Inalda Facincani

Postnatal evaluation of intrauterine hydronephrosis due to ureteropelvic junction obstruction

PURPOSE Fetal hydronephrosis is a frequent finding due to advances in prenatal ultrasonography. The definition of fetal and neonatal urinary tract obstruction is a very difficult task requiring confirmation of reduced renal function and hydronephrosis. In this study we followed a series of consecutive patients with intrauterine hydronephrosis that persisted during post-natal life. METHODS 116 newborns with antenatal hydronephrosis diagnosed by ultrasound and submitted to a specific post-natal evaluative protocol with a follow-up period of 6 years. RESULTS In 45 (38.8%) of 116 patients, ureteropelvic junction (UPJ) obstruction was confirmed and surgical correction of the UPJ obstruction was done in 19 patients. From 26 children who were initially submitted to non-surgical treatment, only 6 (23%) needed a surgical approach during follow up. Overall analysis showed that surgery was performed in 25 patients with UPJ obstruction, and the others 20 patients were kept under clinical observation, since normal renal function was confirmed by scintigraphy scans. CONCLUSION Fetal hydronephrosis due to UPJ obstruction deserves careful postnatal evaluation. UPJ obstruction is the most frequent anomaly and its surgical treatment has very precise indications. The evaluative protocol was useful in identify patients that could be followed-up with a non-surgical approach.

Complications after bladder augmentation in children

PURPOSE Bladder augmentation is an effective surgical procedure for increasing bladder capacity and reducing pressure on the urinary system. It is indicated for patients with anomalies such as spina bifida, myelomeningocele, urethral valve and bladder exstrophy, who progress with low tolerance of medication. CASES This was a retrospective study conducted on pediatric patients submitted to bladder augmentation from 2000 to 2011. RESULTS 34 patients aged 4 to 17 years were submitted to bladder augmentation, 30 of them with an ileal loop and 4 with a ureter.A continent urinary shunt was performed in 16 patients, the Mitrofanoff conduit was associated in 15, and the Macedo technique was used in one. Mean follow-up was 34.35 months (1 to 122 months). Mean creatinine was 1.5 ng/ml (0.4 to 7.5 ng/ml) preoperatively and 1.78 ng/ml postoperatively. Three patients required a renal transplant during follow-up. There was improvement or resolution of vesicoureteral reflux in 83.5% of the kidneys on the right and in 75% on the left. Bladder capacity increased, on average, from 152.5 ml to 410 ml. The main complications were vesical lithiasis in 3 patients and conduit perforation in one. CONCLUSION Bladder augmentation showed good results in this series, preserving renal function in most of the patients.

Pamidronate for the treatment of osteoporosis secondary to chronic cholestatic liver disease in Wistar rats

Osteoporosis is a major complication of chronic cholestatic liver disease (CCLD). We evaluated the efficacy of using disodium pamidronate (1.0 mg/kg body weight) for the prevention (Pr) or treatment (Tr) of cholestasis-induced osteoporosis in male Wistar rats: sham-operated (Sham = 12); bile duct-ligated (Bi = 15); bile duct-ligated animals previously treated with pamidronate before and 1 month after surgery (Pr = 9); bile duct-ligated animals treated with pamidronate 1 month after surgery (Tr = 9). Rats were sacrificed 8 weeks after surgery. Immunohistochemical expression of IGF-I and GH receptor was determined in the proximal growth plate cartilage of the left tibia. Histomorphometric analysis was performed in the right tibia and the right femur was used for biomechanical analysis. Bone material volume over tissue volume (BV/TV) was significantly affected by CCLD (Sham = 18.1 ± 3.2 vs Bi = 10.6 ± 2.2%) and pamidronate successfully increased bone volume. However, pamidronate administered in a preventive regimen presented no additional benefit on bone volume compared to secondary treatment (BV/TV: Pr = 39.4 ± 12.0; Tr = 41.2 ± 12.7%). Moreover, the force on the momentum of fracture was significantly reduced in Pr rats (Sham = 116.6 ± 23.0; Bi = 94.6 ± 33.8; Pr = 82.9 ± 22.8; Tr = 92.5 ± 29.5 N; P < 0.05, Sham vs Pr). Thus, CCLD had a significant impact on bone histomorphometric parameters and pamidronate was highly effective in increasing bone mass in CCLD; however, preventive therapy with pamidronate has no advantage regarding bone fragility.

