Validity of the Adrogué-Madias Formula for the Management of Acute Dysnatremias in Critically Ill Children: A Prospective Multicenter Analysis

OBJECTIVE

Current conventional formulas do not predict the expected changes in serum sodium after administration of various fluids to correct serum sodium abnormalities. The Adrogué-Madias formula is currently the preferred and widely used fluid prescription for adult patients with dysnatremias, but its therapeutic efficacy has not been validated in pediatric patients.

METHODS

In this prospective study, we used the Adrogué-Madias formula for calculating the appropriate rate of various fluids administration to correct serum sodium abnormalities in 7 critically ill children with acute dysnatremias.

RESULTS

After administration of various intravenous fluids using the Adrogué-Madias formula, the anticipated as well as the achieved sodium concentrations were almost similar.

CONCLUSIONS

This study demonstrates that the use of the Adrogué-Madias quantitative formula allows to calculate the appropriate rate of administration of various fluids. The calculated fluid administration resulted in the subsequent actual laboratory values and clinical changes.

Clinical Aspect and Outcome of Henoch-Schoenlein Purpura in Children in Relation to Renal Biopsy Pathologic Findings

The most common childhood vasculitis is Henoch Schoenlein Purpura (HSP). It occurs at any age peaking at around 4-6 years. The classic manifestations of HSP are skin rash, along with any from a triad of other organ system involvement, including gastrointestinal, musculoskeletal, and renal systems. Renal involvement is much more common in children than in adults. 255 HSP patients attending our tertiary referral hospital enrolled in this 10-year retrospective study from 2009 to 2019. According to our study, HSP was more common in males. Most of the patients were between 1-16 years (mean 7.04 years) old. Of these patients, only 19.22% had proteinuria, 17.25% had increased creatinine, 61.7% of patients had hematuria, 67.06 had a fever, and 69.8% had abdominal pain. 24.31% of them had bloody diarrhea. Skin and joint involvement were recorded in 44.7% and 74.9% of patients, respectively. Children affected by HSP may present with different clinical manifestations. We assessed these clinical presentations and outcomes of patients and compared them with renal pathology findings to reveal any prognostic significance of renal pathologic findings in HSP patients.

Revisiting the Management of Pediatric Kidney Transplants, A Multicenter Analysis

The newest Kidney Disease Improving Global Outcomes (KDIGO) guideline recommendations were investigated mainly for the care of adult kidney transplant recipients, but no guideline exists for the management of pediatric transplant recipients. This review provides update recommendations in the management of pediatric kidney transplantation. Four electronic databases, PubMed, EMBASE, Google Scholar, and Web of Science were searched systematically for the last two decades, using Mesh terms in English language. The Grades of Recommendation Assessment, Development, and Evaluation (GRADE) approach was used for grading the quality of the overall evidence and the strength of recommendations for each outcome across the studies. The overall quality of evidence categorized as high (A), moderate (B), low (C), or poor (D). The strength of a recommendation was determined as level 1 (recommended) or level 2 (suggested). The ungraded statements were determined on the basis of common sense to provide general advice. Of the 317 citations which were screened for the evidence review, 62 were included in data extraction. The included studies were randomized controlled trials, prospective cohorts and cross-sectional, descriptive, and review studies. Of the 115 statements, 56 (48.6%) were graded 1 (we recommend), 34 (29.5%) were graded 2 (we suggest), and 25 (21.7%) were ungraded statements. Altogether, only 22 (19.1%) of recommendations reached the "A" or "B" levels of quality of evidence. The pediatric kidney transplant recipients are different from adult recipients regarding the primary kidney diseases, surgical techniques, drug metabolism, adherence to medications, growth and neurocognitive development and immunization needs prior to transplantation.  DOI: 10.52547/ijkd.7179.

Evaluation of the relationship between serum carnitine levels and intradialytic complications in children with kidney failure

BACKGROUND

Carnitine plays a crucial role in the metabolism of fatty acids as well as energy production. Previous research has suggested a significant decrease in carnitine levels in patients with kidney failure and those undergoing hemodialysis. Therefore, we designed this study to assess the prevalence and characteristics of carnitine deficiency and its association with hemodialysis complications in the pediatric population.

METHODS

This research was a pilot study of 29 children undergoing hemodialysis. Before hemodialysis, a 5-mL blood sample was drawn from each patient through a peripheral vein to measure serum-free carnitine levels, complete blood count with differential, blood urea nitrogen (BUN), creatinine, and electrolytes. Each patient was observed for intradialytic complications, including muscle cramps and hypotension, during 12 sessions of hemodialysis.

RESULTS

We included 26 participants with a mean age of 14.23 years undergoing hemodialysis. Carnitine deficiency was revealed in 54.8% of our participants. Also, there was no significant correlation between carnitine deficiency and age, gender, and BUN levels (P = 0.698, P = 0.43, and P > 0.05, respectively). Intradialytic complications, including episodes of hypotension and muscle cramps, were more frequent in patients with carnitine deficiency (P = 0.02, P = 0.01, respectively). Other reasons for muscle cramps, such as fluid overload, nutritional status, dialysis regimen, and other important lab results (phosphorus, magnesium, etc.), were ruled out.

