Alfonso Campos

Clinical Significance of Primary Vesicoureteral Reflux and Urinary Antibiotic Prophylaxis After Acute Pyelonephritis: A Multicenter, Randomized, Controlled Study

OBJECTIVES. To evaluate the role of primary vesicoureteral reflux (VUR) in increasing the frequency and severity of urinary tract infections (UTIs) and renal parenchymal damage among patients with acute pyelonephritis and to determine whether urinary antibiotic prophylaxis reduces the frequency and/or severity of UTIs and/or prevents renal parenchymal damage among patients with mild/moderate VUR. METHODS. Patients 3 months to 18 years of age with acute pyelonephritis, with or without VUR, were assigned randomly to receive urinary antibiotic prophylaxis or not. Patients were monitored every 3 months for 1 year. Dimercaptosuccinic acid renal scans were repeated at 6 months or if there was a recurrence of febrile UTI. Urinalysis and urine culture were performed at each clinic visit. Renal ultrasound scans and voiding cystourethrograms were repeated at the end of 1 year of follow-up monitoring. RESULTS. Of the 236 patients enrolled in the study, 218 completed the 1-year follow-up monitoring. Groups were similar with respect to age, gender, and reflux grade distribution for those with VUR. No statistically significant differences were found among the groups with respect to rate of recurrent UTI, type of recurrence, rate of subsequent pyelonephritis, and development of renal parenchymal scars. CONCLUSIONS. After 1 year of follow-up monitoring, mild/moderate VUR does not increase the incidence of UTI, pyelonephritis, or renal scarring after acute pyelonephritis. Moreover, a role for urinary antibiotic prophylaxis in preventing the recurrence of infection and the development of renal scars is not supported by this study.

Primary vesicoureteral reflux: review of current concepts

Abstract. The well-known association between vesicoureteral reflux and urinary tract infection is the basis for pathophysiological and therapeutic implications which have dominated the literature on the subject for the last 2 decades. We critically review the following issues: (1) does urinary tract infection cause reflux? (2) does reflux predispose to infection? (3) does reflux predispose to pyelonephritis? (4) does reflux predispose to a renal parenchymal scar? (5) does long-term urinary antibiotic prophylaxis prevent renal damage in patients with reflux? We conclude that none of the reviewed issues have been rigorously proven or validated and that the role of vesicoureteral reflux in urinary tract infections needs to be redefined through well-designed, multicenter, prospective, randomized, controlled studies using state of the art renal imaging techniques.

Hamster bite peritonitis: Pasteurella pneumotropica peritonitis in a dialysis patient

Abstract We report the first case of Pasteurella pneumotropica peritonitis in a peritoneal dialysis patient. This rare infection was the result of contamination of the dialysis tubing by a pet hamster. We stress the importance of household pets as a source of infection in the peritoneal dialysis population.

Therapy of Renal Anemia in Children and Adolescents with Recombinant Human Erythropoietin (rHuEPO)

Eleven anemic children and adolescents with a median age of 14 years (range six months-20 years) on chronic hemodialysis were treated with recombinant human erythropoietin (rHuEPO) intravenously three times a week for an average of 9.2 months. After eight weeks of therapy, hematocrit rose from 20.3 ± 1.4% to 31.7 ± 0.7% (0.20 ± 0.01 to 0.31 ± 0.007, p <0.001, mean ± SEM). After reaching the target hematocrit of 30% to 33% (0.30 to 0.33), doses were adjusted individually. Blood transfusions were eliminated in all but one patient. All patients experienced an increase in appetite and energy level. Serum ferritin concentrations decreased in all patients who reached target hematocrit and seven required iron supplementation. Hypertension worsened in two patients and developed in two others. One patients vascular access clotted. Dialysis efficiency and heparin requirements during dialysis did not change significantly. We conclude that rHuEPO is safe, effective, and should be recommended as treatment for anemia in children and adolescents on hemodialysis, but close monitoring for the development of hypertension and/or iron deficiency is necessary

Early Presentation of Tuberous Sclerosis as Bilateral Renal Cysts

We report on an infant in whom bilateral renal cysts were the only initial manifestation of tuberous sclerosis. We review the reported cases of infants with this association and emphasize that tuberous sclerosis can present in infancy as bilateral renal cystic disease. The role of the kidney biopsy in providing the correct diagnosis is discussed.

