomerulopathies at stage 1 or 2; IB: glomerulopathies at stage 3 or 4; IIA: CAKUT at stage 1 or 2; IIB: CAKUT at stage 3 or 4; and III: stages 3 or 4 of other etiologies. In addition, we combined all patients with CKD in one group (IV). Group V was a healthy control group.

RESULTS

Lower values of LMR were observed for groups IB and IIB compared to group V (p = 0.047, p = 0.031, respectively). Increased values of SIRI were found for group III versus group V (p = 0.030). There was no difference for other indexes when the groups were compared two by two.

CONCLUSION

The LMR and SIRI indexes showed promising results in the evaluation of inflammation, as they correlated with CKD etiologies and specially staging in these patients.

The use and role of telemedicine in maternal fetal medicine around the world: an up-to-date

Purpose

The aim of this narrative review is to sumarize data about the use and role of telemedicine in maternal fetal medicine (MFM).

Methods

We searched pubmed and scopus to find articles about telemedicine in MFM by using the terms telmedicine or telehealth and maternal fetal medicine.

Results

Telehealth has been widely used for several medical specialties. During the coronavirus disease 2019 (COVID-19) pandemic, telehealth has gained investment and further research. Even though telemedicine in MFM has not been frequently applied, from 2020 onwards it has increased in both implementation and acceptance worldwide. The need to screen the patients in overloaded centers in a pandemic scenario required telemedicine in MFM, which has exhibited consistently good results concerning health and budget. The aim of this study was to review the telehealth programs and research focused on MFM around the world. Few studies have been applied to MFM and even fewer in developing and undeveloped countries. The majority of studies were concentrated in the USA and in Europe.

Conclusion

Further research is needed, especially in non-developed countries, to comprehend the potential role of telemedicine in MFM for improving the life quality of the patients, health professionals, and to be cost-efficient.

Pharmacogenomic markers of glucocorticoid response in congenital adrenal hyperplasia

Glucocorticoids (GC) replacement are the mainstay treatment for 21-hydroxylase deficiency (21-OHD), the most common cause of congenital adrenal hyperplasia (CAH), in its classical form. There are novel insights into the genetic basis of the GC action diversity that point to an important role for GC receptor (GR) gene polymorphisms, suggesting a possible modulation in occurrence of metabolic disorders, what may be relevant to clinical management of 21-OHD. The aim of this study was to investigate whether the five GR gene polymorphisms Tth111I, ER22, 23EK, BclI, 9β (rs10052957, rs6189, rs6190, rs41423247, rs6198) and their combination into haplotypes are associated to different GC response in a cohort of classic 21-OHD subjects. GR genotype-phenotype associations were explored after a dexamethasone suppression test using very low-doses (VLD-DST), 20 and 40 μg/m². The final sample (n = 28) was selected based on the 102 individuals' previous genotypes classification, according to literature data of GC sensitivity or resistance. Thus, only patients with GC increased resistance (n = 18) or increased sensitivity (n = 10) profiles were selected. Out of 28 subjects aged 12 (2-34) years enrolled in this study, 75% were females, 75% presented the salt-wasting form (SW) and 25% the simple virilizing form (SV). Subjects who carried Tth111I and 9β, associated or not to the ER22/23EK variants, showed an impaired DST response. Results did not differ significantly according to gender or body mass index. SV subjects with GC hypersensitivity-genotypes showed decreased average cortisol levels compared to those with GC resistance-genotypes (p = 0.0023). The Tth111I + 9β/ Wild or Tth111I + ER22/23EK + 9β/ Wild genotypes were associated to GC resistance in this population. This finding may be relevant given the challenges posed by therapeutic management with GC in CAH.

Validation of the Vancouver Symptom Score Questionnaire for bladder and bowel dysfunction for Brazilian children and adolescents

OBJECTIVE

This study aimed to translate, and perform a cross-cultural adaptation, and validation of the Vancouver Symptom Score (VSS) for bladder and bowel dysfunction (BBD) for Brazilian children and adolescents Materials and Methods: Six steps were performed for the translation and cross-cultural adaptation: (1) translation, (2) synthesis of translations, (3) back-translation, (4) pre-final version of the translated instrument, (5) pilot test and degree of comprehensibility and (6) elaboration of the Brazilian version of the VSS. For validation, the Brazilian Dysfunctional Voiding Score (DVSS) questionnaire was used.

RESULTS

Validation was performed on a sample of 107 children and adolescents with a mean age of 9.2 ± 2.84 years, presenting BBD and 107 without BBD (control group-CG). There was a positive correlation (r = 0.91, 95% CI 0.88 to 0.93, p < 0.0001) between total VSS score and total DVSS score. VSS was higher in patients with BBD (p < 0.0001). The internal consistency estimated by Cronbach's alpha was 0.87 for patients with BBD. The VSS showed excellent diagnostic accuracy in detecting cases, with an area under the ROC curve of 98% (95% CI 0.96 to 0.99, p < 0.001). A cut-off value of >11 points produced a sensitivity of 100% (95% CI 96.4% to 100%) and a specificity of 91.8% (95% CI 85.1% to 95.6%).

CONCLUSION

The translated, cross-culturally adapted, and validated VSS for the Brazilian population is a reliable and valid tool to identify symptoms of BBD in children and adolescents aged five to 16 years, whose first language is Brazilian Portuguese.

Relationship between primary monosymptomatic enuresis and process toilet training: a case-control

OBJECTIVE

Primary monosymptomatic nocturnal enuresis (PMNE) is a prevalent condition in childhood, and the pathophysiology is multifactorial. This study investigated the relationship between the toilet training process (TT) and PMNE in children and adolescents.

PATIENTS AND METHODS

A case-control study was carried out from 2015 to 2020. The presence of PMNE was identified according to International Children's Continence Society criteria. A semi-structured questionnaire was applied to assess TT.

