Byung Ok Kwak

Microalbuminuria in normal Korean children.

Purpose Although microalbuminuria is known as a predictor of clinical nephropathy and cardiomyopathy, few studies have investigated the incidence and reference range of microalbuminuria in healthy children. This study aimed to establish a reference range and to study the age-related trend for spot urine microalbumin/creatinine ratio in a Korean pediatric population. Materials and Methods 352 healthy children were studied from July 2007 through March 2010. Height, weight, serum creatinine, spot urine microalbumin/creatinine ratio, and glomerular filtration rate (GFR) were obtained for each subject. We divided the study population into 5 groups according to age, and compared the spot urine microalbumin/creatinine ratio with other variables using one-way analysis of variance (ANOVA), regression analysis and Pearsons correlation analysis. Results In this study, the data showed that the spot urine microalbumin/creatinine ratio decreased with age: 1-12 months, 22.72±13.80 mg/mmol (2SD: 3.33-54.40 mg/mmol); 13-28 months, 16.34±9.58 mg/mmol (2SD: 3.16-35.19 mg/mmol); 29-48 months, 13.12±9.74 mg/mmol (2SD: 3.01-41.57 mg/mmol); 4-6 years, 10.58±8.13 mg/mmol (2SD: 0.00-30.19 mg/mmol); and 7-19 years, 5.13±5.44 mg/mmol (2SD: 0.45-14.45 mg/mmol). The spot urine microalbumin/creatinine ratio showed correlation with age, height, height z-score, weight, weight z-score, GFR, body mass index (BMI) and body surface area (BSA). Conclusion The spot urine microalbumin/creatinine ratio in normal Korean children decreased with age. This ratio could potentially be used to establish reference ranges and cutoff values for Korean children and to predict nephropathy and cardiomyopathy.

Elevation of the index of left ventricular mass during the acute and subacute phase of Kawasaki disease, and its association with indexes of diastolic function.

Our aim was to determine whether the index of left ventricular mass increases during the acute and subacute phase of Kawasaki disease, and to investigate any relationship between this index and clinical and echocardiographic variables. We performed, therefore, a retrospective study of 66 children with Kawasaki disease, having a mean age of 2.85 years, comparing the findings with those obtained from 57 normal controls, having a mean age of 2.99 years. The data from the patients used for comparison was obtained during the acute and subacute phase of the illness, as well as during the phase of convalescence. We performed correlation analysis of the findings during the acute and subacute phase, determining the relationship between the index of left ventricular mass and other variables. The index was higher (p = 0.0461), and the velocity of propagation of left ventricular early diastolic flow was lower (p < 0.0001), during the acute and subacute phase when compared to control values. The index then reduced (p = 0.0001) during the phase of convalescent when compared to the acute and subacute phase. Levels of albumin in the serum (p = 0.0193), peak E velocity (p = 0.0479), and velocity of propagation (p = 0.0360) were found to be related to the index of left ventricular mass. Significant relationships were found between the differences in this index and differences in body weight when findings during the acute and subacute phase were compared to those of the phase of convalescence. The index of left ventricular mass, therefore, is increased during the acute and subacute phase of Kawasaki disease, and is associated with altered diastolic indexes. This elevation may be due to generalized myocardial swelling from acute inflammation and increased vascular permeability. Measuring this index as a potential predictor of diastolic function should be added to studies of cardiac function during the acute and subacute phase of Kawasaki disease.

Reference Values of Body Composition Indices: The Korean National Health and Nutrition Examination Surveys

Purpose An increase in the prevalence of obesity has been observed in children and adolescents. As remarkable changes in body composition occur with growth during the adolescent period, it is important that changes in body composition be monitored. The purpose of this study was to propose reference percentile values for body composition indices including body mass index (BMI) in children and adolescents in Korea. Materials and Methods This study was performed using data from the Fourth and Fifth Korea National Health and Nutrition Examination Surveys. Body composition data were obtained using dual-energy X-ray absorptiometry. The percentile curves of body composition indices were constructed by the LMS method. Results A total of 2123 children and adolescents between the ages of 10 and 19 years were included in this study. We obtained the percentile curves for BMI and body composition indices. Conclusion The reference values for body composition from this study could help with assessing body composition in Korean adolescents.

