Neuropsychiatric involvement in juvenile-onset systemic lupus erythematosus: A multicenter study

INTRODUCTION

Neuropsychiatric (NP) involvement is a restricted area in juvenile-onset systemic lupus erythematosus (jSLE).

AIM

To investigate the prevalence, demographic and clinical features, and outcomes of the neurological involvement in the Turkish jSLE population.

METHODS

This study was based upon 24 referral centers' SLE cohorts, multicenter and multidisciplinary network in Turkey. Patient data were collected by a case report form which was standardized for NP definitions according to American Collage of Rheumatology (ACR). Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SDI) neuropsychiatric part was used to determine NP damage. Variables were evaluated Ward's hierarchical clustering analyses, univariate, and multivariate logistic regression analyses.

RESULTS

A hundred forty-nine of 1107 jSLE patients had NP involvement (13.5%). The most common NPSLE findings were headache (50.3%), seizure (38.3%), and acute confusional state (33.6%). Five clusters were identified with all clinical and laboratory findings. The first two clusters involved neuropathies, demyelinating diseases, aseptic meningitis, and movement disorder. Cluster 3 involved headache, activity markers and other SLE involvements. Idiopathic intracranial hypertension, cerebrovascular disease, cognitive dysfunction, psychiatric disorders and SLE antibodies were in the fourth, and acute confusional state was in the fifth cluster. In multivariate analysis, APA positivity; OR: 2.820, (%95CI: 1.002-7.939), P: 0,050, plasmapheresis; OR: 13.804 (%95CI: 2.785-68.432), P: 0,001, SLEDAI scores; OR: 1.115 (%95CI: (1.049-1.186), P: 0,001 were associated with increased risk for neurologic sequelae.

CONCLUSION

We detected the prevalence of juvenile NPSLE manifestations in Turkey. We have identified five clusters that may shed light pathogenesis, treatment and prognosis of NP involvements. We also determined risk factors of neurological sequelae. Our study showed that new definitions NP involvements and sequelae for childhood period are needed.

Rhabdomyolysis with different etiologies in childhood

AIM

To investigate different etiologies and management of the rhabdomyolysis in children.

METHODS

Eight pediatric rhabdomyolysis cases who applied to the Dokuz Eylul University Faculty of Medicine Department of Pediatric Nephrology with different etiologies between January 2004 and January 2012 were evaluated in terms of age, gender, admission symptoms, physical examination findings, factors provoking rhabdomyolysis, number of rhabdomyolysis attacks, laboratory results, family history and the final diagnosis received after the treatment.

RESULTS

Average diagnosis ages of eight cases were 129 (24-192) ± 75.5 mo and five of them were girls. All of them had applied with the complaint of muscle pain, calf pain, and dark color urination. Infection (pneumonia) and excessive physical activity were the most important provocative factors and excessive licorice consumption was observed in one case. In 5 cases, acute kidney injury was determined and two cases needed hemodialysis. As a result of the further examinations; the cases had received diagnoses of rhabdomyolysis associated with mycoplasma pneumoniae, sepsis associated rhabdomyolysis, licorice-induced hypokalemic rhabdomyolysis, carnitine palmitoyltransferase II deficiency, very long-chain acyl-CoA dehydrogenase deficiency, congenital muscular dystrophy and idiopathic paroxysmal rhabdomyolysis (Meyer-Betz syndrome).

CONCLUSION

It is important to distinguish the sporadic and recurrent rhabdomyolysis cases from each other. Recurrent rhabdomyolysis cases should follow up more regardful and attentive.

Knowledge and attitude changes of pregnant women regarding prenatal screening and diagnostic tests after counselling

OBJECTIVES

This study aimed to reveal the knowledge level of pregnant women about prenatal diagnostic tests, Down syndrome (DS) and amniocentesis, their attitudes toward uptaking these tests, undergoing amniocentesis, and the termination of pregnancy. It also aimed to evaluate the effects of providing information, as well as a written information brochure about all the issues concerning women's knowledge and attitudes.

MATERIALS AND METHODS

The gynecologists provided verbal and written information on prenatal screening tests (PSTs) and invasive prenatal diagnostic tests. Data were collected using an anonymous questionnaire, which was designed by the researchers on the basis of the literature.

RESULTS

Knowledge of both DS and amniocentesis was found to be significantly higher after the education (p = 0.000 and p = 0.000, respectively). Attitudes toward amniocentesis changed significantly after the education.

CONCLUSIONS

This study has shown that women had an inadequate knowledge about PSTs, DS, and amniocentesis. It has also revealed that education provided by gynecologists along with a written brochure of information tended to increase women's knowledge about PSTs.

A case of acute post-streptococcal glomerulonephritis that developed posterior reversible encephalopathy syndrome

A 10-year male patient presented with swelling in the face, legs and scrotal area which developed 8 days after tonsillitis treatment. Acute post-sterotococcal glomerulonephritis (APSGN) was considered in the patient whose urinalysis revealed hematuria and proteinuria at nephrotic level, whose urea, creatinine, lipid profile and anti-streptolysine O antibody levels were increased, albumin and C3 value were decreased and whose 24-hour urine test revealed proteinuria. Renal biopsy was found to be compatible with APSGN. In the follow-up, severe headache, vomiting and convulsion were observed under antihypertensive and diuretic treatment and when the blood pressure was 130/80 mmHg (the 99(th) percentile for the patient: 129/88 mmHg). During the follow-up, the blood pressure values increased to 160/90 mmHg. The electroencephalogram (EEG) performed was found to be normal and magnetic resonance imaging (MRI) findings were compatible with posterior reversible encephalopathy syndrome (PRES). MRI was found to be normal at the first month following antihypertensive and anticonvulsive treatment. In the first year of the follow-up, the blood pressure, neurological examination and urinalysis findings were found to be normal. This patient was presented to draw attention to the fact that PRES can also present with a blood pressure tending to increase and with blood pressure values which are not so high.