RESULTS

The study included 103 children and adolescents with PMNE and 269 participants with normal psychomotor development without PMNE (control group [CG]). Readiness signals were more remembered and less frequent in participants with PMNE (p=0.001) when compared to control group. No differences were found between the groups regarding the onset age of the daytime TT (p= 0.10), the nocturnal TT (p=0.08), the acquisition of daytime continence (p=0.06), and the type of equipment used for the TT (p=0.99). The use of Child-Oriented approach in group of children with enuresis was lower than in controls [87.4% (90/103) versus 94% (250/266)], respectively (OR= 0.44, 95% CI 0.21-0.94, p = 0.039).

CONCLUSIONS

The age of onset of TT, acquisition of daytime continence, and the type of equipment were not associated with higher occurrence of PMNE. On the other hand, the Child-Oriented approach was a protective factor for the occurrence of PMNE.

Modified levels of renin angiotensin related components in the frontal cortex and hippocampus were associated with neuroinflammation and lower neuroprotective effects of NGF during acute hepatic encephalopathy in mice

Background:

Hepatic encephalopathy (HE) is a neuropsychiatric syndrome that involves cognitive and motor dysfunctions due to hepatic failure. Clinical and experimental studies suggest that the angiotensin (Ang) converting enzyme (ACE), Ang II, and angiotensin type 1 receptor (AT1R), that compose the classical pathway of the renin–angiotensin system (RAS), exacerbate neuroinflammation in different neurologic diseases. Conversely, Ang-(1-7), ACE2, and Mas receptor, which integrate the alternative RAS axis, have been shown as a promise therapeutic targets in neuropsychiatric disorders, leading to neuroprotection.

Objective:

This study aimed to investigate the potential participation of the RAS components in thioacetamide (TAA)-induced HE in mice.

Methods:

We also evaluated the levels of neurotrophic factors, pro-inflammatory cytokines, and chemokine in the central nervous system of TAA-induced HE in mice. Mice were submitted to acute liver failure induced by TAA administration by intraperitoneal route. Measurements of RAS components (ACE, Ang II, ACE2 and Ang1-7) and neurotrophic factors (BDNF, GDNF and NGF) were obtained by ELISA assay. Pro-inflammatory cytokines (TNF, IFN-γ, IL-6, IL-12p70) and the chemokine (CCL2) were quantified by cytometric bead array. Student’s t test was applied for statistical analysis.

Results:

Mice presented increased cortical levels of ACE, while Ang-(1-7) levels were decreased in cortical and hippocampal samples compared to controls. Moreover, HE mice had an increase in the Ang II/Ang-(1-7) ratio along with reduced levels of neural growth factor (NGF) in the prefrontal cortex. They also showed elevated levels of IFN-γ and CCL2 in the prefrontal cortex and of TNF, IL-6, IL-12, and CCL2 in the hippocampus, compared with controls

Conclusion:

This study suggested that the reduction of components of the alternative RAS axis was associated with the deleterious effects of neuroinflammation and lower neuroprotective effects of NGF during TAA-induced HE.

Better healthcare can reduce the risk of COVID-19 in-hospital post-partum maternal death: evidence from Brazil

OBJECTIVE

COVID-19 in post-partum women is commonly overlooked. The present study assessed whether puerperium is an independent risk factor of COVID-19 related in-hospital maternal death and whether fatality is preventable in the Brazilian context.

METHODS

We retrospectively studied the clinical data of post-partum/pregnant patients hospitalized with COVID-19 gathered from a national database that registered severe acute respiratory syndromes (SIVEP-Gripe) in Brazil. Logistic regressions were used to examine the associations of in-hospital mortality with obstetric status and with the type of public healthcare provider, adjusting for socio-demographic, epidemiologic, clinical and healthcare-related measures.

RESULTS

As of 30 November 2021, 1943 (21%) post-partum and 7446 (79%) pregnant patients of age between 15 and 45 years with COVID-19 that had reached the clinical endpoint (death or discharge) were eligible for inclusion. Case-fatality rates for the two groups were 19.8% and 9.2%, respectively. After the adjustment for covariates, post-partum patients had almost twice the odds of in-hospital mortality compared with pregnant patients. Patients admitted to private (not-for-profit) hospitals, those that had an obstetric centre or those located in metropolitan areas were less likely to succumb to SARS-CoV-2 infection. Those admitted to the Emergency Care Unit had similar mortality risk to those admitted to other public healthcare providers.

CONCLUSION

We demonstrated that puerperium was associated with an increased odds of COVID-19-related in-hospital mortality. Only part of the risk can be reduced by quality healthcare such as non-profit private hospitals, those that have an obstetric centre or those located in urban areas.

Renin-Angiotensin System in Huntington′s Disease: Evidence from Animal Models and Human Patients

The Renin-Angiotensin System (RAS) is expressed in the central nervous system and has important functions that go beyond blood pressure regulation. Clinical and experimental studies have suggested that alterations in the brain RAS contribute to the development and progression of neurodegenerative diseases. However, there is limited information regarding the involvement of RAS components in Huntington’s disease (HD). Herein, we used the HD murine model, (BACHD), as well as samples from patients with HD to investigate the role of both the classical and alternative axes of RAS in HD pathophysiology. BACHD mice displayed worse motor performance in different behavioral tests alongside a decrease in the levels and activity of the components of the RAS alternative axis ACE2, Ang-(1-7), and Mas receptors in the striatum, prefrontal cortex, and hippocampus. BACHD mice also displayed a significant increase in mRNA expression of the AT1 receptor, a component of the RAS classical arm, in these key brain regions. Moreover, patients with manifest HD presented higher plasma levels of Ang-(1-7). No significant changes were found in the levels of ACE, ACE2, and Ang II. Our findings provided the first evidence that an imbalance in the RAS classical and counter-regulatory arms may play a role in HD pathophysiology.

Risk factors for acute kidney injury after liver transplantation in intensive care unit: a retrospective cohort study

BACKGROUND

Acute kidney injury (AKI) is a frequent complication during the postoperative period following liver transplantation. Occurrence of AKI in intensive care unit (ICU) patients is associated with increased mortality and higher costs.

OBJECTIVE

To evaluate occurrences of moderate or severe AKI among patients admitted to the ICU after liver transplantation and investigate characteristics associated with this complication.