CONCLUSION

In conclusion, we found a higher prevalence of carnitine deficiency in pediatric hemodialysis patients. Carnitine deficiency was significantly associated with increased intradialytic symptoms, including muscle spasms and hypotension. Our results could support a potential role of carnitine supplementation in pediatric patients with kidney failure for controlling intradialytic complications, but this requires further investigation. A higher resolution version of the Graphical abstract is available as Supplementary information.

New Biomarkers in Early Diagnosis of Acute Kidney Injury in Children

Acute Kidney Injury (AKI) is a common condition with a high risk of mortality and morbidity, so, early diagnosis and management of AKI is very important in clinical practice. Despite significant progress in the management of AKI, it still carries high morbidity and mortality. BUN and serum creatinine are not very sensitive nor specific for the diagnosis of AKI because they are affected by many renal and non-renal factors that are independent of kidney injury or kidney function and change significantly only after significant kidney injury and with a substantial time delay. Detection of biomarkers of AKI made predominantly by the injured kidney tissue are essential for the early diagnosis of AKI. An ideal biomarker should be one that could be easily measured, with no interference with other biologic variables, and be able to clarify early phases of kidney damage. The most common biomarkers studied are Neutrophil Gelatinase-Associated Lipocalin (NGAL), Interleukin-18 (IL-18), Kidney Injury Molecule-1 (KIM-1), Cystatin-C, L type Fatty Acid-Binding Protein (L-FABP), N-Acetyl- β-D Glucosaminidase (NAG), netrin-1, vanin-1, and Monocyte Chemoattractant Protein-1 (MCP-1) and calprotectin.

Renal Involvement in a Child with COVID-19 Infection and its Management with CRRT

Novel Coronavirus disease (COVID-19) is a contagious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV 2) presenting mainly as an acute respiratory illness with interstitial and alveolar pneumonia. It can also affect multiple organs such as the kidney, heart, intestinal tract, blood, and nervous system. We report a 10-year-old boy presenting with severe cough, tachypnea, retraction and respiratory distress, fever, myalgia, oliguria, and anuria thereafter. He had no history of diarrhea, vomiting, or a runny nose. Laboratory findings include leukopenia and lymphopenia. CRP, ESR, and procalcitonin levels were high, but serum LDH was normal. RT-PCR test was positive. In the initial days of admission, he needed mechanical ventilation support due to ARDS and received antiviral drugs, renal replacement therapy, hemoperfusion, and other necessary supportive cares. Thirty-five days later, he weaned from the ventilator and discharged from hospital. Two weeks later, COVID-19 specific IgG was found in serologic test.

Efficacy of rituximab therapy in children with nephrotic syndrome: a 10-year experience from an Iranian pediatric hospital

Background

There are controversy results in the optimal management of children with steroid-dependent and steroid-resistant nephrotic syndrome (SDNS, SRNS). This study aimed to determine the efficacy and safety of rituximab (RTX) in these pediatric patients.

Methods

Medical records of 1–18-year-old Iranian children with SDNS (n = 26) and SRNS (n = 22) with a follow-up for at least 24 months were included from 2009 to 2019. The short- and long-term responses to RTX were respectively evaluated to determine the random protein-to-creatinine ratio after 6 and 24 months and classified as complete (CR) and partial (PR) remission or no response.

Results

Male patients (n = 26) were slightly predominate. The median age of patients at the time of RTX therapy was 8.6 ± 4.01 years. At the end of the 6-month follow-up, CR and PR occurred in 23 (47.9%) and 12 (25%) patients, respectively. Of 23 patients with CR, 18 (69.2%) and 5(22.7%) had SDNS and SRNS, respectively (p < 0.005). However, only 18 (37.5%) of patients after 24 months had been in CR. No significant difference in the CR rate was found between the two groups. RTX was more effective when administered during the proteinuria-free period (p = 0.001).

Conclusion

In the short term, RTX significantly was efficient in inducing complete or PR in SDNS and SRNS patients. However, the favorable response rate in a long-term follow-up was insignificantly lower between the two groups.

Evaluating the value of different sonographic findings in diagnosis of acute appendicitis in children

INTRODUCTION

Appendicitis is one of the most common paediatric surgical emergencies occurring in about 7% of healthy children. To make a definitive diagnosis preferably avoiding unnecessary X-ray radiation exposure, ultrasound is the ideal modality. The aim of this study is to evaluate the diagnostic value of sonographic findings in children with acute appendicitis and comparing them with surgical findings to demonstrate the safety, simplicity and accuracy of this procedure in emergency departments as the first diagnostic procedure.