Chronic kidney disease in an adolescent with hyperuricemia: familial juvenile hyperuricemic nephropathy

Chronic kidney disease (CKD) is a life-long condition associated with substantial morbidity and premature death due to complications from a progressive decrease in kidney function. Especially in children, early diagnosis and detection of the etiologic factors are important to improve their health outcomes. Familial juvenile hyperuricemic nephropathy (FJHN) is a rare autosomal-dominant disorder characterized by hyperuricemia with renal uric acid under-excretion and CKD. Genetic studies have revealed mutations in the uromodulin (UMOD) gene. Highlighting the importance of CKD in children, a 14-year-old girl with the rare diagnosis of FJHN is reported herein.

Effects of pentoxifylline on gentamicin-induced nephrotoxicity

We aimed to investigate the underlying mechanisms responsible for the renoprotective effects of pentoxifylline (PTX) in gentamicin (GEN)-induced nephropathy. On this purpose, 26 female Wistar rats (200-250 g) were included and four groups were formed. The first one was the control group (n:5). The rats in other groups (n:7 for each) received 50 mg/kg twice daily intraperitoneal (i.p.) PTX, 100 mg/kg i.p. GEN and both GEN and PTX at the same doses for consecutive 8 days, respectively. Rats were weighed both at the beginning and end of the study. After the last dose, 24-hour urines were collected and the rats were sacrificed. Blood samples and kidney tissues were obtained for biochemical, histological, oxidative stress, and apoptotic parameters. Body weights were similar in all groups at the beginning of the study. Rats in GEN group had significant weight loss, tubular damage, and increased apoptosis, while GEN + PTX group had significantly better outcomes. Scr, urinary protein/creatinine, and TBARS levels were significantly higher and Ccr and SOD levels were significantly lower in GEN and GEN + PTX groups in comparison to control and PTX groups, but the levels were similar between GEN and GEN + PTX groups. In conclusion, concomitant administration of PTX provides renoprotection via suppressing apoptosis in GEN-induced nephropathy.

The relationships between renal compensatory hypertrophy etiologic factors and anthropometric development in the pediatric age group

OBJECTIVE

To evaluate the factors associated with compensatory hypertrophy in the functional kidneys of children.

METHODS

The medical files of patients with a solitary functional kidney were reviewed retrospectively. Data regarding anthropometric measurements, functional renal length, functional renal length of standard deviation score (SDS) of functional kidney at diagnosis, and end of follow-up were obtained. Patients were divided into 2 groups, those with a unilateral kidney function of <10% (hypoplasia, dysplasia, and atrophy, group 1) and those with a solitary kidney (agenesis, and multicystic dysplastic kidney, group 2).

RESULTS

A total of 126 patients (70 boys) were evaluated. Both the sizes of the functional kidney and functional kidney SDS values at diagnosis were greater in group 1 relative to group 2. At the end of the follow-up period, anthropometric values including functional kidney size were higher in group 2. Functional kidney size of 2 SDS above the normal was mostly predictive at age 17.5 months (odds ratio [OR] 5.06) and at a body height of 82 cm (OR 5.57).

CONCLUSION

The most determining factors for renal length SDS values were age and height. Solitary kidneys complete compensatory hypertrophy by 17.5 months of age, and after that their growth continues in parallel to normal growth.

Concurrent protracted febrile myalgia syndrome in a child with diabetic ketoacidosis

Familial Mediterranean Fever (FMF), characterized by recurrent attacks of inflammation in predominantly serosal and synovial membranes, is caused by MEFV gene mutations resulting in abnormal pyrin. Protracted febrile myalgia syndrome (PFMS), a kind of vasculitis requiring corticosteroid treatment, is associated with M694V mutation of MEFV gene. Here, we report a case where the patient developed PFMS leading to the diagnosis of FMF concurrently at the time of treatment for diabetic ketoacidosis (DKA) of new-onset type 1 diabetes mellitus and discuss the possible mechanisms of simultaneous DKA and FMF-associated PFMS. DKA-associated cytokine release may be a predisposing factor or trigger for FMF-associated PFMS.

Two adolescent girls with keratinizing squamous metaplasia of the bladder

Squamous metaplasia is a proliferative lesion characterized by the replacement of the transitional epithelium with stratified squamous cells. In the urinary system, it is mostly seen in the bladder. It can be nonkeratinized or keratinized. We report the cases of 2 adolescent girls with keratinizing metaplasia, 1 of whom presented with difficulty with indwelling catheterization and 1 with final terminal hematuria. The predisposing factors were recurrent urinary tract infection and additional catheterization in 1 of the patients. The diagnosis was confirmed by histologic examination in both patients. We report on these cases to draw attention to this rare entity in children.

Sirolimus in pediatric renal transplantation

SRL, an mTOR inhibitor that inhibits cell cycle progression, represents an important alternative to CNIs, which are still the cornerstones of pediatric solid organ tx. Because there are still limited data on SRL use among pediatric solid organ recipients, further studies are needed to verify the efficacy and safety of SRL. It has unique pharmacokinetic characteristics concerning dosing intervals and reduction of the dose in combination with other immunosuppressants. SRL also has antineoplastic, antiviral, and antiatherogenic advantages over other immunosuppressive agents. The adverse effects of SRL including thrombocytopenia, hyperlipidemia, proteinuria, impaired wound healing, mouth ulcers, edema, male hypogonadism, TMA, and interstitial pneumonitis must be considered carefully in pediatric population. This article reviews the most recent data on SRL application in the field of pediatric renal tx.