DESIGN AND SETTING

Single-center retrospective cohort study in a public hospital, Belo Horizonte, Brazil.

METHODS

Forty-nine patients admitted to the ICU between January 2015 and April 2017 were included. AKI was defined from a modified Kidney Disease Improving Global Outcomes (KDIGO) score (i.e. based exclusively on serum creatinine levels).

RESULTS

Eighteen patients (36.7%) developed AKI KDIGO 2 or 3; mostly KDIGO 3 (16 out of the 18 patients). Lactate level within the first six hours after ICU admission (odds ratio, OR: 1.3; 95% confidence interval, CI: 1.021-1.717; P = 0.034) and blood transfusion requirement within the first week following transplantation (OR: 8.4; 95% CI: 1.687-41.824; P = 0.009) were independently associated with development of AKI. Patients with AKI KDIGO 2 or 3 underwent more renal replacement therapy (72.2% versus 3.2%; P < 0.01), had longer hospital stay (20 days versus 15 days; P = 0.001), higher in-hospital mortality (44.4% versus 6.5%; P < 0.01) and higher mortality rate after one year (44.4% versus 9.7%; P = 0.01).

CONCLUSION

Need for blood transfusion during ICU stay and hyperlactatemia within the first six postoperative hours after liver transplantation are independently associated with moderate or severe AKI. Developing AKI is apparently associated with poor outcomes.

MO947: Evaluation of Bone Metabolism Markers in Kidney Transplant Recipients

BACKGROUND AND AIMS

Immunosuppressive therapies, pre-existing renal osteodystrophy, de novo hyperparathyroidism, and other traditional risk factors influence Mineral and Bone Disorder (MBD) after kidney transplantation. However, little is known about their effect on bone metabolism biomarkers. Therefore, we aimed to understand how kidney transplant affects bone metabolism markers in comparison to patients on hemodialysis and healthy individuals.

METHOD

This is a cross-sectional study with 57 kidney transplant patients, 36 patients on hemodialysis, and 31 healthy controls. Plasma concentrations of Dickkopf-related protein 1 (DKK1), osteoprotegerin (OPG), osteocalcin (OC), osteopontin (OPN), sclerostin (SOST) and fibroblast growth factor 23 (FGF-23) were measured using the Luminex-based microbead assay (HBNMAG-51K,  Millipore, Billerica, MA) in these three groups. Associations between the measurements of these molecules with clinical, demographic, and laboratory data were evaluated. For variables without Gaussian distribution, Mann–Whitney test was used to compare two groups and the Kruskal–Wallis test for comparisons between more than two groups. For variables with normal distribution, comparisons between two groups were made by unpaired Student's t-test and for more than two groups by analysis of variance followed by Bartlett’s post-test. Pearson or Spearman tests were adopted to evaluate correlations according to the variables’ distribution. All statistical tests were two-tailed with a significance level of P  &lt; 0.05.

RESULTS

Transplant recipients had significantly lower levels of DKK1 (P  &lt; 0.001), OPG (P  &lt; 0.001), OC (P  &lt; 0.001), OPN (P = 0.001), OST (P  &lt; 0.001) and FGF-23 (P  &lt; 0.001) when compared with patients on hemodialysis. In comparison to healthy controls, transplant recipients also presented lower levels of DKK1 (P = 0.019), OPG (P  &lt; 0.001), OC (P = 0.027), SOST (P  &lt; 0.001) and FGF-23 (P = 0.043) (Figure 1). Regarding demographic data, women presented lower plasma SOST levels when compared with men in the hemodialysis group (P = 0.012). Different correlations between the human bone metabolism components were detected in transplant recipients and hemodialysis patients. In the transplant group, DKK1 was positively correlated with SOST (r = 0.484, P = 0.001), OPN (r = 0.420, P = 0.005) and OPG (r = 0.521, P  &lt; 0.001). In the same group, SOST levels were positively correlated with FGF-23 (r = 0.424, P = 0.027, Figure 2D) and OPG (r = 0.703, P  &lt; 0.001), while OC only positively correlated with OPN (r = 0.572, P  &lt; 0.001). By contrast, patients on hemodialysis only showed positive correlations between OPN and DKK1 (r = 0.420, P = 0.005) and between SOST and OPG (r = 0.757, P  &lt; 0.001). Concerning laboratory parameters and their correlations with human bone metabolism molecules, both transplant recipients and hemodialysis patients showed a negative correlation between 25(OH)vitamin D levels and FGF-23. On the other hand, ALP levels were positively correlated with different molecules in the two groups. In transplant patients, ALP levels positively correlated with OPN (r = 0.572, P  &lt; 0.001), while, in hemodialysis patients, the positive correlation was with OPG (r = 0.548, P = 0.012).

CONCLUSION

Our findings showed a reduction in bone metabolism markers, DKK1, OPG, OC, OPN and SOST after kidney transplantation. The first years after kidney transplantation modulate MBD markers, revealing a significant improvement of MBD associated with end-stage kidney disease.

Outcomes and risk factors of death among hospitalized children and adolescents with obesity and COVID-19 in Brazil: An analysis of a nationwide database

BACKGROUND

Obesity is a well-recognized risk factor for critical illness and death among adult patients with SARS-CoV-2 infection.

OBJECTIVE

This study aimed to characterize the clinical outcomes and risk factors of death related to obesity in a cohort of hospitalized paediatric patients with COVID-19.

METHODS

We performed an analysis of all paediatric patients with obesity and COVID-19 registered in SIVEP-Gripe, a Brazilian nationwide surveillance database, between February 2020 and May 2021. The primary outcome was time to death, which was evaluated by using cumulative incidence function.