MATERIALS AND METHODS

One hundred and eight children aged 1-15 years suspected of acute appendicitis in our tertiary hospital emergency department enrolled the study. Patients presenting as acute abdomen suspected as having acute appendicitis underwent abdominal ultrasonography (US) at first. Sonographic findings were compared to surgical and pathologic results, and sensitivity and specificity of each sonographic parameter in paediatric appendicitis were evaluated.

RESULTS

The analysis of sonographic results showed that 67.6% of patients had acute appendicitis, 13.9% had perforated appendicitis and 18.5% had normal appendix. On the other hand, there were acute appendicitis in 63.9% of patients, perforated appendicitis in 12% and normal appendix in 8.3% in surgical reports. Sensitivity of uncompressible appendicitis, appendicitis, maximal outer diameter (MOD) above 6 mm, maximal mural thickness (MMT) above 3 mm, round appendix was 98.68%, 28.04%, 94.74%, 61.84% and 68.42%, respectively. Specificity of incompressible appendicitis, appendicitis, MOD above 6 mm, MMT above 3 mm, round appendix was 64.71%, 96.15%, 64.71%, 82.35% and 94.12%, respectively. Overall sensitivity and specificity of US in appendicitis were 97.56% and 69.23%, respectively.

CONCLUSION

According to the findings of this study, sensitivity of US in diagnosing appendicitis is higher than other studies, but its specificity was lower. Ultrasonographic accuracy and efficacy to diagnose acute appendicitis in children are high enough to allow clinicians to do it as an imaging modality of first choice, and also, in problematic cases to assist correct clinical diagnosis avoiding unnecessary X-ray exposure, decreasing negative appendectomies, decreasing perforation rate and lowering the cost of patients. Furthermore, negative US do not justify immediate computed tomography because clinical re-evaluation and a second US can help greatly the clinicians in the correct diagnosis.

New Biomarkers in Early Diagnosis of Acute Kidney Injury in Children

Acute Kidney Injury (AKI) is a common condition with a high risk of mortality and morbidity, so, early diagnosis and management of AKI is very important in clinical practice. Despite significant progress in the management of AKI, it still carries high morbidity and mortality. BUN and serum creatinine are not very sensitive nor specific for the diagnosis of AKI because they are affected by many renal and non-renal factors that are independent of kidney injury or kidney function and change significantly only after significant kidney injury and with a substantial time delay. Detection of biomarkers of AKI made predominantly by the injured kidney tissue are essential for the early diagnosis of AKI. An ideal biomarker should be one that could be easily measured, with no interference with other biologic variables, and be able to clarify early phases of kidney damage. The most common biomarkers studied are Neutrophil Gelatinase-Associated Lipocalin (NGAL), Interleukin-18 (IL-18), Kidney Injury Molecule-1 (KIM-1), Cystatin-C, L type Fatty Acid-Binding Protein (L-FABP), N-Acetyl-β-D Glucosaminidase (NAG), netrin-1, vanin-1, and Monocyte Chemoattractant Protein-1 (MCP-1) and calprotectin.

Comparative Analysis between Urinary Calprotectin and Serum Creatinine for Early Detection of Intrinsic Acute Kidney Injury

Background

Acute kidney injury (AKI) is a common and important clinical condition that may lead to chronic kidney disease if it is not diagnosed and treated in its early stages. Urinary calprotectin is a valuable recognized biomarker that can be used to differentiate prerenal and intrinsic AKI. However, till date only a few reports on urine calprotectin measurement in early diagnosis of intrinsic AKI are available. In this study, we compared the sensitivity and specificity of urinary calprotectin with those of serum creatinine in detecting early intrinsic AKI.

Methods

Over 6 months period (April to October 2018), 81 of 408 patients admitted to the pediatric intensive care unit met the criteria of this cross-sectional study. Their serum creatinine and urinary calprotectin were measured on the first and third day of admission using Jaffe and Elisa radioimmunoassay methods, respectively. The AKI was defined according to the pRIFLE criteria.

Results

Of the total 81 patients, 67 had the criteria of intrinsic AKI. Of these 62% were female and 38% were male. The mean age of the patients was 22 months. According to data analysis, the area under the curve of ROC of urinary calprotectin on day-1 to detect renal failure is 0.93 with the best cutoff point obtained at 530 ng/mL. The sensitivity, specificity, positive, and negative predictive values of urinary calprotectin levels in diagnosing AKI at this cutoff point are 92.5%, 92.8%, 98.4, and 72.2%, respectively. Besides, urinary calprotectin changes occur much earlier than the rising of serum creatinine.

Conclusion

Urinary level of calprotectin is a very sensitive biomarker for early diagnosis of intrinsic AKI in children and it can be used in intensive care units or anywhere critically ill children admitted to detect intrinsic AKI. Besides, this study shows that urine calprotectin may be a more sensitive and specific biomarker than serum creatinine in the early phases of intrinsic AKI.

