Hafez M. Bazaraa

Plasma neutrophil gelatinase-associated lipocalin as an early biomarker for prediction of acute kidney injury after cardio-pulmonary bypass in pediatric cardiac surgery

Introduction Cardiopulmonary bypass (CPB) surgery is considered one of the most frequent surgical procedures in which acute kidney injury (AKI) represents a frequent and serious complication. The aim of the present study was to evaluate the efficiency of neutrophil gelatinase-associated lipocalin (NGAL) as an early AKI biomarker after CPB in pediatric cardiac surgery. Material and methods The study included forty children aged 2 to 78 months undergoing CPB. They were divided into group I: patients who suffered AKI grades II and III; and group II: patients who did not develop AKI or at risk. Peripheral venous blood was withdrawn pre- and post-operatively for serial measurements of NGAL and creatinine. Statistical analysis was performed using Statistical Package for Social Sciences version 14. Results Mean plasma NGAL levels showed highly significant elevations in group I patients at 2, 12, and 24 h after surgery (p < 0.0001) compared to group II. Significant correlations were found between NGAL and creatinine at different time intervals. Highly significant correlations (p < 0.0001) were found between plasma NGAL and AKI at 2, 12 and 24 h after surgery. A cut-off level of 100 ng/ml at 2 h, and 125 ng/ml at 12 h post-operatively both recorded the highest accuracy, being 95% accurate, with sensitivity of 100% and 89.5% respectively, and specificity of 90.5% and 100% respectively. Conclusions This study showed that plasma NGAL could be used as an early biomarker for detection of AKI following CPB. We recommend further studies on a wider scale to validate the current study results.

Genetic polymorphism of ACE and the angiotensin II type1 receptor genes in children with chronic kidney disease.

Aim and MethodsWe investigated the association between polymorphisms of the angiotensin converting enzyme-1 (ACE-1) and angiotensin II type one receptor (AT1RA1166C) genes and the causation of renal disease in 76 advanced chronic kidney disease (CKD) pediatric patients undergoing maintenance hemodialysis (MHD) or conservative treatment (CT). Serum ACE activity and creatine kinase-MB fraction (CK-MB) were measured in all groups. Left ventricular mass index (LVMI) was calculated according to echocardiographic measurements. Seventy healthy controls were also genotyped.ResultsThe differences of D allele and DI genotype of ACE were found significant between MHD group and the controls (p = 0.0001). ACE-activity and LVMI were higher in MHD, while CK-MB was higher in CT patients than in all other groups. The combined genotype DD v/s ID+II comparison validated that DD genotype was a high risk genotype for hypertension .~89% of the DD CKD patients were found hypertensive in comparison to ~ 61% of patients of non DD genotype(p = 0.02). The MHD group showed an increased frequency of the C allele and CC genotype of the AT1RA1166C polymorphism (P = 0.0001). On multiple linear regression analysis, C-allele was independently associated with hypertension (P = 0.04).ConclusionACE DD and AT1R A/C genotypes implicated possible roles in the hypertensive state and in renal damage among children with ESRD. This result might be useful in planning therapeutic strategies for individual patients.

Outcomes of living donor renal transplantation in children with lower urinary tract dysfunction: a comparative retrospective study.

To compare outcomes of renal transplantation (RTx) in children with end‐stage renal disease (ESRD) resulting from lower urinary tract dysfunction (LUTD) vs other causes.

Risk factors for urological complications following living donor renal transplantation in children

The aim of this study was to detect possible risk factors for UC and UTI following pediatric renal Tx and effect of these complications on outcome. One hundred and eight children who underwent living donor Tx between 2009 and 2015 were retrospectively included. Extraperitoneal approach was used with stented tunneled extravesical procedure. Mean recipient age was 9.89 ± 3.46 years while mean weight was 25.22 ± 10.43 kg. Seventy‐three (67.6%) recipients were boys while 92 (85.2%) were related to donors. Urological causes of ESRD were present in 33 (30.6%) recipients (14 [13%] posterior urethral valve, 16 [14.8%] VUR, and 3 [2.8%] neurogenic bladder). Augmentation ileocystoplasty was performed in 9 (8.3%) patients. Mean follow‐up was 39.3 ± 17.33 months. UC were detected in 10 (9.3%) children (leakage 4 [3.7%], obstruction 3 [2.8%], and VUR 3 [2.8%]) while UTIs were reported in 40 (37%) children. After logistic regression analysis, UC were significantly higher in children with cystoplasty (44.4% vs 6.1%; P = .001). UTIs were significantly higher in girls (51.4% vs 30.1%; P = .001) and in children with urological causes of ESRD (51.5% vs 30.7%; P = .049). UC and UTI were not significantly associated with increased graft loss or mortality. UC were significantly higher in children with cystoplasty while UTIs were significantly higher in girls and children with urological causes of ESRD. Presence of UC did not affect the rate of graft loss or mortality due to its early detection and proper management.