Microalbuminuria in children with urinary tract infection

Purpose Microalbuminuria is defined as increased urinary albumin excretion (30-300 mg/day) or microalbumin/creatinine ratio (30-300 mg/g) in a spot urine sample. Although microalbuminuria is a predictor of clinical nephropathy and cardiomyopathy, few studies have investigated microalbuminuria in children with urinary tract infection (UTI). Methods Therefore, we compared the spot urine microalbumin/creatinine ratio in pediatric UTI patients with that of control subjects. We investigated the correlation between the ratio in children with UTI and age, height, weight, blood pressure, glomerular filtration rate (GFR), hematuria, vesicoureteral reflux, renal parenchymal defect, and renal scar, and its predictability for UTI complications. Results We studied 66 patients (42 boys, 24 girls) and 52 healthy children (24 boys, 28 girls). The mean microalbumin/creatinine ratio in UTI patients was statistically significantly increased compared to the control group (340.04±321.36 mg/g (38.47±36.35 mg/mmol) in patient group vs. 225.68±154.61 mg/g (25.53±17.49 mg/mmol) in control group, P=0.0141). The mean value of spot urine microalbumin/creatinine ratio (384.70±342.22 mg/g (43.47±37.67 mg/mmol) in patient group vs. 264.92±158.13 mg/g (29.94±17.86 mg/mmol) in control group, P=0.0341) in 1-23 months age patient group showed statistically significant increase compared to control group. Microalbumin/creatinine ratio showed negative correlation to age (r=-0.29, P=0.0167), body surface area (BSA) (r=-0.29, P=0.0173) and GFR (r=-0.26, P=0.0343). The presence of hematuria (P=0.0169) was found to be correlated. Conclusion The spot urine microalbumin/creatinine ratio in children with UTI was significantly greater than that in normal children, and it was positively correlated with GFR. This ratio is a potential prescreening and prognostic marker in UTI patients. Further studies are required to validate the predictability of microalbuminuria in pediatric UTI patients.

Adolescent Build Plotting on Body Composition Chart and the Type of Diabetes Mellitus

Although the prevalence of type 2 diabetes is increasing, there are cases difficult to categorize into certain type in pediatric diabetic patients. The aims of this study were to detect and choose a proper treatment modality for atypical cases of diabetes mellitus, using the body composition chart. We conducted a retrospective study from August 2005 to 2012 with patients who visited Konkuk University Medical Center, and were diagnosed with diabetes mellitus. The medical records were reviewed for the anthropometric data and indices of body composition. The subjects were grouped by the type of diabetes and gender. We constructed a body composition chart plotting fat free mass index and fat mass index (FMI). Body mass index and all body composition indices were higher in type 2 diabetes, in each gender in analysis with Mann-Whitney test. Significant determinant of diabetes type was revealed as FMI and contributing factors on FMI were analyzed with regression analysis. Six atypical cases were identified by a body composition chart including non-obese type 2 diabetes showing suboptimal growth with lower BMI related to relatively lower insulin secretion and type 1 diabetes with insulin resistance resulted from obesity. Body composition chart analysis might be useful in characterization of diabetes type and detection of atypical cases and early adjustment of diabetes management strategy.

Kidney size estimation in Korean children with Technesium-99m dimercaptosuccinic acid scintigraphy

Purpose Renal size is an important indicator to determine adequate organ growth in children. The aim of this study was to estimate renal size with Technesium-99m dimercaptosuccinic acid (DMSA) scan and propose a simple formula for predicting renal length in normal Korean children. Methods This study included 346 children (148 boys and 198 girls; age range, 1 month to 17 years) in whom renal length was measured using the DMSA scan. Patients with anatomical renal abnormalities or acute pyelonephritis were excluded. Children were divided into two groups: 214 children (61.8%) were less than a year old (group 1) and 132 (38.2%) were ≥1 year (group 2). Results Renal length was larger on the left side than the right side, and there was no significant gender-related difference in renal length. We propose the following formula for renal length based on the analysis of the 346 children in our study: the formula was as follows: 4.682×age (month)0.137, R2=0.780. In group 1, the formula was renal length (cm)=0.127×age (month)+5.144, R2=0.354, and in group 2, the formula was 0.334×age (year)+6.477, R2=0.829. Conclusion It is difficult to establish simple formulae in infants (R2=0.354). Therefore, further studies including relevant variables are needed for this age group. We proposed formulae to estimate renal length in Korean children over 1 year of age by using the DMSA scan.

Regression and progression of microalbuminuria in adolescents with childhood onset diabetes mellitus