Cutaneous vesicostomy in children

OBJECTIVE In this report we assessed the results obtained with cutaneous vesicostomy for the temporary diversion of urine in small children. PATIENTS AND METHODS We analyzed the medical records of 20 patients (17 boys and 3 girls) that underwent this type of diversion at our institution. Cutaneous vesicostomy was done due to severe hydronephrosis with low renal function and/or urinary tract infection with metabolic acidosis. RESULTS The urinary tract anomalies were posterior urethral valves in 12 children, vesicoureteral reflux in 7 and anterior urethral valve in one. Elevated levels of serum urea and creatinine were found in 16 patients during pre-operative evaluation. During the follow-up there was a reduction of hydronephrosis in all patients, and 5 progressed to chronic renal failure. These patients had worse development of weight and body lenght when compared to those with normal renal function. The post-operative complications were prolapse in 2 patients and stenosis of the stoma in 2. CONCLUSION cutaneous vesicostomy has proved to be an useful form of urinary diversion. In our experience it is an effective and easily reversible temporary treatment for infants and children with severe hydronephrosis associated with urinary tract infection due to infravesical obstruction or vesicoureteral reflux.

Prospective cohort analyzing risk factors for chronic kidney disease progression in children

OBJECTIVE To identify risk factors for chronic kidney disease progression in Brazilian children and to evaluate the interactions between factors. METHODS This was a multicenter prospective cohort in São Paulo, involving 209 children with CKD stages 3-4. The study outcome included: (a) death, (b) start of kidney replacement therapy, (c) eGFR decrease >50% during the followup. Thirteen risk factors were tested using univariate regression models, followed by multivariable Cox regression models. The terms of interaction between the variables showing significant association with the outcome were then introduced to the model. RESULTS After a median follow-up of 2.5 years (IQR=1.4-3.0), the outcome occurred in 44 cases (21%): 22 started dialysis, 12 had >50% eGFR decrease, seven underwent transplantation, and three died. Advanced CKD stage at onset (HR=2.16, CI=1.14-4.09), nephrotic proteinuria (HR=2.89, CI=1.49-5.62), age (HR=1.10, CI=1.01-1.17), systolic blood pressure Z score (HR=1.36, CI=1.08-1.70), and anemia (HR=2.60, CI=1.41-4.77) were associated with the outcome. An interaction between anemia and nephrotic proteinuria at V1 (HR=0.25, CI=0.06-1.00) was detected. CONCLUSIONS As the first CKD cohort in the southern hemisphere, this study supports the main factors reported in developed countries with regards to CKD progression, affirming the potential role of treatments to slow CKD evolution. The detected interaction suggests that anemia may be more deleterious for CKD progression in patients without proteinuria and should be further studied.

Oral administration of powdered dried rhizomes of Curcuma longa L. (turmeric, Zingiberaceae) is effective in the treatment of doxorubicin-induced kidney injury in rats: Curcuma longa protects kidney from doxorubicin toxicity

Curcumin is a polyphenol present in the rhizomes of the species Curcuma longa L. (“turmeric,” Zingiberaceae), which has been used for centuries as an anti‐inflammatory. We aimed to evaluate the anti‐inflammatory effects of C. longa in renal injury induced by doxorubicin (DOX, 3.5 mg.kg−1 IV). We studied four groups of Wistar rats: two groups with DOX‐induced kidney injury, one fed with standard food and another with standard food mixed with C. longa (5 mg.g−1). Two other control groups without kidney injury were fed with the same foods. We measured albuminuria, body weight, and food intake every 2 weeks. After 8 weeks, treatment with C. longa did not change albuminuria, but it significantly attenuated the excretion of urinary inflammatory markers monocyte chemoattractant protein‐1 (MCP‐1) and transforming growth factor‐β (TGF‐β) and significantly attenuated immunostaining for desmin, vimentin, and ED‐1+ cells in renal tissues of rats with DOX‐induced kidney injury. In addition, treatment with C. longa resulted in significantly lower glomerular and tubule interstitial injury scores, compared with that in the DOX‐STD group. In conclusion, administration of powdered rhizomes of C. longa for 8 weeks to rats with DOX‐induced kidney injury did not reduce albuminuria but led to a significant decrease in urinary inflammatory markers MCP‐1 and TGF‐β and decreased histopathological alterations and immunostaining for desmin, vimentin, and ED‐1+ cells kidneys tissues.