Resolution of chyloperitoneum in a preterm with octreotide, diet and cessation of dialysis

The diagnosis of chyloperitoneum (CP) is based on the presence of high levels of triglycerides (TGs) in the dialysate. It is a rare complication of peritoneal dialysis (PD) and even rarer in neonates. We report here the case of CP in a 1700-g male baby delivered at the 30th gestational week due to posterior urethral valve and associated oligohydramnios. On postnatal day 2, the serum creatinine (Scr) was 1.6 mg/dL, and he was anuric. PD was instituted via a Tenckhoff catheter. At the end of the second week, after the initiation of enteral feeding, the ultrafiltrate became cloudy, with a leukocyte count of 900/mm(3). A treatment regimen consisting of intraperitoneal vancomycin and ceftazidime was then started. Five days later, the fluid became milky, with a TG level of 251 mg/dL. The patient was then placed on a diet based on medium-chain triglycerides and octreotide (1 microg/kg/h; increasing up to 2 microg/kg/h over 15 days). Although the TG and leukocyte levels decreased, the milky appearance persisted. PD was stopped for 2 days when the Scr decreased to 1.7 mg/dL. When it was resumed, the fluid was totally clear, with a TG level of 7 mg/dL. The infant was discharged with a nightly intermittent peritoneal dialysis program and has had no recurrence. In summary, we report a preterm infant who developed CP during PD and recovered following treatment that included diet modification, octreotide, and temporary discontinuation of the PD.

Acute kidney injury following hypokalemic rhabdomyolysis: complication of chronic heavy cola consumption in an adolescent boy

A 16-year-old boy presented with acute kidney injury (AKI) which was attributed to chronic heavy cola consumption. Habitual heavy cola ingestion might lead to hypokalemic rhabdomyolysis by its glycyrrhizin content. AKI has been described rarely in association with this clinical picture. It is important for physicians to keep heavy cola and other soft drink consumption in mind as a cause for hypokalemic rhabdomyolysis and AKI.

WITHDRAWN: TRANSIENT TACHYPNEA OF THE NEWBORN: A PREDICTIVE FACTOR FOR PROLONGED TACHYPNEA

Ahead of Print article withdrawn by publisher.

[Evaluation of mammography and risk of developing breast cancer in patients with ovarian or endometrial cancer]

AIM

In this study our aim is to evaluate the reproductive factors determining the risk for breast cancer and the mammographical density in patients with ovarian or endometrial carcinoma.

MATERIALS AND METHODS

24 patients with epithelial ovarian carcinoma and 35 patients with endometrial adenocarcinoma who were hospitalized at Izmir Ataturk Training and Research Hospital between the dates of May 2005 and June 2006 for diagnosis, treatment and follow-up were included to our study. The control group was formed with 25 healthy women of over 40 years of age applied to our mammography unit for routine screening. All patients were questioned by means of reproductive risk factors for breast cancer. Mammographical images were gained in two projections as craniocaudal and mediolateral. Mammographical images were evaluated by using BI-RADS scoring system in terms of density and by one radiologist. Plasma E2 levels were taken from all postmenaupausal patients.

RESULTS

Mean age was higher in patients with endometrial carcinoma. The age of menarche was higher in patients with ovarian carcinoma. There were no significant differences between the groups in terms of age of menaupose, age of first delivery, lactation and duration of lactation, HRT use and incidence of type-2 diabetes. No any significant difference was detected in terms of E2 levels and mammographical density.

DISCUSSION

Reproductive risk factors for breast cancer in patients with ovarian and endometrial carcinoma were not different from the healthy population. The results of our study didn't reflect the reported increased risk rates for breast cancer.

Protective effect of Epo on oxidative renal injury in rats with cyclosporine nephrotoxicity

The aim of our study was to determine the effect of recombinant human erythropoietin (rhEPO) on cyclosporine (CsA) nephrotoxicity. Twenty-six female Wistar rats were injected with 15 mg/kg subcutaneous CsA and intraperitoneal saline/rhEPO for 28 days. Four groups were formed: Group 1 (n = 5), a control group; Group 2 (n = 7), CsA + saline; Group 3 (n = 7), CsA + low dose (20 U/kg per day) rhEPO; Group 4 (n = 7), CsA + high dose (100 U/kg per day) rhEPO. Body weights, creatinine clearance, urinary protein/creatinine, hematocrit, serum creatinine levels, histopathological parameters, apoptosis and lipid peroxidation tests were compared between the three groups. Body weights and renal functions were similar in Groups 2, 3 and 4 rats but significantly lower than the values found for the control group at the end of the study. The hematocrit was significantly different between the four groups, showing a positive association with the strength of the injected rhEPO doses. Tubular and arteriolar damage was significantly lower in Groups 3 and 4 rats than in Group 2 rats, while chronic changes were similar between the three groups. TUNEL-positive cells and thiobabarbituric acid reacting substance (TBARS) levels were significantly higher in Group 2 rats, whereas superoxide dismutase levels were significantly lower in Group 2 rats than in those of the other three groups. Low or high dose rhEPO had no significant protective effects on body weight, renal functions, chronic fibrotic changes, but both doses reduced tubular and arteriolar changes, apoptotis and oxidative stress.

Growth in familial mediterranean fever: effect of attack rate, genotype and colchicine treatment

We evaluated the effect of attack frequency, homozygosity for the M694V mutation and colchicine treatment on growth in children with familial Mediterranean fever (FMF). Prepubertal patients with FMF (19 M, 14 F) were evaluated retrospectively for height SDS, weight SDS and body mass index (BMI) before and after 46.2 +/- 39.8 months of colchicine therapy. Pretreatment attack frequency and acute phase markers at diagnosis were also recorded. While acute phase markers were not correlated to anthropometric variables, attack rate was negatively, albeit insignificantly, correlated to height and weight SDS. Height SDS did not change, while BMI showed a slight but significant increase during colchicine therapy (16.2 +/- 2.6 to 17.3 +/- 3.1 kg/m2, p = 0.035). Homozygosity for M694V did not affect time from the onset of symptoms to diagnosis, anthropometric variables and acute phase markers. In conclusion, pre-treatment attack rate and anthropometric development correlated negatively. Colchicine therapy improved BMI slightly, but significantly. Homozygosity for M694V had no effect on anthropometric development.