RESULTS

Among 21 591 hospitalized paediatric patients with COVID-19, 477 cases (2.2%) had obesity. Of them, 71 (14.9%) had a fatal outcome as compared with 7.5% for patients without obesity (hazard ratio [HR] = 2.0, 95% confidence interval [CI] 1.59-2.53, p < 0.001). After adjustment, the factors associated with death among patients with obesity were female gender (HR = 2.8, 95% CI 1.70-4.61), oxygen saturation < 95% (HR = 2.58, 95% CI 1.38-4.79), presence of one (HR = 1.91, 95% CI 1.11-3.26), and two or more comorbidities (HR = 4.0, 95% CI 2.21-7.56).

CONCLUSIONS

Children and adolescents with obesity had higher risk of death compared with those without obesity. The higher risk of death was associated with female gender, low oxygen saturation at admission, and presence of other comorbidities.

The Curcumin Supplementation with Piperine Can Influence the Acute Elevation of Exercise-Induced Cytokines: Double-Blind Crossover Study

Simple Summary

Inflammation is an immune response to harmful stimuli, such as pathogens and damaged cells. Intense exercise can induce a local and systemic inflammatory response as well. We believe that exercise-induced inflammatory responses are essential for muscle repair and regeneration. However, uncontrolled acute inflammation in athletes during the training process and competition could reduce the level of performance. In this study, we investigate the effects of curcumin and piperine on the exercise-induced inflammatory response.

Abstract

Background: to evaluate the effects of one week of supplementation with curcumin combined with piperine on physical performance, immune system cell counts, muscle damage, and plasma levels of inflammatory markers after a treadmill running training session. Methods: This study is a double-blind, crossover-balanced clinical trial with a three-week intervention. Sixteen male runners with a mean age of 36 ± 9 years and VO2 max of 60.6 ± 9.03 mL.kg ⁻¹ min ⁻¹ were recruited and randomly divided into 2 groups: the first group (CPG) was supplemented daily for 7 days with 500 mg of curcumin + 20 mg piperine, and the second group (PG) was supplemented with 540 mg of cellulose. After the 7th day of supplementation, the volunteers participated in the experimental running protocol, where blood samples were collected before, after, and one hour after exercise for analysis of the number of leukocytes, creatine kinase, and cytokine concentration (IL-2, TNF-α, IFN, IL-6, and IL-10) using flow cytometry. This process was repeated, reversing the supplementation offered to the groups. Results: curcumin and piperine supplementation could not change the physical performance, immune cell counts, and muscle damage; however, the aerobic fatiguing exercise protocol inhibited the elevation of the plasmatic levels of some cytokines. The running exercise protocol could elevate the circulating levels of IL-2 (from 49.7 to 59.3 pg/mL), TNF-α (from 48.5 to 51.5 pg/mL), INF (from 128.8 to 165.0 pg/mL), IL-6 (from 63.1 to 77.3 pg/mL), and IL-10 (from 48.9 to 59.6 pg/mL) 1 h after the end of the running protocol. However, the curcumin and piperine supplementation could inhibit this elevation. Conclusions: curcumin and piperine supplementation had no effect on physical performance, immune cell counts, or muscle damage; however, the supplementation could modulate the kinetics of IL-2, TNF-α, INF, IL-6, and IL-10 1 h after the end of exercise.

Risk factors for COVID-19-related mortality in hospitalized children and adolescents with diabetes mellitus: An observational retrospective cohort study

BACKGROUND

Diabetes has been recognized as a major comorbidity for COVID-19 severity in adults. This study aimed to characterize the clinical outcomes and risk factors for COVID-19-related death in a large cohort of hospitalized pediatric patients with diabetes.

METHODS

We performed an analysis of all pediatric patients with diabetes and COVID-19 registered in SIVEP-Gripe, a Brazilian nationwide surveillance database, between February 2020 and May 2021. The primary outcome was time to death, which was evaluated considering discharge as a competitive risk by using cumulative incidence function.

RESULTS

Among 21,591 hospitalized pediatric patients with COVID-19, 379 (1.8%) had diabetes. Overall, children and adolescents with diabetes had a higher prevalence of ICU admission (46.6% vs. 26%), invasive ventilation (16.9% vs. 10.3%), and death (15% vs. 7.6%) (all P < 0.0001). Children with diabetes had twice the hazard of death compared with pediatric patients without diabetes (Hazard ratio [HR] = 2.0, 95% CI, 1.58-2.66). Among children with diabetes, four covariates were independently associated with the primary outcome, living in the poorest regions of the country (Northeast, HR, 2.17, 95% CI 1.18-4.01, and North, (HR 4.0, 95% CI 1.79-8.94), oxygen saturation < 95% at admission (HR 2.97, 95% CI 1.64-5.36), presence of kidney disorders (HR 3.39, 95% CI 1.42-8.09), and presence of obesity (HR 3.77, 95% CI 1.83-7.76).

CONCLUSION

Children and adolescents with diabetes had a higher risk of death compared with patients without diabetes. The higher risk of death was associated with clinical and socioeconomic factors.

Chronic Kidney Disease-Mineral Bone Disease biomarkers in kidney transplant patients

Background:

Chronic Kidney Disease associated with Mineral Bone Disease (CKD-MBD) is frequent in kidney transplant patients. Post-transplantation bone disease is complex, especially in patients with pre-existing metabolic bone disorders that are further affected by immunosuppressive medications and changes in renal allograft function. Main biochemical abnormalities of mineral metabolism in kidney transplantation (KTx) include hypophosphatemia, hyperparathyroidism (HPTH), insufficiency or deficiency of vitamin D, and hypercalcemia.

Objective:

This review aimed to summarize the pathophysiology and main biomarkers of CKD-MBD in KTx.

Methods:

A comprehensive and non-systematic search in PubMed was independently made with an emphasis on biomarkers in mineral bone disease in KTx.

Results:

CKD-MBD can be associated with numerous factors including secondary HPTH, metabolic dysregulations before KTx, and glucocorticoids therapy in post-transplant subjects. Fibroblast growth factor 23 (FGF23) reaches normal levels after KTx with good allograft function, while calcium, vitamin D and phosphorus, ultimately, result in hypercalcemia, persistent vitamin D insufficiency, and hypophosphatemia respectively. As for PTH levels, there is an initial tendency of a significant decrease, followed by a raise due to secondary or tertiary HPTH. In regard to sclerostin levels, there is no consensus in the literature.