Primary Vesicoureteral Reflux: Review of Current Concepts

The well-known association between vesicoureteral reflux and urinary tract infection is the basis for pathophysiological and therapeutic implications which have dominated the literature on the subject for the last 2 decades. We critically review the following issues: (1) does urinary tract infection cause reflux? (2) does reflux predispose to infection? (3) does reflux predispose to pyelonephritis? (4) does reflux predispose to a renal parenchymal scar? (5) does long-term urinary antibiotic prophylaxis prevent renal damage in patients with reflux? We conclude that none of the reviewed issues have been rigorously proven or validated and that the role of vesicoureteral reflux in urinary tract infections needs to be redefined through well-designed, multicenter, prospective, randomized, controlled studies using state of the art renal imaging techniques.

THE CAPTOPRIL RENOGRAM: A NEW TOOL FOR DIAGNOSING AND PREDICTING OBSTRUCTION IN CHILDHOOD HYDRONEPHROSIS

PURPOSE We evaluated the difference in response patterns of captopril versus standard renography for assessing hydronephrosis due to suspected ureteropelvic and ureterovesical junction obstruction. This technique may identify hydronephrotic kidneys in which normal function is maintained by vasoactive compensatory mechanisms. Sustained obstruction may cause these mechanisms to fail, and expose the kidneys to permanent functional deterioration in the long term. MATERIAL AND METHODS We prospectively studied 15 boys and 8 girls with a mean age of 3.5 years with grades III to IV/IV hydronephrosis. Evaluations included renal sonography, standard diuretic and captopril renography, glomerular filtration rate, voiding cystography, serum creatinine, blood pressure, and urinalysis with culture and sensitivity. Obstruction was suspected at the ureteropelvic junction in 19 kidneys and at the ureterovesical junction in 9. We compared differential function values obtained by standard diuretic and captopril renography. RESULTS We observed certain patterns in response to captopril renography, including pattern 1--unilateral decrease in hydronephrotic kidney relative function in 5 of 23 cases, 2--bilateral decreased function in 2, 3--bilateral increased function in 4 and 4--no change in function in 12 on standard renography. When half-time was more than 20 minutes on standard diuretic renography in 8 cases, captopril renography showed an ipsilateral decrease and bilateral increase in glomerular filtration rate in 4 and 1, respectively, and no change in 3. In 12 of the 23 patients (52%) there was no difference in the results of captopril and diuretic renography as well as no change in differential function on standard diuretic renography during 1 1/2 years of observation. Surgical correction was performed in 4 patients in whom half-time was greater than 20 minutes and differential function was decreased on captopril renography. CONCLUSIONS Our preliminary study reveals that there may be a role for captopril renography for detecting renin-angiotensin system mediated compensatory mechanisms in obstructive uropathy. When such compensatory mechanisms are activated, they may be unmasked by captopril, producing 1 of 4 patterns on renography and glomerular filtration rate. Patterns may indicate different degrees of impending renal function impairment and, thus, they may become useful for determining the progression of injury, when present, and the appropriate timing of surgical intervention.

MRI changes in the central nervous system in a child with lupus erythematosus

We report on a 10-year-old girl with systemic lupus erythematosus who presented in status epilepticus as the only manifestation of central nervous system involvement. MRI of the brain showed diffuse gray and white matter lesions which almost completely resolved after treatment with methylprednisolone. MRI findings in this child are similar to those in adults with diffuse clinical manifestations. The study is essential in the initial evaluation of patients suspected of central nervous system lupus.

Diabetic nephropathy in a prepubertal diabetic female.

Diabetic nephropathy is an uncommon finding in the pediatric age group. Previous reports have demonstrated that persistent proteinuria does not occur during the first five years following the diagnosis of insulin dependent diabetes mellitus. We report a prepubertal female child with less than five years duration of diabetes who developed persistent proteinuria and histologic changes diagnostic of diabetic nephropathy. The earlier than expected diabetic nephropathy noted in our patient raises the question regarding the need for earlier surveillance for diabetic nephropathy in children with a family history of chronic diabetic complications.

Membranous nephropathy associated with multiple sclerosis

Membranous nephropathy and multiple sclerosis are believed to be mediated by immune mechanisms. A patient is reported with the first described association of membranous nephropathy and multiple sclerosis. Its significance and possible pathogenetic mechanisms are discussed.