Transient tachypnea of the newborn: predictive factor for prolonged tachypnea

BACKGROUND

Because there is a lack of well-established criteria, the aim of the present paper was to determine risk factors to predict the duration of tachypnea in transient tachypnea of the newborn (TTN).

METHODS

Data from 95 newborns with TTN were evaluated retrospectively. Clinical and laboratory findings were compared between patients in whom tachypnea lasted <72 h (group 1) or >72 h (group 2).

RESULTS

Male gender, prematurity and delivery by cesarean section were the major risk factors for TTN. Parenteral furosemide had no effect on the clinical course. Peak respiratory rate (RRpeak) at the first 36 h was significantly higher in group 2 (P > 0.000). The cut-off for RRpeak during the first 36 h (RRpeak36) was 90/min and RRpeak36 > 90/min caused a 7.04-fold risk of prolonged tachypnea. White blood cell count and hematocrit levels were lower whereas duration of hospitalization and antibiotic treatment were longer in group 2.

CONCLUSIONS

Assessment of RRpeak36 may be useful in predicting clinical course of TTN.

Does feeding in infancy effect the development of IgA nephropathy?

Gut permeability to antigens is immature at birth, and while early administration of antigenic foods delays its maturation, breast-feeding accelerates it. We aimed to evaluate whether exposure to antigenic foods in early life is associated with a predisposition for immunoglobulin A nephropathy (IgAN). Three groups of children with IgAN (group 1), non-IgA glomerulopathies (group 2), and healthy controls (group 3) were formed. Parents filled out a questionnaire regarding gestational and postnatal ages, birth weight, and feeding by breast milk, formula, cow's milk, and complementary foods. All groups were similar for age, gender, birth weight, rate and duration of breast-feeding, and rate of formula feeding. Cow's milk consumption rate was higher in groups 1 and 2 than in group 3. Whereas introduction of formula was earlier in groups 1 and 2 than in group 3, feeding by cow's milk and weaning were earlier in group 1 than in the other groups. The respective best cutoff ages were 3.5 [odds ratio (OR) 28)], 3.75 (OR 5.7), and 5.5 (OR 10.5) months for formula, cow's milk, and complementary foods, respectively, for predicting the presence of IgAN. The results of this preliminary study indicate that early introduction of antigenic foods might increase the risk of future primary IgAN.

Predictive value of clinical and laboratory variables for vesicoureteral reflux in children

We aimed to determine the predictability of clinical and laboratory variables for vesicoureteral reflux (VUR) in children with urinary tract infection (UTI). Data of children with febrile UTI who underwent voiding cystoureterography between 2002 and 2005 were evaluated retrospectively for clinical (age, gender, fever > or = 38.5 degrees C, recurrent UTI), laboratory [leukocytosis, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), pyuria, serum creatinine (S(Cr))] and imaging (renal ultrasonography) variables. Children with VUR (group 1) vs. no VUR (group 2) and children with high-grade (III-V) VUR (group 3) vs. no or low-grade (I-II) VUR (group 4) were compared. Among 88 patients (24 male), 38 had VUR and 21 high-grade VUR. Fever > or = 38.5 degrees C was associated with VUR [odds ratio (OR): 7.5]. CRP level of 50 mg/l was the best cut-off level for predicting high-grade VUR (OR 15.5; discriminative ability 0.89 +/- 0.05). Performing voiding cystourethrography based on this CRP level would result in failure to notice 9% of patients with high-grade VUR, whereas 69% of children with no/low-grade VUR would be spared from this invasive test. In conclusion, fever > or = 38 degrees C and CRP > 50 mg/l seem to be potentially useful clinical predictors of VUR and high-grade VUR, respectively, in pediatric patients with UTI. Further validation of these findings could limit unnecessary voiding cystourethrography.

Schimke immunoosseous dysplasia: suggestions of genetic diversity

Schimke immunoosseous dysplasia (SIOD), which is characterized by prominent spondyloepiphyseal dysplasia, T-cell deficiency, and focal segmental glomerulosclerosis, is a panethnic autosomal recessive multisystem disorder with variable expressivity. Biallelic mutations in switch/sucrose nonfermenting (swi/snf) related, matrix-associated, actin-dependent regulator of chromatin, subfamily a-like 1 (SMARCAL1) are the only identified cause of SIOD. However, among 72 patients from different families, we identified only 38 patients with biallelic mutations in the coding exons and splice junctions of the SMARCAL1 gene. This observation, the variable expressivity, and poor genotype-phenotype correlation led us to test several hypotheses including modifying haplotypes, oligogenic inheritance, or locus heterogeneity in SIOD. Haplotypes associated with the two more common mutations, R820H and E848X, did not correlate with phenotype. Also, contrary to monoallelic SMARCAL1 coding mutations indicating oligogenic inheritance, we found that all these patients did not express RNA and/or protein from the other allele and thus have biallelic SMARCAL1 mutations. We hypothesize therefore that the variable expressivity among patients with biallelic SMARCAL1 mutations arises from environmental, genetic, or epigenetic modifiers. Among patients without detectable SMARCAL1 coding mutations, our analyses of cell lines from four of these patients showed that they expressed normal levels of SMARCAL1 mRNA and protein. This is the first evidence for nonallelic heterogeneity in SIOD. From analysis of the postmortem histopathology from two patients and the clinical data from most patients, we propose the existence of endophenotypes of SIOD.