Conclusion:

KTx patients should be continuously evaluated for mineral homeostasis and bone status, both cases with successful kidney transplantation and those with reduced functionality. Additional research on CKD-MBD pathophysiology, diagnosis, and management is essential to guarantee long-term graft function, better prognosis, good quality of life, and reduced mortality for KTx patients.

An analysis of chronic kidney disease as a prognostic factor in pediatric cases of COVID-19

Advanced age is a risk factor for severe infection by acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Children, however, often present with milder manifestations of Coronavirus Disease 2019 (COVID-19). Associations have been found between COVID-19 and multisystem inflammatory syndrome in children (MIS-C). Patients with the latter condition present more severe involvement. Adults with comorbidities such as chronic kidney disease (CKD) are more severely affected. This narrative review aimed to look into whether CKD contributed to more severe involvement in pediatric patients with COVID-19. The studies included in this review did not report severe cases or deaths, and indicated that pediatric patients with CKD and previously healthy children recovered quickly from infection. However, some patients with MIS-C required hospitalization in intensive care units and a few died, although it was not possible to correlate MIS-C and CKD. Conversely, adults with CKD reportedly had increased risk of severe infection by SARS-CoV-2 and higher death rates. The discrepancies seen between age groups may be due to immune system and renin-angiotensin system differences, with more pronounced expression of ACE2 in children. Immunosuppressant therapy has not been related with positive or negative effects in individuals with COVID-19, although current recommendations establish decreases in the dosage of some medications. To sum up with, CKD was not associated with more severe involvement in children diagnosed with COVID-19. Studies enrolling larger populations are still required.

2020 update on the renin-angiotensin-aldosterone system in pediatric kidney disease and its interactions with coronavirus

The last decade was crucial for our understanding of the renin-angiotensin-aldosterone system (RAAS) as a two-axis, counter-regulatory system, divided into the classical axis, formed by angiotensin-converting enzyme (ACE), angiotensin II (Ang II), and the angiotensin type 1 receptor (AT1R), and the alternative axis comprising angiotensin-converting enzyme 2 (ACE2), angiotensin-(1-7) (Ang-(1-7)), and the Mas receptor. Breakthrough discoveries also took place, with other RAAS endopeptides being described, including alamandine and angiotensin A. In this review, we characterize the two RAAS axes and the role of their components in pediatric kidney diseases, including childhood hypertension (HTN), pediatric glomerular diseases, congenital abnormalities of the kidney and urinary tract (CAKUT), and chronic kidney disease (CKD). We also present recent findings on potential interactions between the novel coronavirus, SARS-CoV-2, and components of the RAAS, as well as potential implications of coronavirus disease 2019 (COVID-19) for pediatric kidney diseases.

Emotional, Behavioral, and Psychological Impact of the COVID-19 Pandemic

The emergence of SARS-CoV-2 in December 2019 prompted consternation in many parts of the world. Due to its fast dissemination, the World Health Organization declared a pandemic in March 2020. Aiming to contain the spread of the virus, leaders of many countries restrained social movement, targeting to flatten the curve of contamination with social distancing. This review aimed to analyze how human behavior has changed throughout this period. We also approached the key components of the emotional reaction to the pandemic, how internal and external factors, such as personality traits, gender, the media, the economy and the governmental response, influence the social perception of the pandemic and the psychological outcomes of the current scenario. Moreover, we explored in depth the groups at increased risk of suffering mental health burden secondary to these circumstances. These include the healthcare professionals, elderly individuals, children, college students, black subjects, latin and LGBTQ+ communities, economically disadvantaged groups, the homeless, prisoners, the rural population and psychiatric patients. We also discussed several measures that might minimize the emotional impact derived from this scenario. It is crucial that the health authorities, the government and the population articulate to assist the vulnerable groups and promote emotional and psychological support strategies. Moreover, it is fundamental that the population is provided with accurate information concerning the COVID-19 pandemic.

Two protocols of aerobic exercise modulate the counter-regulatory axis of the renin-angiotensin system

Aims

The renin-angiotensin system (RAS) is a dual system with two opposite arms: i) the classical one formed by the angiotensin converting enzyme (ACE), angiotensin (Ang) II and angiotensin type 1 (AT1) receptors; ii) the counter-regulatory arm consisting of ACE2, Ang-(1–7) and Mas receptor. Physical exercise can modulate this system, however, only animal studies have compared the effects of different intensity protocols on the RAS. No data with humans were provided. Therefore, we investigated the acute effect of two protocols of isowork aerobic exercise [High-Intensity Interval Exercise (HIIE) and Moderate-Intensity Continuous Exercise (MICE)] in plasma and urinary levels of RAS components in physically active men.

Main methods

The HIIE protocol included a 5-minute warm-up cycling at 60–70% of heart rate peak (HRp) intensity followed by 10 sets of 30 s above 90% with 1 min of recovery and 3 min of cool down. The MICE protocol was performed at a constant power corresponding to 60–70% of HRp and finalized at the same total work of HIIE. Blood and urine samples were collected before and after the protocols. Plasma and urinary levels of ACE, ACE2, Ang-(1–7) and Ang II were analyzed by enzyme-linked immunoassay.

Key findings

While the HIIE protocol significantly increased urinary levels of ACE and plasma levels of ACE2, the MICE protocol elevated urinary concentrations of ACE2 and of Ang-(1–7). A greater increase of urine concentrations of Ang-(1–7) occurred in the MICE if compared with the HIIE protocol.

Significance

Aerobic physical exercise acutely increases the activity of the counter-regulatory RAS axis, mostly the MICE protocol.

Vancomycin-associated nephrotoxicity in non-critically ill patients admitted in a Brazilian public hospital: A prospective cohort study

Introduction

Vancomycin is widely used to treat infections caused by Gram positive bacteria, mostly methicillin-resistant strains. Despite its therapeutic effectiveness, vancomycin is a nephrotoxic drug that has been associated with the occurrence of acute kidney injury (AKI). In this study, we sought to evaluate the variability of serum trough concentrations of vancomycin and to determine the incidence and risk factors of vancomycin-associated nephrotoxicity (VAN) in non-critically ill patients.