The Effect of Oral Cyclophosphamide in the Treatment of Children with Refractory Idiopathic Nephrotic Syndrome

INTRODUCTION

Nephrotic syndrome (NS) is the most common chronic kidney disease in children. Patients who do not respond to steroids are steroid resistance nephrotic syndrome (SRNS). Cyclophosphamide (CP) has been used in the treatment of SRNS, but its effectiveness has been questioned. The aim of this study was to evaluate the drug response and side effects of CP in the treatment of SRNS.

METHODS

This study performed as a historical cohort (1997 to 2017) in idiopathic SRNS patients over one year of age who did not enter remission and used oral. All patients were followed up with CBC and regular visits to control drug side effects.

RESULTS

In this study, 52 SRNS patients with a mean age of 5.3 ± 5.3 years were studied, of whom 24 (46%) were male and 22 (54%) were female. The follow-up period of patients was 1 to 264 months. In this study, 38.5% of patients were sensitive to CP and 61.5% of patients were resistant to CP. The response to CP was not significantly different between the ages of higher 6 years and under (P > .05). There was no significant relationship between remission rate and type of pathology and CP addition to treatment. But there was a significant difference between ESRD and CP resistance.

CONCLUSION

It can be concluded that CP has no significant effect on the remission of SRNS patients, but has made a significant difference in the development of ESRD in patients.

Urinary carbohydrate antigen 19-9 level as a biomarker in children with acute pyelonephritis

Early and prompt diagnosis of pyelonephritis is of great importance in children. The aim of this study is to evaluate the diagnostic accuracy of urinary carbohydrate antigen 19-9 (CA19-9) levels for predicting acute pyelonephritis (APN) in children with urinary tract infection (UTI). Patients were allocated into two groups of APN and acute cystitis according to their diagnosis. Urine samples of all patients were collected. Also, complete history was taken, and physical examination, kidney and bladder ultrasonography, ^99mTc-dimercaptosuccinic acid renal cortical scintigraphy, and urine analysis and culture were performed. Urinary CA19-9 was measured by an electrochemiluminescence enzyme immunometric kit. In addition, CA19-9 levels were measured in the APN group 2 weeks and 3 months later. A total of 100 children were included in this study (mean age 46 ± 31 months, 16 males and 84 females). CA19-9 levels were significantly greater in the APN group than acute cystitis group (510 ± 328 vs. 18.7 ± 18.6 U/ml, P < 0.001). During follow-up periods of the APN group, CA19-9 levels decreased to 180 ± 124 U/ml after 2 weeks (P < 0.001) and 30 ± 23 U/ml after 3 months (P < 0.001). Urinary CA-19-9 had 95.3% sensitivity and 80% specificity for the diagnosis of APN. The area under the curve value of CA19-9 was 0.904 (95% CI 0.831-0.977).Conclusion: Urinary CA19-9 level can be used as a reliable biomarker for early detection of APN prior to urine culture confirmation in children with UTI. What is known: • Early and prompt diagnosis of pyelonephritis is necessary in children to prevent renal damage. • Acute pyelonephritis can present with vague and nonspecific symptoms in infants and children. What is new: • Urinary carbohydrate antigen 19-9 is a reliable biomarker for early detection of acute pyelonephritis prior to urine culture confirmation. • Urinary carbohydrate antigen 19-9 has 95.3% sensitivity and 80% specificity for diagnosis of acute pyelonephritis.

The level of allergens in dust samples collected from selected schools in Shiraz, Iran and its asthma-risk implications

BACKGROUND

Both home and school are important places where children are exposed to various indoor allergens. This study aimed to identify the profile of indoor allergens in schools and its impact on asthma development.

METHODS

A total of 104 classrooms from 52 schools were selected for dust collection during the fall of 2017. The levels of indoor allergens including dust mite (Der f1, Der p1), cat (Fel d1), cockroach (Bla g1) and mouse (Mus m1) were measured by enzyme linked immunosorbent assay (ELISA). The diagnosis of asthma was made in all students of the selected classes by the allergist. The collected data were analyzed using SPSS version 21.0.

RESULTS

Out of 2816 students in the selected classes, 180 students were involved with asthma. Students were mostly exposed to Bla g1 (83.1%), followed by Der f1 (51.5%), Mus m 1 (45.5%), Der p1 (8.9%) and Fel d1 (7.9%) in the dust collected from 101 classrooms. Although levels of all studied allergens in the settled dust of the classrooms were low, there was a relationship between Fel d1 in the classroom dust and development of asthma.

CONCLUSION

This study showed considerable levels of cockroach allergens in schools. Exposure to cat allergen in our schools played an important role in asthma development; further school-based investigations require evaluating the role of classroom allergen on asthma development.

Relationship of Urinary Tract Infection to Lower Urinary Tract Dysfunction and Kidney Scar Formation in Children

Background:

Urinary tract infection (UTI) is the most common infection during childhood. Lower urinary tract dysfunction (LUTD) is a broad term that indicates an abnormal voiding pattern in a child without anatomical and neurological impairment. The purpose of this study was to determine the relationship between UTI and LUTD.