The role of calcium utilization of intestinal flora in urinary calcium excretion

OBJECTIVE

We aimed to evaluate whether Ca(+2) utilization of intestinal flora (IF) has an effect on urinary excretion of Ca(+2) (UCaE) levels.

MATERIALS AND METHODS

Fecal samples (0.1 g/mL) of children who underwent UCaE examination in the past year were implanted in broths. Labeled (45)Ca (5 muL) was added to the samples and incubated. From these samples, a 200-muL quantity was filtrated with a 0.45-micrometer membrane and was rinsed in 200 muL pure water. (45)Ca activity in the membrane was measured and defined as percent activity per bacteria ((45)Ca(act) %/CFU). Levels of aerobic and anaerobic (45)Ca(act) %/CFU and their correlations with UCaE were compared between hypercalciuric (Group I) and normocalciuric (Group II) patients.

RESULTS

Levels of (45)Ca %/CFU were similar between groups (P > .05). Aerobic and anaerobic (45)Ca(act)%/CFU levels were not significantly correlated to UCaE, either in normocalciuric (P = .079, r = -0.503; P = .260, r = -0.420, stray mart respectively) or in hypercalciuric children (P = .509, r = 0.223; P = .623, r = -0.257, respectively).

CONCLUSION

Similar (45)Ca(act)%/CFU levels in the 2 groups imply that calcium utilization of IF does not have a distinct effect on UCaE.

Paracellin-1 gene mutation with multiple congenital abnormalities

Familial hypomagnesemia with hypercalciuria and nephrocalcinosis is an autosomal recessive renal tubular disorder characterized by renal magnesium wasting, hypercalciuria, advanced nephrocalcinosis and progressive renal failure. Mutations in the paracellin-1 (CLDN16) gene have been defined as the underlying genetic defect. The tubular disorders and progression in renal failure are usually resistant to magnesium substitution and hydrochlorothiazide therapy, but hypomagnesemia may improve with advanced renal insufficiency. We present a patient with a homozygous truncating CLDN16 gene mutation (W237X) who had early onset of renal insufficiency despite early diagnosis at 2 months. He also had additional abnormalities including horseshoe kidney, neonatal teeth, atypical face, cardiac abnormalities including coarctation of the aorta associated with atrial and ventricular septal defects, umbilical hernia and hypertrichosis. To the best of our knowledge, this is the youngest case diagnosed as familial hypomagnesemia with hypercalciuria and nephrocalcinosis and the first case having such additional congenital abnormalities independent of the disease itself.

Inhibition of vascular endothelial growth factor-induced retinal neovascularization by retinoic acid in experimental retinopathy of prematurity

Vascular endothelial growth factor (VEGF) has an important role in the pathogenesis of retinopathy of prematurity (ROP) and inhibition of VEGF expression in the neovascular phase might prevent destructive neovascularization in ROP. It is suggested that retinoids exert a highly potent antiangiogenic activity by inhibiting VEGF expression. The aim of this study was to demonstrate the preventive effect of retinoic acid (RA) on the VEGF-induced retinal neovascularization in a rat model of ROP. Wistar albino rats were placed into incubators at birth and exposed to an atmosphere alternating between 50 % and 10 % O(2) every 24 hours. After 14 days, the animals were removed to room air and received either an intraperitoneal injection of RA (5 mg/kg/day) (n=9) or saline (n=4) daily for six days, and sacrificed at 21 days. Other rats (n=4) were raised in room air and served as age-matched controls. The globe of each eye was cut through the cornea and embedded in paraffin. Serial sections were stained with hematoxylin-eosin for quantification of neovascular nuclei. The avidin-biotin peroxidase method was performed for evaluation of VEGF expression. The average number of neovascular nuclei was significantly lower in the control group compared to that in the ROP groups. In addition, it significantly decreased in the RA-treated ROP group compared to that of the saline-administrated ROP group. VEGF immunostaining was overall negative in room air-exposed rats. The VEGF immunostaining score significantly decreased in the RA-treated ROP group compared to that in the saline-administered ROP group. RA treatment might be beneficial in preventing neovascularization resulting from oxygen-induced retinopathy by downregulation of VEGF expression.

Medullary sponge kidney associated with distal renal tubular acidosis in a 5-year-old girl

INTRODUCTION

Medullary sponge kidney (MSK) is characterized by cystic dilatation of the inner medullary collecting ducts, which causes the kidneys to resemble a sponge.

CASE REPORT

Although distal renal tubular acidosis (dRTA) is commonly observed in patients with MSK, we report a 5-year-old girl with MSK who had features of both dRTA (nephrocalcinosis, hypercalciuria, hypocitraturia) and proximal tubular dysfunction (hyperuricosuria, impaired tubular phosphate reabsorption and proteinuria).

DISCUSSION

Metabolic acidosis, hypercalciuria, hypocitraturia, tubular phosphate reabsorption and growth retardation in the patient improved with alkali therapy.

Correlation of C0 and C2 levels with lipid profiles in adolescent renal transplant recipients in the early and late posttransplant periods