Methods

This was a prospective cohort including Brazilian public hospital inpatients from April 2017 to June 2018. The participants received intravenous vancomycin therapy for at least 48 hours for any suspected or confirmed infection by Gram positive bacteria. Demographic, clinical and laboratory data were collected. Information on vancomycin therapy and concomitant use of other nephrotoxic drugs were also recorded. Patients were followed up until discontinuation of vancomycin treatment or death, whatever occurred first. The primary outcome was the occurrence of AKI. We performed a Poisson regression to determine risk factors for AKI.

Results

Overall, 98 participants were included in the study. Median age was 55.9 (interquartile range [IQR] 40.6–66.8) years and 58 (59.2%) were men. Most of them showed subtherapeutic (<10mg/L) or supratherapeutic (>20mg/L) trough levels of vancomycin; 42.9% and 15.3%, respectively. A total of 19 (19.4%) patients developed AKI. Poisson regression showed that male sex (odds ratio [OR] 2.90; confidence interval [CI] 95% 1.28–6.53; p = 0.011), concomitant use of piperacillin-tazobactam (OR 4.66; CI 95% 2.26–9.58; p <0.001) and vancomycin trough levels above 20mg/mL (OR 4.21; CI 95% 1.57–11.278; p = 0.004) were independently associated with AKI.

Conclusions

Our study showed that usual doses of vancomycin did not reach recommended therapeutic serum trough levels of vancomycin in non-critically ill patients. Besides that, nephrotoxicity was common in this population, being associated with male sex, concomitant use of piperacillin-tazobactam and supra-therapeutic trough serum levels of vancomycin.

Hepatic encephalopathy: Lessons from preclinical studies

Hepatic encephalopathy (HE) is a major complication that is closely related to the progression of end-stage liver disease. Metabolic changes in advanced liver failure can promote cognition impairment, attention deficits and motor dysfunction that may result in coma and death. HE can be subdivided according to the type of hepatic injury, namely, type A, which results from acute liver failure, type B, which is associated with a portosystemic shunting without intrinsic liver disease, and type C, which is due to chronic liver disease. Several studies have investigated the pathogenesis of the disease, and most of the mechanisms have been explored using animal models. This article aimed to review the use of preclinical models to investigate HE. The most used animal species are rats and mice. Experimental models of type A HE include surgical procedures and the administration of hepatotoxic medications, whereas models of types B and C HE are generally surgically induced lesions in liver tissue, which evolve to hepatic cirrhosis. Preclinical models have allowed the comprehension of the pathways related to HE.

Liver

The discovery that renin–angiotensin system (RAS) components are locally expressed in the liver tissue, pointed out to a role for this system in the pathogenesis of hepatic fibrosis and cirrhosis. The RAS counter-regulatory axis composed by the angiotensin converting enzyme 2 (ACE2), angiotensin-(1-7) [Ang-(1-7)] and Mas receptor mediates pro-inflammatory, pro-thrombotic, and pro-fibrotic processes, frequently opposing the classical RAS arm (ACE-Ang II-AT₁ receptor) actions. Therefore, the balance between both RAS axes most likely affects the clinical and histopathological expression of liver diseases. It is worth noticing that liver diseases are major causes of morbidity and mortality worldwide. Without proper treatment, all types of chronic hepatitis will progress to end-stage liver diseases, including cirrhosis, liver failure, and hepatocellular carcinoma, which ultimately lead to death. In this context, to better comprehend the role of RAS components in liver failure might pave the way for the search of potential predictive biomarkers as well as the development of novel therapeutic approaches. Valuable data have been generated from preclinical and clinical studies. Herein, we summarize the current evidence, mainly focusing in the ACE2-Ang-(1-7)-Mas receptor arm, regarding the role of RAS in liver diseases. The therapeutic potential of the modulation of RAS molecules in liver diseases is also discussed.

Serum levels of angiotensin converting enzyme as a biomarker of liver fibrosis

The renin angiotensin system (RAS) is classically conceived as a circulating hormonal system involved in blood pressure control and hydroelectrolyte balance. The discovery that RAS components are locally expressed in a wide range of organs and tissues, including the liver, pointed to a role for this system in the pathogenesis of several conditions including hepatic fibrosis and cirrhosis. It has been widely reported that the classical RAS axis composed by the angiotensin converting enzyme (ACE)-angiotensin (Ang) II-Ang type 1 (AT1) receptor mediates pro-inflammatory, pro-thrombotic, and pro-fibrotic processes. On the other hand, the alternative axis comprising ACE2-Ang-(1-7)-Mas receptor seems to play a protective role by frequently opposing Ang II action. Chronic hepatitis B (CHB) is one of the leading causes of liver fibrosis, accounting for the death of nearly one million people worldwide. Liver fibrosis is a key factor to determine therapeutic interventions for patients with CHB. However, the establishment of non-invasive and accurate methods to detect reversible stages of liver fibrosis is still a challenge. In an elegant study published in the 36^th issue of the World Journal of Gastroenterology, Noguchi et al showed the predictive value of serum ACE levels in detecting not only advanced stages of liver fibrosis but also initial and intermediate fibrotic stages. The serum levels of ACE might represent an accurate, non-invasive, widely available, and easy method to evaluate fibrosis related to CHB. Moreover, therapies involving the inhibition of the classical RAS axis components might be promising in the control of CHB-related liver fibrosis.

Renin angiotensin system in liver diseases: Friend or foe?