Development of Height and Body Mass Index After Pediatric Kidney Transplantation: Experience of the Nephrology Pediatric Service at HCFMRP- USP, 2005-2014.

Introduction Chronic kidney disease in children often determines poor nutritional status. Although renal transplantation (RTx) resolves endocrine and metabolic disorders, growth continues to be suboptimal and excessive weight gain may result in obesity. Objectives Evaluating the development of height and body mass index in renal transplanted children and adolescents and identifying associated factors with final nutritional status. Methods We reviewed the medical records of 17 patients with regular follow-ups up to 24 months after RTx. Nutritional status was assessed by height-for-age (H/A) and body mass index-for-age (BMI/A). It was considered catch-up growth the increase in z-score H/A ≥ 0.5 standard deviation. Multiple linear regression was used to estimate the influence of factors clinical and demographic variables on anthropometric indicators at 24 months after RTx. Results Mean age was 9.1 ± 4.1 years old. Twenty-four months after RTx the mean z-score H/A increased from -2.66 ± 1.66 to -1.93 ± 1.08 (p ≤ 0.05), 47.0% of the patients showed catch-up growth and the same proportion showed z-score H/A < -2. Mean z-score BMI/A increased from -0.48 ± 1.03 at RTx to 0.80 ± 0.94 at third month after RTx (p < 0.001) and remained unchanged up to 24 months. The frequency of weight excess increased from 5.9% at RTx to 41.2% at 24 months. Age (r = -0.66; p = 0.006) and z-score H/A (r = -0.72; p = 0.002) at RTx were inversely associated with growth. Conclusion Twenty-four months after transplant it was verified inadequate growth to recovery from stunting and excessive weight gain. RTx promoted greater growth in the youngest patients and most stunted at RTx.

Prevalence and Nutritional Status of Infants With Cystic Fibrosis and Pseudo-Bartter Syndrome During the First Year of Life

Background. Cystic fibrosis (CF) is an autosomal recessive disease more commonly occurring among Caucasians. An electrolyte derangement, pseudo-Bartter syndrome (PBS) is a complication leading to failure to thrive. Objectives. To describe the prevalence of PBS and related nutritional status in infants with CF detected after a newborn screening test who were treated in a Brazilian town with a very warm climate. Methods. This was a retrospective study with data collected from medical records. The diagnosis of PBS was based on hypokalemia (K+ 7.45; bicarbonate >28 mEq/L). The anthropometric data assessed were weight and length at the following: birth, diagnosis of CF, diagnosis of PBS, and discharge from hospital after correction of PBS and at 12 months of age. The nutritional indicators were weight/height, weight/age, length/age, and body mass index/age ratios. The cutoff point was z-score < p ...

[Protein/creatinine ratio in single urine samples for the semiquantitation of proteinuria in children with nephrosis]

OBJECTIVE: To estimate, semiquantitatively, the proteinuria of nephrotic patients by the use of the value of protein/creatinine ratio in single urine samples and determine its correlation with 24-hour proteinuria.METHODS: Analysis of 30 single urine samples and thirty 24-hour urine samples from 20 children with nephrosis followed up at the Division of Pediatric Nephrology of the University Hospital, Faculty of Medicine of Ribeirão Preto, University of São Paulo. Proteinuria in single urine samples and 24-hour urine samples was measured by the turbidimetric method with 3% sulfosalicylic acid. Urinary creatinine concentration was measured by the method of Hare, modified by Haugen and Blegen, adapted to the microtechnique.RESULTS: An excellent correlation was observed between 24-hour proteinuria and the protein/creatinine ratio in single urine samples, by linear regression analysis before (r = 0.82; p < 0.001) and after logarithmic transformation (r = 0.93; p < 0.001). All patients with 24-hour proteinuria at physiological levels (less than 0.1 g/m(2)/day) had a protein/creatinine ratio of less than 0.1 (mg/mg) in single urine samples. All patients with nephrotic 24-hour proteinuria (more than 1.0 g/m(2)/day) had a protein/creatinine ratio of more than 1.0 (mg/mg). The patients with intermediate proteinuria (between 0.1 and 1.0 g/m(2)/day) had a protein/creatinine ratio distributed on the three levels.CONCLUSIONS: The protein/creatinine ratio in a single urine sample is a simple and reliable method for the evaluation of proteinuria and eliminates the errors due to inadequate 24-hour urine collection.