Hyperlipidemia is a frequent complication after renal transplantation. Cyclosporine therapy is an important cause of hyperlipidemia. It is still controversial whether C0 or C2 is the most effective way to monitor blood cyclosporine concentrations to guide dosages. We sought to evaluate the relationship of C0 or C2 to serum lipid levels in the early and late posttransplant periods among adolescent renal transplant recipients. The posttransplantation charts of 26 adolescent renal transplant recipients were evaluated retrospectively. Serum C0 and C2 levels and serum lipid (triglyceride and total cholesterol) levels were analyzed both in the early (first 6 months) and the late (thereafter) posttransplant periods. Hypertriglyceridemia and hypercholesterolemia were defined as levels above the 95th percentile adjusted for age and gender. To evaluate the influence of C0 and C2 levels on serum lipids, we excluded one patient with familial hyperlipidemia. In addition, serum lipid levels of the remaining 25 patients were excluded in acute rejection periods and when the serum creatinine levels were above 2.5 mg/dL, representing chronic allograft nephropathy. Concurrently recorded serum C0 and C2 levels were present for only 21 patients. Overall, we evaluated the records of 245 visits for these 21 patients. The incidence of hyperlipidemia decreased in the late posttransplant period, being significant for hypercholesterolemia. C2 had strong negative correlation with serum lipids; it was significant for total cholesterol in the early posttransplant period (r=-0.542, P=.005), but weaker in the late posttransplant and whole posttransplant periods. Thus correlation of C2 with serum lipids showed differences during posttransplant follow-up. C0, on the other hand, was positively correlated with total cholesterol levels in all periods, being significant for the whole posttransplant period (r=0.293, P=.000) and for the late posttransplant period (r=0.196, P=.025). Although not statistically significant, C0 levels were higher among hypertriglyceridemic or hypercholesterolemic episodes both in the early and the late posttransplant periods. When only the C0 levels of all 25 patients were analyzed (789 visits), C0 and serum cholesterol levels were positively correlated both in the early and the late posttransplant periods (P=.013, r=0.198 and P=.000, r=0.177, respectively). We concluded that C0 has a more predictable correlation with serum cholesterol levels after renal transplantation in adolescent patients.

Effect of obesity and overweight on cyclosporine blood levels and renal functions in renal adolescent recipients

INTRODUCTION

The impact of obesity, a frequent problem after renal transplantation, which has been associated with poor graft and patient survival, was evaluated on renal function and cyclosporine (CsA) blood levels.

PATIENTS

We retrospectively evaluated the data of adolescent renal recipients between 1994 and 2004. Patients with serum creatinine > or = 2.5 mg/dL were excluded. We grouped the data with regard to the body mass index (BMI) percentiles as group I (BMI > 95th), group II (BMI < 95th), group III (BMI > 85th), group IV (BMI < 85th). We compared the clinical and laboratory findings between groups I and II and between groups III and IV.

RESULTS

We evaluated 778 visits of 27 patients (M/F: 19/8). There were 30 visits in the obesity period (group I) and 72 visits after the overweight periods were added (group III). Serum creatinine levels were significantly higher and glomerular filtration rate levels significantly lower among obese and/or overweight than lean periods (P < .05). Proteinuria levels were similar in groups I and II, but significantly higher in group III than group IV (P = .356 and .000, respectively). CsA(mg/bw), CsA(mg/bmi), and CsA(mg/bsa) levels were significantly lower in group I than group II and in group III than group IV (P < .05), while C0 and C2 levels were similar (P > .05).

CONCLUSION

Weight gain is associated with worse renal functions but not greater proteinuria in our patients. Smaller CsA doses were sufficient to maintain C0 and C2 levels similar to the lean patients, results that were parallel to those of adult renal recipients.

Febrile Myalgia Syndrome in Familial Mediterranean Fever

Familial Mediterranean fever is characterized by recurrent polyserositis episodes associated with fever. However, the clinical spectrum of this disease has been expanded recently and myalgia is now a frequently recognized component. Protracted febrile myalgia syndrome was first described in patients with familial Mediterranean fever in 1994. This syndrome is characterized by severe paralyzing myalgia, high fever, abdominal pain, diarrhea, arthritis/arthralgia, and transient vasculitic rashes mimicking Henoch-Schonlein purpura. Recently, we evaluated 6 patients with the clinical picture of protracted febrile myalgia syndrome in our clinic. One of them was a patient with known familial Mediterranean fever, but the others were subsequently diagnosed to have familial Mediterranean fever by mutational analyses. Thus, introduction of genetic analysis would possibly change the diagnostic criteria for familial Mediterranean fever. In addition, all 6 patients presented in the spring months when streptococcal infections are at their peak rate and 3 of them had elevated ASO levels indicating that streptococci could be one of the agents triggering protracted febrile myalgia syndrome.

In vitro analysis of the effect of hyperbilirubinemia on rabbit ureter and bladder

Spontaneous resolution of intrauterine pelvic dilatations after birth is an expected outcome. In nonobstructive pelvic dilatations, changes in ureteral and bladder physiology may also play a part. We aimed to demonstrate the effect of increased concentrations of bilirubin on ureteral and bladder muscles in vitro. Normal and pathologic concentrations of bilirubin (3.5x10(-7)-10(-5)M and 10(-4)-4x10(-4)M, respectively) caused no change in the basal ureter tension (343.9+/-29.4 mg). Normal concentrations of bilirubin caused no difference in basal bladder tension (430.2+/-70.2 mg), but pathologic concentrations caused a decrease of 303.8+/-52.9 mg. Normal and pathologic amounts of bilirubin were cumulatively applied to rabbit ureteral and bladder tissues both after reaching basal tension and when contracted with KCl (80 mM and 120 mM KCl for ureter and bladder, respectively). The cumulative addition of normal bilirubin concentrations to the ureteral tissues precontracted with KCl produced 86.4+/-7.2% relaxation, while the addition of pathologic bilirubin concentrations produced a relaxation of 133.9+/-17.4%, which was significantly higher (p=0.04). Similarly, the addition of normal concentrations of bilirubin to the bladder tissues precontracted with KCl produced a maximal relaxation of 35.3+/-2.2%, while pathologic concentrations produced a maximal relaxation of 53.5+/-3.5%, which was significantly higher (0.001). Consequently, high concentrations of bilirubin caused a mild relaxation in basal ureteral and bladder tensions, while pathologically increased concentrations led to significant relaxation in both types of precontracted tissues. We suggest that high bilirubin levels may partly but not directly contribute to the spontaneous recovery of hydronephrosis because of the relaxation effect on bladder while probably causing susceptibility to urinary tract infections because of relaxation of both ureteral and bladder tissues.