In the last three decades, the understanding of the renin angiotensin system (RAS) has been changed by the discoveries of functional local systems, novel biologically active peptides, additional specific receptors, alternative pathways of angiotensin (Ang) II generation, and new roles for enzymes and precursor components other than those in Ang II synthesis. In this regard, the discovery that Ang-(1-7) opposes the pressor, proliferative, pro-fibrotic, and pro-inflammatory effects mediated by Ang II has contributed to the realization that the RAS is composed of two axes. The first axis consists of the angiotensin-converting enzyme (ACE), with Ang II as the end product, and the angiotensin type 1 (AT₁) receptor as the main effector mediating the biological actions of Ang II. The second axis results from ACE2-mediated hydrolysis of Ang II, leading to the production of Ang-(1-7), with the Mas receptor as the main effector conveying the vasodilatory, anti-proliferative, anti-fibrotic, and anti-inflammatory effects of Ang-(1-7). Experimental and clinical studies have shown that both axes of the RAS may take part in the pathogenesis of liver diseases. In this manuscript, we summarize the current evidence regarding the role of RAS in hepatic cirrhosis and its complications, including hemodynamic changes and hepatorenal syndrome. The therapeutic potential of the modulation of RAS molecules in liver diseases is also discussed.

Zika virus challenges for neuropsychiatry

Before 2007, Zika virus (ZIKV) was generally considered as an arbovirus of low clinical relevance, causing a mild self-limiting febrile illness in tropical Africa and Southeast Asia. Currently, a large, ongoing outbreak of ZIKV that started in Brazil in 2015 is spreading across the Americas. Virus infection during pregnancy has been potentially linked to congenital malformations, including microcephaly. In addition to congenital malformations, a temporal association between ZIKV infection and an increase in cases of Guillain-Barré syndrome is currently being observed in several countries. The mechanisms underlying these neurological complications are still unknown. Emerging evidence, mainly from in vitro studies, suggests that ZIKV may have direct effects on neuronal cells. The aim of this study was to critically review the literature available regarding the neurobiology of ZIKV and its potential neuropsychiatric manifestations.

Influence of ACE I/D Polymorphism on Circulating Levels of Plasminogen Activator Inhibitor 1, D-Dimer, Ultrasensitive C-Reactive Protein and Transforming Growth Factor β1 in Patients Undergoing Hemodialysis

BACKGROUND

There is substantial evidence that chronic renal and cardiovascular diseases are associated with coagulation disorders, endothelial dysfunction, inflammation and fibrosis. Angiotensin-Converting Enzyme Insertion/Deletion polymorphism (ACE I/D polymorphism) has also be linked to cardiovascular diseases. Therefore, this study aimed to compare plasma levels of ultrassensible C-reactive protein (usCRP), PAI-1, D-dimer and TGF-β1 in patients undergoing HD with different ACE I/D polymorphisms.

METHODS

The study was performed in 138 patients at ESRD under hemodialysis therapy for more than six months. The patients were divided into three groups according to the genotype. Genomic DNA was extracted from blood cells (leukocytes). ACE I/D polymorphism was investigated by single polymerase chain reaction (PCR). Plasma levels of D-dimer, PAI-1 and TGF-β1 were measured by enzyme-linked immunosorbent assay (ELISA), and the determination of plasma levels of usCRP was performed by immunonephelometry. Data were analyzed by the software SigmaStat 2.03.

RESULTS

Clinical characteristics were similar in patients with these three ACE I/D polymorphisms, except for interdialytic weight gain. I allele could be associated with higher interdialytic weight gain (P = 0.017). Patients genotyped as DD and as ID had significantly higher levels of PAI-1 than those with II genotype. Other laboratory parameters did not significantly differ among the three subgroups (P = 0.033). Despite not reaching statistical significance, plasma levels of usCRP were higher in patients carrying the D allele.

CONCLUSION

ACE I/D polymorphisms could be associated with changes in the regulation of sodium, fibrinolytic system, and possibly, inflammation. Our data showed that high levels of PAI-1 are detected when D allele is present, whereas greater interdialytic gain is associated with the presence of I allele. However, further studies with different experimental designs are necessary to elucidate the mechanisms involved in these associations.

Dental findings in Brazilian patients with Fanconi syndrome

BACKGROUND

Fanconi syndrome (FS) is a generalized dysfunction of renal proximal tubules resulting in impaired reabsorption of amino acids, phosphate, urate, bicarbonate, glucose, and electrolytes. FS can be a primary renal impairment due to genetic origin or secondary to inborn errors of metabolism or systemic diseases. Main clinical findings are polyuria, failure to thrive, rickets/osteomalacia, metabolic acidosis, bone deformities, and, occasionally, nephrocalcinosis. Although dental abnormalities have been reported in patients with tubulopathies, oral manifestations in FS were very rarely described.

CASE REPORT

Two patients with FS exhibiting important dental alterations were reported. Oral examination of the first patient revealed teeth with rough surfaces and white opaque areas. Early loss of primary teeth and delayed eruption of permanent teeth were also observed. Oral examination of the second patient detected delayed eruption of permanent teeth and X-ray images revealed loss of contrast between enamel and dentin. In both patients with FS, loss of bone density in maxilla and mandible was observed in X-ray images.

CONCLUSIONS

This study is the first report of dental abnormalities in Brazilian patients with FS. Furthermore, our findings support the general idea that renal tubular disorders might impact on mineralized tissues of the oral cavity.

Whole-exome sequencing as a diagnostic tool for distal renal tubular acidosis

OBJECTIVE

Distal renal tubular acidosis (dRTA) is characterized by metabolic acidosis due to impaired renal acid excretion. The aim of this study was to demonstrate the genetic diagnosis of four children with dRTA through use of whole-exome sequencing.

METHODS

Two unrelated families were selected; a total of four children with dRTA and their parents, in order to perform whole-exome sequencing. Hearing was preserved in both children from the first family, but not in the second, wherein a twin pair had severe deafness. Whole-exome sequencing was performed in two pooled samples and findings were confirmed with Sanger sequencing method.

RESULTS

Two mutations were identified in the ATP6V0A4 and ATP6V1B1 genes. In the first family, a novel mutation in the exon 13 of the ATP6V0A4 gene with a single nucleotide change GAC → TAC (c.1232G>T) was found, which caused a substitution of aspartic acid to tyrosine in position 411. In the second family, a homozygous recurrent mutation with one base-pair insertion (c.1149_1155insC) in exon 12 of the ATP6V1B1 gene was detected.