Methods:

This study was conducted at the Children Medical Center Hospital in 2014–2016. The inclusion criteria of this study were at least one UTI confirmed by a positive urine culture and active urine analysis in children who were well toilet-trained previously. Complete physical examination of the genitourinary and skeletal systems was performed to identify patients with anomalies in these systems. The patients with genitourinary system anomalies and obvious and prediagnosed neurological defects of the urinary system such as neurogenic bladder were excluded from the study. To confirm the presence of LUTD, the scoring system of Akbal et al. was applied.

Results:

A total of 260 patients including 9.2% of males and 90.8% of females were included in this study. The prevalence of LUTD was 63.8% (166 cases) in these patients. In this study, the prevalence of LUTD in patients with a single episode of UTI was 50.5%, while in patients with recurrence of UTI it was 88.9%. In patients with unilateral kidney scar formation, 90.9% had a recurrence of UTI (P = 0.003) which shows a strong correlation of unilateral scar formation with recurrence of UTI.

Conclusions:

These data suggest that there is a significant relationship between UTI and LUTD in children, so evaluation of voiding dysfunction is necessary in this group. With early diagnosis and appropriate treatment, we can reduce the possible serious and permanent sequels of LUTD in patients with UTIs.

A new MEFV gene mutation in an Iranian patient with familial Mediterranean fever

Familial mediterranean fever (FMF) is an inherited autoinflammatory disorder characterized by recurrent episodes of fever and painful inflammation involving the intra-abdominal organs, the lungs and the joints, which is highly prevalent in specific ethnic groups including the Iranians. We report a 12-year-old boy from Iran, with a clinical history of recurrent fever. Based on the suggestive clinical data, mutational analysis revealed the presence of the novel c.1945C>T heterozygous variant in exon 10, which leads to a leucine to phenylalanine change at position 649 of the protein. The mutation was inherited from the mother. This novel mutation lies in exon 10 of the MEFV gene, which encodes for a domain called B30.2-SPRY, located in the C-terminal region of the pyrin protein and contains the most frequent mutations associated with FMF. The present report expands the spectrum of MEFV gene mutations associated with FMF. The uniqueness of this study, compared with other published case reports, consists in the new mutation found in the MEFV gene. In fact, new mutations in this gene are of high interest, in order to better understand the role of this gene in autoinflammation.

Influence of zinc deficiency on one year recurrence in children with nephrotic syndrome

Introduction: Relapses in children with steroid sensitive nephrotic syndrome (SSNS) are common and sometimes triggered by various infections. Low zinc levels have been described in children with nephrotic states. It is supposed to that zinc deficiency might lead to dysregulation of immune system and an increased risk of infection. Objectives: This study sought to examine whether the plasma level of zinc in nephrotic patients is related to the number of relapses in these patients. Patients and Methods: Forty-three children aged 1-10 years were entered in this study. Baseline data including age, serum zinc level, number of relapses during one year was recorded. The t test and chi-square tests were used to compare the mean values and proportions respectively with significant P value (P < 0.05). Results: Forty-three children with storied sensitive nephrotic syndrome enrolled in this study. Twenty-three (53.5%) of them were male and 20 (46.5%) were female. Around 74.4 % of patients experienced relapses of nephrotic syndrome in one-year period. There was a significant relation between zinc deficiency and recurrence rate. Conclusion: Zinc deficiency is common in children suffering from nephrotic syndrome and is related to recurrence of relapses in these patients.

Prevalence of Acanthosis nigricans and Related Factors in Iranian Obese Children

INTRODUCTION

Recognition of Acanthosis nigricans (AN) provides important opportunities for screening of obesity syndrome, dyslipidemia, hypertension and insulin resistance with diabetes mellitus 2. Considering the high prevalence of obesity among Iranian children, we designed this study to estimate the prevalence of AN and related laboratory factors in Iranian obese children.

MATERIALS AND METHODS

Seventy-one obese children were enrolled in this study. Diagnosis of AN was done by clinical examination. Body mass index (BMI), fasting blood sugar, total cholesterol, triglycerides (TG), alanine aminotransferase, aspartate aminotransferase (AST), alkaline phosphatase, high- and low-density lipoprotein cholesterol, insulin, thyroid-stimulating hormone, free thyroxin (fT4), calcium, phosphorus and 25-hydroxyvitamin D were measured with routine techniques. Collected data were compared between cases with AN and without AN. Independent t-test was used for comparison of variables.

RESULTS

Twenty-five of children were female (35.2%). Forty-eight children (67.6%) had AN. In 20 cases (28.2%), homeostasis model assessment-insulin resistance (HOMA-IR) was <2.5 and in 51 (71.8%), HOMA-IR was more than 2.5. Mean BMI, insulin, HOMA-IR, TG and AST levels were significantly higher in cases with AN.

CONCLUSION

Obese children with AN are at risk of developing diabetes. Hence early identification of this feature and precise evaluation of children is recommended.