Renal medullary changes in renal allograft recipients with raised serum creatinine

OBJECTIVE

To test the hypothesis that the renal medulla may reflect rejection related changes and thus have a predictive value in the assessment of acute renal allograft rejection or chronic graft damage.

METHODS

75 post-transplant biopsies from 57 patients were scored according to the Banff 1997 scheme. The biopsies with adequate cortical and medullary tissue (n = 23) were selected and medullary tissues were reviewed for rejection related lesions except intimal arteritis. Chronic damage was determined by image analysis depending on periodic acid-methenamine silver (PAMS)-Masson trichrome (MT) staining. Medullary and cortical changes were compared.

RESULTS

Interstitial inflammation and tubulitis were more frequent and severe in the cortex (p<0.001). Medullary tubulitis was associated with intimal arteritis (p = 0.003, r = 0.598). Medullary interstitial inflammation (n = 8) and tubulitis (n = 4) were associated with cortical borderline changes (n = 5) or allograft rejection (n = 3). The sensitivity, specificity, and positive and negative predictive values of medullary inflammatory changes in predicting cortical allograft rejection were 43%, 69%, 37%, and 73%, respectively. A significant association was observed between medullary MT-SAP and cortical PAMS-SAP values (p = 0.02, R(2) = 0.23).

CONCLUSIONS

Acute rejection related lesions are more common and severe in the cortex, and the renal medulla does not sufficiently reflect cortical rejection. The positive and negative predictive values of medullary changes for allograft rejection are low, and medullary inflammation is not a reliable indicator of allograft rejection. Increased medullary fibrosis is correlated with chronic cortical damage.

Relationship of increased renal cortical echogenicity with clinical and laboratory findings in pediatric renal disease

PURPOSE

To correlate the clinical and laboratory findings with increased renal cortical echogenicity in children with acute renal diseases.

MATERIALS AND METHODS

Children with increased renal cortical echogenicity were evaluated retrospectively. Laboratory findings and final diagnoses were reviewed. Patients with increased echogenity were classified into group 1 (mild; grade I) or group 2 (more severe; grades II and III).

RESULTS

There were 7 newborns and 114 children (67 male, 47 female) with increased renal cortical echogenicity with a mean (+/-SD) age of 7.0 (+/-4.4) years. The clinical diagnosis was anatomic abnormality (including vesicoureteral reflux, ureteropelvic junction obstruction, ureterovesical junction obstruction, double collecting system) in 9%, urinary tract infection in 21%, urolithiasis in 6%, nephrotic syndrome in 20%, glomerulonephritis in 32%, and other diseases in 12%. Hyperechogenicity was bilateral in 72%, right-sided in 19%, and left-sided in 9%. There were 81 patients in group 1 and 33 patients in group 2 (grade II, 29; grade III, 4). There was no statistically significant difference between the groups with regard to age, sex, and serum blood urea nitrogen level, serum creatinine level, uric acid level, urine pH, and specific gravity. Hematuria was more frequent in group 2, whereas proteinuria and pyuria incidences were similar in the 2 groups. In patients with hematuria, glomerulonephritis was the most common cause.

CONCLUSIONS

Glomerulonephritis is the most frequent acute disease causing increased renal echogenicity in childhood, and higher echogenicity is more likely to be associated with hematuria.

Efficacy of COX-2 inhibitors in a case of congenital nephrogenic diabetes insipidus

A 17-month-old boy presented with failure to thrive, polyuria, and vomiting. He had been diagnosed clinically with nephrogenic diabetes insipidus and treated by amiloride and hydrochlorothiazide combination without a satisfactory outcome at another center since 1 year of age. The diagnosis was confirmed by genetic analysis (AVPR2mutation), and the treatment was modified to include rofecoxib (a selective cyclooxygenase-2 inhibitor) in addition to hydrochlorothiazide and amiloride. This combination along with a low-salt diet resulted in a dramatic decrease in urinary free-water loss, while no side effect was noted. Because of prohibition of rofecoxib, it had to be substituted first by indomethacin and then by ibuprofen. However, both drugs were ineffective in controlling water diuresis. Thus, we had to replace these drugs by celecoxib (another selective cyclooxygenase-2 inhibitor). We conclude that the combination hydrochlorothiazide/amiloride/cyclooxygenase-2 inhibitor could be successfully used to treat congenital nephrogenic diabetes insipidus.

An adolescent girl with Meyer-Betz syndrome

Idiopathic paroxysmal rhabdomyolysis indicating a classical triad of symptoms consisting of muscle pain, weakness, and discolored urine is known as "Meyer-Betz syndrome". It may result in acute renal failure due to precipitation of the myoglobin casts in the tubuli or to the direct toxic effects of myoglobin to the tubular epithelium. On the other hand, outcome may be uneventful. In this study, we reported the case of a 16-year-old girl who was admitted with red-colored urine after a slight exertion. She had tenderness and weakness in upper parts of her legs and bilateral flank pain. She had a positive urine dipstick test for heme despite absent red cells on microscopic examination. White cell count, liver function tests, serum creatine kinase (CK), lactate dehydrogenase (LDH), and urine myoglobin levels were raised. All metabolic tests were in normal ranges and EMG was normal. A muscle biopsy performed after recurrent exertional rhabdomyolysis attacks demonstrated normal findings and ruled out metabolic disorders. At the time of attacks, hydration along with alkalinization was applied and she did not experience renal failure. She was advised to avoid strenuous physical exertion and had an uneventful outcome for the last 5 months. We reported the clinical course and follow-up of an adolescent girl with Meyer-Betz syndrome.