Clinical and ultrasonographical characterization of childhood cystic kidney diseases in Egypt

Abstract Background: Renal cystic disorders (RCD) constitute an important and leading cause of end-stage renal disease (ESRD) in children. It can be acquired or inherited; isolated or associated with extrarenal manifestations. The precise diagnosis represents a difficult clinical challenge. Methods: The aim of this study was to define the pattern of clinical phenotypes of children with renal cystic diseases in Pediatric Nephrology Center, Cairo University. We have studied the clinical phenotypes of 105 children with RCD [45 (43%) of them had extrarenal manifestations]. Results: The most common disorders were the presumably inherited renal cystic diseases (65.7%) mainly nephronophthisis and related ciliopathies (36.2%), as well as polycystic kidney diseases (29.5%). Moreover, multicystic dysplastic kidneys accounted for 18% of study cases. Interestingly, eight syndromic cases are described, yet unclassified as none had been previously reported in the literature. Conclusion: RCD in this study had an expanded and complex spectrum and were largely due to presumably inherited/genetic disorders (65.7%). Moreover, we propose a modified algorithm for clinical and diagnostic approach to patients with RCD.

Levels of cystatin C in low- and high-flux hemodialysis in children with end-stage renal disease

BackgroundCystatin-C (CyC) is a middle molecule that is freely filtered at the glomerulus and almost completely reabsorbed by the proximal tubules. The aim of this study was to evaluate serum CyC and its reduction ratio as a biomarker for assessing the adequacy of the hemodialysis (HD) sessions in children with end-stage renal disease on maintenance HD. We also compared levels of CyC in patients on low-flux HD (LFH) and high-flux HD (HFH).MethodsForty patients were included in the study and divided into two groups, with one group (16 patients) receiving HFH and the other group receiving LFH (24 patients) (high-flux and low-flux polysulfone filters, respectively). Before and after each dialysis session serum CyC and beta-2-microglobulin (B2M) levels were measured using an ELISA technique, and routine laboratory tests were performed for each patient.ResultsPre-dialytic levels of CyC were significantly lower in the patients receiving HFH than in those receiving LFH (7.33 ± 1.35 vs. 9.73 ± 0.93, respectively; p < 0.0001). In the HFH group, post-dialytic levels of serum CyC were significantly lower than pre-dialytic levels (4.49 ± 0.71 vs. 7.33 ± 1.35, respectively; p < 0.0001). The reduction ratio (RR) of CyC was significantly higher in the HFH group than in the LFH group (38.2 ± 3.91 vs. −6.49 ± 5.05, respectively; p < 0.0001). Serum CyC level significantly correlated with B2M, urea and creatinine levels in both the LFH and HFH groups, whereas its RR significantly correlated with the RRs of urea, creatinine, and B2M in the HFH group.ConclusionThe results of our study emphasize the role of CyC as a good marker for assessing the adequacy of HD sessions in children on HFH and show that the CyC RR may be used as an index of middle-molecule toxin clearance following HFH sessions.

Localized Renal Graft Aspergillosis in a Child after Kidney Transplantation:Case Report and Review of Literature

Pediatric kidney transplant recipients are at special risk of infection with opportunistic fungi, such as Aspergillus spp., which is uncommon but can be fatal. We report a 16 year male renal transplant recipient, who suffered from acute graft dysfunction five months post transplantation. Imaging of the graft revealed sever back pressure and increased echogenic contents with a distinct pelviureteric ill-defined small mass. Percutaneous nephrostomy was done to relieve the obstruction and microscopic examination and fungal culture of the nephrostomy urine were done which revealed the organism (Aspergillus fumigatus). He developed initial improvement subsequent to relief of obstruction; graft function partially regained and received voriconazole for six months. His radiological finding gradually disappeared and graft function resumed to an acceptable level 4 weeks later. As of September 2016 (6 years later), despite the graft injuries, graft function had been conserved. This case serves to reinforce the concept that high index of suspicion of such infection and repeated examination with specific culture media are mandatory for transplant recipients particularly being potentially treatable and if neglected might be fatal infection.