Preventive Kidney Stones: Continue Medical Education

Nephrolithiasis is a common health problem across the globe with a prevalence of 15%-20%. Idiopathic hypercalciuria is the most common cause of nephrolithiasis, and calcium oxalate stones are the most common type of stones in idiopathic hypercalciuric patients. Calcium phosphate stones are frequently associated with other diseases such as renal tubular acidosis type 1, urinary tract infections, and hyperparathyroidism. Compared with flat abdominal film and renal sonography, a noncontrast helical computed tomography scan of the abdomen is the diagnostic procedure of choice for detection of small and radiolucent kidney stones with sensitivity and specificity of nearly 100%. Stones smaller than 5 mm in diameter often pass the urinary tract system and rarely require surgical interventions. The main risk factors for stone formation are low urine output, high urinary concentrations of calcium, oxalate, phosphate, and uric acid compounded by a lower excretion of magnesium and citrate. A complete metabolic workup to identify the risk factors is highly recommended in patients who have passed multiple kidney stones or those with recurrent disease. Calcium oxalate and calcium phosphate stones are treated by the use of thiazide diuretics, allopurinol, and potassium citrate. Strategies to prevent kidney stone recurrence should include the elimination of the identified risk factors and a dietary regimen low in salt and protein, rich in calcium and magnesium which is coupled with adequate fluid intake.

Mutations in KEOPS-complex genes cause nephrotic syndrome with primary microcephaly

Galloway-Mowat syndrome (GAMOS) is an autosomal-recessive disease characterized by the combination of early-onset nephrotic syndrome (SRNS) and microcephaly with brain anomalies. Here we identified recessive mutations in OSGEP, TP53RK, TPRKB, and LAGE3, genes encoding the four subunits of the KEOPS complex, in 37 individuals from 32 families with GAMOS. CRISPR-Cas9 knockout in zebrafish and mice recapitulated the human phenotype of primary microcephaly and resulted in early lethality. Knockdown of OSGEP, TP53RK, or TPRKB inhibited cell proliferation, which human mutations did not rescue. Furthermore, knockdown of these genes impaired protein translation, caused endoplasmic reticulum stress, activated DNA-damage-response signaling, and ultimately induced apoptosis. Knockdown of OSGEP or TP53RK induced defects in the actin cytoskeleton and decreased the migration rate of human podocytes, an established intermediate phenotype of SRNS. We thus identified four new monogenic causes of GAMOS, describe a link between KEOPS function and human disease, and delineate potential pathogenic mechanisms.

Angiotensin-Converting Enzyme Gene Polymorphism in Children with Idiopathic Nephrotic Syndrome, Effect on Biopsy Findings

OBJECTIVE

Angiotensin converting enzyme (ACE) converts angiotensin I into angiotensin II. The ACE gene shows an I/D polymorphism, which correlates with ACE concentrations. The aim of this study is to evaluate the distribution of the ACE I/D genotype in children with idiopathic nephrotic syndrome (INS) and healthy controls and study the effect of this polymorphism on clinical and pathologic findings.

METHODS

ACE gene I/D polymorphism of 104 patients with INS and 119 controls were determined.

RESULTS

The DD, ID, and II genotypes were found in 58.7%, 22.1%, and 19.2% of the patients, and in 79.8%, 2.5%, and 17.6% of controls, respectively (p > 0.05). The ID genotype was seen more frequently in patients resistant to treatment.

CONCLUSION

The observed differences with previous reports suggest the influence of the genetic background on disease course. The ACE I/D gene polymorphism's role seems to be more important in renal disease progression than susceptibility.

Primary Antibody Deficiency in a Tertiary Referral Hospital: A 30-Year Experiment

BACKGROUND

Primary antibody deficiency (PAD) is the most common group of primary immunodeficiency disorders (PID), with a broad spectrum of clinical features ranging from severe and recurrent infections to asymptomatic disease.

OBJECTIVES

The current study was performed to evaluate and compare demographic and clinical data in the most common types of PAD.

MATERIALS AND METHODS

We performed a retrospective review of the medical records of all PAD patients with a confirmed diagnosis of common variable immunodeficiency (CVID), hyper IgM syndrome (HIgM), selective IgA deficiency (SIgAD), and X-linked agammaglobulinemia (XLA) who were diagnosed during the last 30 years at the Children's Medical Center, Tehran, Iran.

RESULTS

A total number of 280 cases of PAD (125 CVID, 32 HIgM, 63 SIgAD, and 60 XLA) were enrolled in the study. The median (range) age at the onset of disease in CVID, HIgM, SIgAD, and XLA was 2 (0-46), 0.91 (0-9), 1 (0-26), and 1 (0-10) years, respectively. Gastrointestinal infections were more prevalent in CVID patients, as were central nervous system infections in XLA patients. Autoimmune complications were more prevalent in HIgM patients, malignancies in CVID patients, and allergies in SIgAD patients. The mortality rate for CVID, HIgM, and XLA was 27.2%, 28.1%, and 25%, respectively. No deaths were reported in SIgAD patients.