Megacalycosis: report of two cases

Congenital megacalycosis is a rare renal disorder consisting of caliceal dilatation without evidence of renal pelvic or ureteral obstruction. Since its first description in 1963, only a few cases have been reported. The defect is mostly unilateral, shows male predominance and does not disrupt the renal functions. We report on two male patients with bilateral megacalycosis and different clinical presentations. The first case was diagnosed in adolescence during examination for a urinary tract infection and was followed-up uneventfully for nearly ten years. The second case was found to have megacalycosis during the assessment of antenatal hydronephrosis. We aimed to emphasize the importance of considering megacalycosis in the differential diagnosis of both antenatal hydronephrosis and other causes of caliceal dilatation to prevent unnecessary diagnostic and therapeutic interventions.

Clinical quiz: a pediatric case presenting with fever and diffuse myalgia

Familial Mediterranean fever (FMF) is a multisystem disease characterized by recurrent polyserositis episodes seen in certain ethnic groups. In recent years the clinical picture of FMF has been expanded and severe myalgia is a frequently recognized component of the syndrome. Protracted febrile myalgia syndrome (PFMS), characterized by severe paralyzing myalgia, high fever, abdominal pain, diarrhea, arthritis/arthralgia, and transient vasculitic rashes mimicking Henoch-Schonlein purpura, was first described in patients with FMF in 1994. We describe an 11-year-old Turkish girl with a second attack of PFMS before being diagnosed as having FMF, emphasizing the importance of myalgia for the diagnosis of FMF even in the absence of other symptoms.

Sarcoidosis with an uncommon presentation: apropos of a case

A 17-year-old male presenting with chronic renal failure whose supporting clinical manifestations of the disease had appeared independently over a four-year period is reported. The renal biopsy specimen of the patient revealed tubulointerstitial nephritis and membranous glomerulonephritis. He never had hilar adenopathy, but maculopapular rashes, erythema nodosum, arthritis, chronic lymphocytopenia, hepatomegaly, splenomegaly, and lymphadenomegaly had been observed at different periods over four years. The presence of non-caseating granulomatous lesions in the liver biopsy accompanying uveitis verified the diagnosis of sarcoidosis. Low dose steroid was applied to this hepatitis-C carrier, and uveitis was suppressed. No recurrence has been observed in two-year follow-up.

Two-hour post-dose cyclosporin A levels in adolescent renal transplant recipients in the late post-transplant period

Although the success of renal transplantation is closely linked to the immunosuppression provided by cyclosporin A (CsA), the best way to monitor the blood levels of CsA is still not clear. Trough CsA levels (C(0)) are commonly used, but the 2-h post-dose CsA levels (C(2)) are reported to correlate better with area under the curve. The aim of this study was to evaluate the correlation of C(2) levels with allograft function in adolescent renal transplant recipients in the late post-transplant period (6 months after transplantation) compared with C(0 )levels. The data of 17 adolescent renal transplant recipients (12 males, 5 females) were evaluated retrospectively. The mean age at the time of transplantation was 15.212+/-2.918 years and the mean follow-up period was 53.172+/-34.090 months. C(0) levels correlated with oral CsA and diltiazem doses, while C(2) levels exhibited no correlation. When C(2) levels were classified as 0-400, 401-800, and 801-1200 ng/ml, no statistically significant difference was found between these groups with respect to glomerular filtration rate (P=0.830). Although 82% of the patients had C(2 )beneath the therapeutic level (<800 ng/ml), none had an acute rejection episode. In conclusion, optimum C(2) levels could be different from levels in the adult population. Furthermore, the correlation of C(2) levels with CsA dose seems to be weaker than in the adult population. Thus, further studies are needed to determine a more reliable predictor for CsA dose monitoring and target blood CsA levels in adolescent patients.

The factors affecting blood pressure in pediatric renal transplant recipients

To investigate the parameters affecting systemic blood pressure in pediatric renal transplant recipients, we retrospectively examined the data from 19 adolescent renal transplant recipients including 6 girls overall, mean age of 15,47 +/- 3.56 years. Serum creatinine (Scr), fractional extraction of sodium (FENa), whole blood trough cyclosporine(C0), plasma total cholesterol (TC) and triglyceride levels, and systolic and diastolic blood pressure (SBP and DBP) were monitored during a total of 677 visits. SBP and DBP, classified as <95p (groups 1s and 1d) and >95p (groups 2s and 2d), were correlated with differences between groups 1 and 2. Group 2s Scr and FENa levels were higher than group 1s (P =.002 and P =.048, respectively), whereas C0 and FENa levels were higher in Group 2d than Group 1d (P = 0.028 and P = 0.036, respectively). Among the entire group, SBP and DBP positively correlated with C0; Scr and SBP, with FENa. While there was a positive correlation between SBP and C0 in groups 1s and 2s (r = 0.188, P <.000; and r = 0.145, P =.040), DBP was only associated with C0 in group 1d (P =.03, r = 0.156). In contrast, DBP showed a positive correlation with Scr in group 2d (P =.023, r = 0.132), and SBP with Scr in Group 1s. C0 and Scr levels were correlated in Groups 1s, 1d and 2d. At high BP levels (>95p), SBP is mostly affected by C0; DBP, with Scr. However, in both groups these two parameters positively correlate with each other. Thus, in adolescent renal transplant recipients the cause of high blood pressure does not appear to be solely related to cyclosporine related to induced allograft dysfunction.

Doppler sonographic indices in diagnosing the nutcracker phenomenon in a hematuric adolescent

Compression of the left renal vein between the aorta and the superior mesenteric artery, known as the nutcracker phenomenon, may cause gross or microscopic hematuria, pain in the flank, proteinuria, or a combination of these symptoms. We report the case of a hematuric adolescent diagnosed with a high index of suspicion by noninvasive Doppler sonography using the diagnostic indices of Doppler sonography established for adults with hematuria. Compression of the patient's left renal vein at the aortomesenteric portion and dilatation at the hilar portion were visualized by magnetic resonance angiography, which verified the diagnosis.