CONCLUSION

These results confirm the value of whole-exome sequencing for the study of rare and complex genetic nephropathies, allowing the identification of novel and recurrent mutations. Furthermore, for the first time the application of this molecular method in renal tubular diseases has been clearly demonstrated.

Update on the approach of urinary tract infection in childhood

OBJECTIVE

Urinary tract infection (UTI) is the most common bacterial infection in childhood. UTI may be the sentinel event for underlying renal abnormality. There are still many controversies regarding proper management of UTI. In this review article, the authors discuss recent recommendations for the diagnosis, treatment, prophylaxis, and imaging of UTI in childhood based on evidence, and when this is lacking, based on expert consensus.

SOURCES

Data were obtained after a review of the literature and a search of Pubmed, Embase, Scopus, and Scielo.

SUMMARY OF THE FINDINGS

In the first year of life, UTIs are more common in boys (3.7%) than in girls (2%). Signs and symptoms of UTI are very nonspecific, especially in neonates and during childhood; in many cases, fever is the only symptom.

CONCLUSIONS

Clinical history and physical examination may suggest UTI, but confirmation should be made by urine culture, which must be performed before any antimicrobial agent is given. During childhood, the proper collection of urine is essential to avoid false-positive results. Prompt diagnosis and initiation of treatment is important to prevent long-term renal scarring. Febrile infants with UTIs should undergo renal and bladder ultrasonography. Intravenous antibacterial agents are recommended for neonates and young infants. The authors also advise exclusion of obstructive uropathies as soon as possible and later vesicoureteral reflux, if indicated. Prophylaxis should be considered for cases of high susceptibility to UTI and high risk of renal damage.

Usefulness of positron emission tomography in the differentiation between tumor and infectious lesions in pediatric oncology: a case report

BACKGROUND

Sometimes, in pediatric oncology, it is difficult to differentiate the relapse of primary tumor from other diagnoses such as post-ischemic lesions or fungal abscess, without performing an organ biopsy. In addition, patients frequently are not under clinical conditions to be biopsied, mainly due to febrile neutropenia. A growing number of studies has focused on the use of Positron emission tomography/computed tomography with 18 Fluorodeoxyglucose ([(18)F]FDG-PET/CT) to distinguish tumor relapse from infectious lesions in patients with febrile neutropenia.

CASE PRESENTATION

This case report describes a 6 years-old girl with febrile neutropenia during the treatment of neuroblastoma. Blood culture showed Candida sp. Abdominal ultrasonography revealed multiple unspecific hypoechoic areas of variable sizes in spleen, which might be either tumor or Candida-induced abscesses. [(18)F]FDG-PET/CT was performed to help the diagnosis and revealed small splenic lesions highly suggestive of disseminated candidiasis. Patient was then treated with systemic antifungal agent. After the recovery from febrile neutropenia, a spleen biopsy was performed, confirming the diagnosis of fungal abscess. Due to the small size of lesions, modalities such as ultrasonography, CT and magnetic nuclear resonance were not able in distinguishing tumor relapse from infectious lesions.

CONCLUSION

This case provides an excellent example in which the use of [(18)F]FDG-PET/CT is valuable in helping to localize potential sites of disseminated fungal infection to be diagnosed within clinical context. [(18)F]FDG-PET /CT seems to have a role in the evaluation of pediatric patients with febrile neutropenia.

Profile and scientific production of the Brazilian Council for Scientific and Technological Development (CNPq) researchers in the field of Hematology/Oncology

OBJECTIVE

several studies have examined the academic production of the researchers at the CNPq, in several areas of knowledge. The aim of this study was to evaluate the scientific production of researchers in Hematology/Oncology who hold scientific productivity grants from the Brazilian Council for Scientific and Technological Development.

METHODS

the Academic CVs of 28 researchers in Hematology/Oncology with active grants in the three-year period from 2006 to 2008 were included in the analysis. The variables of interest were: institution, researchers' time after doctorate, tutoring of undergraduate students, masters and PhD degree, scientific production and its impact.

RESULTS

from a total of 411 researchers in Medicine, 28 (7%) were identified as being in the area of Hematology/Oncology. There was a slight predominance of males (53.6%) and grant holders in category 1. Three Brazilian states are responsible for approximately 90% of the researchers: São Paulo (21,75%), Rio de Janeiro (3,11%), and Minas Gerais (2, 7%). During their academic careers, the researchers published 2,655 articles, with a median of 87 articles per researcher (IQR = 52 to 122). 65 and 78% of this total were indexed on the Web of Science and Scopus databases, respectively. The researchers received 14,247 citations on the WoS database with a median of 385 citations per researcher. The average number of citations per article was 8.2.

CONCLUSION

in this investigation, it was noted that researchers in the field of Hematology/Oncology have a relevant scientific output from the point of view of quantity and quality compared to other medical specialties.

Anthropometric and biochemical profile of children and adolescents with chronic kidney disease in a predialysis pediatric interdisciplinary program

This is longitudinal retrospective observational cohort study that evaluated anthropometric and biochemical variables of children and adolescents admitted to a Predialysis Interdisciplinary Management Program (PDIMP) responsible for the follow-up of children and adolescents at stages 2 to 4 of chronic kidney disease (CKD) at a tertiary center. One hundred thirty-eight patients with CKD on predialysis treatment with median age at admission of 9 years and the median follow-up time of 5 years were evaluated. Seventy-four (53%) had CKD stage 3 at admission and 70 (51%) reached CKD stage 5 at the end of the follow-up. There was no significant difference between the mean initial and final hemoglobin and serum albumin. However, the final serum bicarbonate presented a significant improvement. Analyses stratified according to clinical variables of interest showed a significant improvement in body mass index (BMI) Z score, especially in the subgroup of children admitted under two years of age. In relation to stature-for-age Z score, data show a significant improvement in stature SD at the end of the study. In conclusion, the present study showed improvement of nutritional status of CKD patients and that the deterioration of renal function was not correlated with BMI-for-age Z score.