CONCLUSIONS

SIgAD patients had the best prognosis. While all PAD patients should be monitored for infectious complications, special attention should be paid to the finding of malignancy and autoimmune disorders in CVID and HIgM patients, respectively.

Animal allergen sensitization in veterinarians and laboratory animal workers

BACKGROUND

Animals secrete allergens into the environment and exposure to these in the workplace may cause sensitization.

AIMS

To identify the frequency of animal allergen sensitization and symptoms in animal workers.

METHODS

Using skin prick tests (SPT), we assessed sensitization to 15 mammal and bird allergens in animal workers and controls. We also recorded symptoms and pulmonary function tests.

RESULTS

There were 100 animal workers and 50 controls included in the study. Thirty-six per cent of animal workers and 10% of controls had positive SPT (P < 0.001, odds ratio [OR] = 5.1, 95% CI 1.7-16.0). The most common sensitizations were to horse (16% in animal workers versus 0% in controls, P < 0.01), canary (16% in animal workers versus 2% in controls, P < 0.05, OR = 9.3, 95% CI 1.2-194), cattle (13% in animal workers versus 0% in controls, P < 0.05), cat (12% in animal workers versus 6% in controls, not significant), rabbit and hamster (10% each in animal workers versus 0% in controls, P < 0.05). Allergy symptoms were reported by 52 animal workers, but only 36 of them had positive SPT. Twelve animal workers had abnormal pulmonary function tests and six had positive SPT.

CONCLUSIONS

Animal workers are at high risk of occupational sensitization to animal allergens. Exposure should be minimized through control measures and worker education about the risks of exposure and sensitization.

A treatment algorithm for children with lupus nephritis to prevent developing renal failure

Chronic kidney disease is one of the most common complication of systemic lupus erythematosus, which if untreated can lead to the end-stage renal disease (ESRD). Early diagnosis and adequate treatment of lupus nephritis (LN) is critical to prevent the chronic kidney disease incidence and to reduce the development of ESRD. The treatment of LN has changed significantly over the past decade. In patients with active proliferative LN (Classes III and IV) intravenous methylprednisolone 1 g/m2/day for 1-3 days then prednisone 0.5-1.0 mg/kg/day, tapered to <0.5 mg/kg/day after 10-12 weeks of treatment plus mycophenolate mofetile (MMF) 1.2 g/m2/day for 6 months followed by maintenance lower doses of MMF 1-2 g/day or azathioprine (AZA) 2 mg/kg/day for 3 years have proven to be efficacy and less toxic than cyclophosphamide (CYC) therapy. Patients with membranous LN (Class V) plus diffuse or local proliferative LN (Class III and Class IV) should receive either the standard 6 monthly pulses of CYC (0.5-1 g/m2/month) then every 3(rd) month or to a shorter treatment course consisting of 0.5 g/m2 IV CYC every 2 weeks for six doses (total dose 3 g) followed by maintenance therapy with daily AZA (2 mg/kg/day) or MMF (0.6 g/m2/day) for 3 years. Combination of MMF plus rituximab or MMF plus calcineurin inhibitors may be an effective co-therapy for those refractory to induction or maintenance therapies. This report introduces a new treatment algorithm to prevent the development of ESRD in children with LN.

Early detection of acute kidney injury by serum cystatin C in critically ill children

BACKGROUND

We prospectively evaluated whether serum cystatin C (CysC) detected acute kidney injury (AKI) earlier than basal serum creatinine (Cr).

METHODS

In 107 pediatric patients at high risk of developing AKI, serum Cr and serum CysC were measured upon admission. Baseline estimated creatinine clearance (eCCl) was calculated using a CysC-based glomerular filtration rate (GFR) equation from a serum Cr measured at the pediatric intensive care unit (PICU) entrance.

RESULTS

The median age was 10 months (interquartile range, 3-36 months). Serum Cr, serum CysC, and eCCl (mean ± standard deviation [range]) were 0.5 ± 0.18 mg/dl (0.2-1.1 mg/dl), 0.53 ± 0.78 (0.01-3.7 mg/l), and 72.55 ± 28.72 (20.6-176.2) ml/min per 1.73 m(2), respectively. The serum CysC level in patients with AKI was significantly higher than children with normal renal function (p < 0.001). The values for the cut-off point, sensitivity, specificity, and the area under curve (AUC) were determined for CysC as 0.6 mg/l, 73.9 %, 78.9 %, and 0.92 [95 % confidence interval (0.82-1)], respectively, and for Cr the values were 0.4 mg/dl, 68 %, 46.2 %, and 0.39, [95 % confidence interval (0.24-0.54)], respectively. The receiver operating characteristics (ROC) curve analysis revealed that CysC had a significantly higher diagnostic accuracy than eCCl (p < 0.001).

CONCLUSIONS

Our results identify that the sensitivity of serum CysC for detecting AKI is higher than that of serum Cr in a heterogeneous pediatric intensive care unit (PICU) population.