A study of apelin level in children with chronic kidney disease: relation with endothelial function, cardiac function, and nutritional intake

ObjectiveThe aim of this study was to evaluate serum apelin levels in Egyptian pediatric patients with chronic kidney disease (CKD) and its relation with markers of endothelial dysfunction, cardiac functions, and nutritional status. Patients and methodsOur study comprised 66 clinically stable CKD patients and 20 normal healthy volunteers. We performed enzyme-linked immunosorbent assay technique to assess serum levels of apelin and; vascular cell adhesion molecule-1 (VCAM-1). Cardiac functions were assessed by means of echocardiogram. Nutritional analysis was achieved with the 24 h dietary recall method. ResultsVCAM-1 levels were significantly elevated in children with CKD as compared with controls. No difference in apelin mean levels was found between patients and controls. VCAM-1 levels positively correlated with interventricular septum thickness, and inversely correlated with both vitamin B1 and magnesium intake determined by means of food analysis. ConclusionChildren with CKD had endothelial dysfunction that was detected by means of elevated levels of serum VCAM-1, which showed a relation to height and weight of the patients, as well as a relation to interventricular septum thickness and with magnesium and vitamin B1 intake. However, there was no difference in serum apelin levels between the patients and controls and no relation was found with VCAM-1.

Endothelial Dysfunction in Pediatric Renal Transplant Recipients

Background: Cardiovascular disease is a major cause of morbidity and mortality after kidney transplantation. Endothelial dysfunction was shown to constitute an independent predictor of cardiovascular events. This study aimed at detecting endothelial dysfunction in pediatric renal transplant recipients. Methods: This was a prospective cohort study of 36 pediatric renal transplant recipients during their first posttransplantation year (transplantation group), 30 patients with end stage renal disease (ESRD) on regular hemodialysis (HD) (dialysis group) and 30 normal subjects (control group). Doppler ultrasound was performed for assessment carotid artery intima-media thickness (IMT) and brachial artery flow-mediated dilatation (FMD). Results: Carotid artery IMT measurements in the transplantation group (mean ± SD = 0.43 ± 0.08 mm) were significantly (p=0.001) lower than the dialysis group (0.5 ± 0.1mm) and insignificantly higher than the control group (0.41 ± 0.07mm). FMD was significantly impaired in the dialysis group. The median (IQR) FMD of the transplantation group, 8.7% (2.5-20.4), tended to be higher than that of the dialysis group, 4.4% (2.6-10.8) and lower than that of normal controls, 14% (8.5-19.7); p=0.055 and 0.12 respectively. Conclusion: Pediatric renal transplant recipients tend to show evidence of endothelial dysfunction at an apparently lesser extent than those on regular hemodialysis.Children and young adults, who suffer from cancer, receive gonadotoxic therapy, which destroys their fertile abilities after survival. Ovarian cryopreservation and transplantation provide the promising solution to this problem, where the ovary can be removed before the gonadotoxic therapy and reimplanted after patients survival, where the ovary is to be cryopreserved during the period of the therapy. However, cryopreservation of the whole ovary is still facing great obstacles, namely the ischemic reperfusion injury and the defective cryopreservation related to the defective ability to universally deliver the cryopreservation/warming solutions through the ovarian vascular bed. Meanwhile, the currently applied technique of ovarian tissue cryopreservation provides limited follicular recovery because many follicles are lost until the development of revascularization post-transplantation. To solve the problems, an innovative system has been developed to insure immediate and universal delivery of the cryopreservation/warming solutions to the graft, in addition to keeping the graft under continuous perfusion before and after cryopreservation, minimizing any chance for microthrombi formation or ischemia-reperfusion. This innovative system can be applied in the following surgical and clinical interventions: 1) Allogeneic ovarian transplantation; 2) Preservation of fertility after systemic chemotherapy or bone marrow transplantation in young females, where the ovaries could be removed before the therapy and exposed to the adequate cryopreservation provided by the system till re-implantation after the patients survival; 3) The system is also suitable for the corresponding applications on the testicles.

Nutritional Status in Children with Chronic Renal Failure on Hemodialysis

Abstract Background and Aim: Growth retardation is still an important manifestation of children with chronic renal failure (CRF). The aim of this study is to evaluate the growth in relation to nutritional status in Egyptian children with CRF on hemodialysis. Subjects and Methods: The study included 30 Egyptian children above the age of six years on regular haemodialysis at the Haemodialysis Unit of the Centre of Pediatric Nephrology and Transplantation of Cairo University. Anthropometry, biochemical parameters and dietary intake were measured. Anthropometric measurements were expressed as z - scores. Results: Data shows that height was the most affected anthropometric parameter. Short stature in CRF is proportionate and body weight is less affected than height. Dietary analysis showed that 76.7 % of patients had recommended dietary allowance of calories. Height z-score showed a significant positive correlation with caloric intake. On the other hand, the protein intake showed a significant positive correlation with blood urea nitrogen and a significant negative correlation with serum bicarbonate. Conclusions: Nutritional assessment is essential to the management of children with CRF. Anthropometry is a sensitive indicator of the nutritional status. The study recommends avoiding excessive protein intake to prevent metabolic acidosis and accumulation of toxic nitrogen waste products.