Purpose Although microalbuminuria is considered as an early marker of nephropathy in diabetic adults, available information in diabetic adolescents is limited. The aim of this study was to investigate prevalence and frequency of regression of microalbuminuria in type 1 (T1DM) and type 2 diabetes mellitus (T2DM) patients with childhood onset. Methods One hundred and nine adolescents (median, 18.9 years; interquartile range (IQR), 16.5-21.0 years) with T1DM and 18 T2DM adolescents (median, 17.9 years; IQR, 16.8-18.4 years) with repeated measurements of microalbuminuria (first morning urine microalbumin/creatinine ratios) were included. The median duration of diabetes was 10.1 (7.8-14.0) years and 5.0 (3.5-5.6) years, respectively, and follow-up period ranged 0.5-7.0 years. Growth parameters, estimated glomerular filtration rate, glycosylated hemoglobin (HbA1c) and lipid profiles were obtained after reviewing medical record in each subject. Results The prevalence of microalbuminuria at baseline and evaluation were 21.1% and 17.4% in T1DM, and 44.4% and 38.9% in T2DM. Regression of microalbuminuria was observed in 13 T1DM patients (56.5%) and 3 T2DM patients (37.5%), and progression rate was 10.5% and 20% in T1DM and T2DM respectively. In regression T1DM group, HbA1c at baseline and follow-up was lower, and C-peptide at baseline was higher compared to persistent or progression groups. In T2DM, higher triglyceride was observed in persistent group. Conclusion Considerable regression of microalbuminuria more than progression in diabetes adolescents indicates elevated urinary microalbumin excretion in a single test does not imply irreversible diabetic nephropathy. Careful monitoring and adequate intervention should be emphasized in adolescents with microalbuminuria to prevent rapid progression toward diabetic nephropathy.

The Association between Asthma and Invasive Pneumococcal Disease: A Nationwide Study in Korea

The purpose of this study was to investigate the association between asthma and invasive pneumococcal disease (IPD) in Korea. A retrospective population-based cohort study was conducted using the Korean Health Insurance Review and Assessment database 2010-2011. The subjects included 935,106 (2010) and 952,295 (2011), of whom 398 (2010) and 428 (2011) patients with IPD were identified. There was significant difference in the prevalence of IPD in patients with and without asthma (0.07% vs. 0.02% in 2010 and 0.08% vs. 0.01% in 2011; P<0.001). After adjusting for age and gender, patients with asthma showed over a three-fold increased risk of IPD compared with patients without asthma (adjusted odds ratio [aOR] 3.90, 95% confidence interval [CI] 3.02-5.03 in 2010 / aOR, 5.44; 95% CI, 4.10-7.22 in 2011; P<0.001). These findings were also significant in children (aOR, 2.08; 95% CI, 1.25-3.45 in 2010; P=0.005 / aOR, 3.26; 95% CI, 1.74-6.11 in 2011; P<0.001). Although diabetes mellitus was also significantly associated with IPD, relatively low ORs compared with those of asthma were noted (aOR, 1.85; 95% CI, 1.35-2.54 in 2010 / aOR, 2.40; 95% CI, 1.78-3.24 in 2011; P<0.001). Both children and adults with asthma are at increased risk of developing IPD. Graphical Abstract

A case of recurrent acute pancreatitis in an obese child

OBJECTIVE The aim of this report was to elucidate the relation between pancreatitis and obesity in children. METHODS We present a case of recurrent acute pancreatitis in an obese girl. RESULTS A 7-y-old healthy obese girl was admitted with epigastric pain and vomiting. She had prior history of three similar episodes with epigastric pain, and diagnosed as having acute pancreatitis 2 mo ago. At time of admission, her height was 128.5 cm (>95th percentile), weight 35.8 kg (>95th percentile), and body mass index 21.7 kg/m(2) (>95th percentile for age). Serum amylase and lipase levels were elevated, and other laboratory findings including viral markers, autoantibodies, and genetic testing were negative. Abdominal ultrasonography and computed tomography scan revealed acute pancreatitis with no evidence of stone or tumor. Anomalous pancreaticobiliary ductal union with choledochal cyst was suspected on magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography. After the surgery, with supportive care and diet, her symptoms were improved and no new episode of pancreatitis was observed. CONCLUSIONS Our experience suggests that obesity is associated with recurrence as well as severity of acute pancreatitis in children.

Necrotizing fasciitis and streptococcal toxic shock syndrome secondary to varicella in a healthy child.

Varicella is usually considered to be a benign disease in healthy children; however, serious complications can occur such as necrotizing fasciitis and toxic shock syndrome. We describe a 38-month-old girl with necrotizing fasciitis and streptococcal toxic shock syndrome following varicella. She was previously healthy and vaccinated against varicella at 12 months of age. She had been diagnosed with varicella three days prior to presenting at our facility; she developed fever, vomiting, and painful swelling on her left flank. Her skin lesions worsened, she became lethargic, and had episodes of hypotension and coagulopathy. Necrotizing fasciitis on the left abdominal wall, buttocks, and left thigh was diagnosed by magnetic resonance imaging, and group A Streptococcus was isolated from a tissue culture. She was diagnosed as necrotizing fasciitis and streptococcal toxic shock syndrome, and successfully treated with repeated surgical debridement and fasciotomy, in addition to intensive antibiotics. Our experience suggests that necrotizing fasciitis in patients with varicella should be considered to be a rare complication even with widespread vaccine use. Early diagnosis and intensive treatment are required to prevent a fatal outcome.