Screening for microscopic hematuria in school-age children of Gorgan City

Screening for hematuria was carried out in 3000 school-age children (6 to14 years old) in Gorgan, Iran, using a fresh morning urine sample. At the initial step, 208 (6.8%) had positive dipstick tests for blood, which decreased to 35 (1.2%) at the second step. Of the 35 children with hematuria, 27 (77.1%) were girls and 8 (22.9%) were boys. Twenty-six children were further evaluated of whom 5 had normal findings, and 7 had hypercalciuria, 13 had nephrolithiasis, and in 1 had a large cystic lesion on ultrasonography, ultimately diagnosed as oncocystoma.

Preventing kidney injury in children with neurogenic bladder dysfunction

The most common cause of neurogenic bladder dysfunction (NBD) in newborn infants is myelomeningocele. The pathophysiology almost always involves the bladder detrusor sphincter dyssynergy (DSD), which if untreated can cause severe and irreversible damage to the upper and lower urinary tracts. Early diagnosis and adequate management of NBD is critical to prevent both renal damage and bladder dysfunction and to reduce chances for the future surgeries. Initial investigation of the affected newborn infant includes a renal and bladder ultrasound, measurement of urine residual, determination of serum creatinine level, and urodynamics study. Voiding cystogram is indicated when either hydronephrosis or DSD is present. The main goal of treatment is prevention of urinary tract deterioration and achievement of continuance at an appropriate age. Clean intermittent catheterization (CIC) in combination with anticholinergic (oxybutynin) and antibiotics are instituted in those with high filling and voiding pressures, DSD and/or high grade reflux immediately after the myelomeningocele is repaired. Botulium toxin-A injection into detrusor is a safe alternative in patients with insufficient response or significant side effects to anticholinergic (oral or intravesical instillation) therapy. Surgery is an effective alternative in patients with persistent detrusor hyperactivity and/or dyssynergic detrusor sphincter despites of the CIC and maximum dosage of anticholinergic therapy. Children with NBD require care from a multidisciplinary team approach consisting of pediatricians, neurosurgeon, urologist, nephrologists, orthopedic surgeon, and other allied medical specialists.

Clinical course and outcome of children with steroid-sensitive nephrotic syndrome

We conducted a retrospective study on children with primary nephrotic syndrome (NS) to evaluate the clinical course and outcome of children with steroid-sensitive NS (SSNS). The medical records of 226 children, median 3.46 years (min 1.00, max 15.08) who referred to our clinics with SSNS between January 1978 and September 2005 were reviewed and entered into the study. Minimum duration of follow-up was 5 years and maximum 20 years (median 7.25 years). Of 226 patients who were treated with corticosteroids, 38 (16.8%) had no relapse but the remaining 188 (83.2%) patients experienced several relapses of which 128 patients (56.6%) required additional immunosuppressive agents for the remission. Of these, 122 (95%) were treated with levamisole, 22 (17%) with cyclosporine, 36 (28%) with cyclophosphamide, and ten (7.8 %) treated with mycophenolate mofetil. Several patients had to switch from one medication to others due to lack of response. On the last follow-up visit, 64(28.3%) patients were still under treatment, some patients had taken all of the above-mentioned drugs but still had multiple recurrences. Only 103 (45.5%) patients were in remission off the drug more than 3 years. This study shows that nearly one-third of pediatric patients with SSNS experience frequent relapses despite the combination of multiple immunosuppressive medications, which may continue until adulthood.

Effect of levamisole in steroid-dependent nephrotic syndrome

INTRODUCTION. Childhood idiopathic nephrotic syndrome is characterized by frequent relapsing courses or steroid dependency. Levamisole is a popular drug for treatment of these patients. The purpose of this study was to evaluate levamisole in children with steroid-dependent nephrotic syndrome. MATERIALS AND METHODS. We retrospectively studied 304 children with a diagnosis of steroid-dependent nephrotic syndrome or frequently relapsing nephrotic syndrome. The mean age at the time of diagnosis was 4.84 years. Following induction of complete remission with steroid therapy based on the International Study of Kidney Disease in Children's protocol and when they were taking alternative days of steroid, 2.5 mg/kg of levamisole was administered. RESULTS. The steroid dose was significantly decreased (mean reduction of 0.39 ± 0.46 g to 0.33 ± 0.38 g) after treatment with levamisole (P < .001). The number of relapses also significantly decreased (mean reduction of 0.92 ± 0.98 episodes to 1.07 ± 1.20 relapses per year; P < .001). The 14.5-month administration of levamizole had a sensitivity of 67.5% and a specificity of 71.9% to reach a dose reduction of more than 50% in steroid therapy. The duration of levamizole treatment was associated with more than 50% reduction in the number of relapses (P < .001). A 14.5-month treatment with levamizole had a sensitivity of 62.3% and a specificity of 63.6% to reach a relapse reduction of more than 50%. CONCLUSIONS. Levamisole appears to be effective in prolonging the duration of remission and decreasing the steroid dose in children with steroid-dependent nephrotic syndrome.