Irit Krause

Prevalence of Vesicoureteral Reflux in Neonatal Urinary Tract Infection

Vesicoureteral reflux (VUR) after a first episode of urinary tract infection (UTI) is apparently diagnosed much more frequently (25%-40%) in children than in neonates. The aims of the study were to determine the actual rate of VUR in neonates with UTI and to define the clinical clues to its diagnosis. The study sample included term infants with a diagnosis of UTI during their first month of life who were seen in this hospital between January 1997 and May 1999. All infants underwent complete diagnostic work-up (renal ultrasound and voiding cystourethrography [VCUG]). The medical files were reviewed for patient sex, age at UTI diagnosis, laboratory findings (including causative pathogen), and ultrasonographic findings. These parameters were correlated with the finding of VUR on VCUG. Sixty-four neonates (55 males, 9 females) with UTI were included in this study. UTI was 6 times more common in males than females, although the incidence of VUR was equal between the sexes (about 20%). The presence of VUR was associated with a significantly younger age at presentation of UTI (11.4±4 vs 16.9±6.6 days, p<0.01). VUR was diagnosed at a fourfold higher rate in neonates with Klebsiella-induced UTI compared to those with E. Coli-UTI. In 80% of those with significantly abnormal ultrasonographic findings VUR was found on VCUG. Jaundice was noted at UTI diagnosis 3 times more often in infants with VUR, and elevated creatinine level, 2.5 times more often.

Acute renal failure, associated with non-steroidal anti-inflammatory drugs in healthy children

Seven patients aged 13 to 17.5 years developed acute renal failure after treatment with a variety of non-steroidal anti-inflammatory drugs (NSAID): naproxen, diclofenac, ibuprofen, dipyrone and paracetamol. Six of the patients used more than one kind of NSAID. None of the patients had previous history of renal disease or concomitant treatment with other drugs. The time interval between NSAID administration to the emergence of symptoms ranged from 1 to 4 days. The most common presenting symptoms were flank pain (4 patients), abdominal pain (3 patients) and vomiting (3 patients). All patients had normal urine output. Microscopic hematuria and proteinuria were found in 5 patients and leukocyturia in 2. Serum creatinine ranged from 1.3 to 8.3xa0mg% at presentation. Kidney biopsy was performed in 3 patients and showed findings consistent with mild interstitial inflammation in 1 patient, and normal renal tissue in 2. All patients were treated with intravenous fluids, 1 received corticosteroids. Renal function completely normalized in all patients within 7 to 16 days.

Acquired proximal renal tubular dysfunction in β-thalassemia patients treated with deferasirox.

Deferasirox is a recently approved oral iron chelator for treatment of patients with transfusion-related iron overload. Although renal function disturbances were recognized, proximal renal tubulopathy was not addressed in published safety reports for deferasirox. Although subclinical proximal tubulopathy was described in β-thalassemia homozygotes, overt Fanconi kidney is not an established disease complication. We describe 4 cases out of 50 children and adults with transfusion-dependent β-thalassemia, treated with deferasirox for iron overload, who developed clinically significant Fanconi syndrome. Three had concomitant infectious events; the fourth case was entirely spontaneous. In addition, all 4 patients were moderately to well chelated. Cessation of deferasirox resulted in prompt recovery. We propose the necessity for diligent monitoring for proximal tubule nephropathy, possibly related to infectious events, during treatment with deferasirox.

A longitudinal assessment of the natural rate of decline in renal function with age

BackgroundCross-sectional studies have long suggested that renal function declines with age. Longitudinal studies regarding this issue are limited.MethodsWe retrospectively analyzed a database of subjects attending a screening center in Israel between the years 2000–2012. Only subjects with normal estimated glomerular filtration rate (eGFR) were included. eGFR was assessed consequently at 5 or more yearly visits. The rate of decline in GFR with age was assessed in healthy subjects and in subjects with comorbidities.ResultsThe cohort included 2693 healthy subjects and 230 subjects with different comorbidities. Mean (±standard error) annual rate of decline in eGFR in healthy subjects was 0.97xa0±xa00.02xa0ml/min/year/1.73xa0m2. This decline increased significantly from 0.82xa0±xa00.22 in age-group 20–30xa0years to 0.84xa0±xa00.08, 1.07xa0±xa00.08 and 1.15xa0±xa00.12xa0ml/min/year/1.73xa0m2 in age groups 31–40, 41–50 and 50xa0years and older respectively (pxa0<xa00.001). No correlation was found between the annual decline in eGFR and body mass index. In subjects with hypertension, diabetes mellitus, impaired fasting glucose or combined comorbidity the decline in eGFR was 1.12xa0±xa00.12, 0.77xa0±xa00.16, 0.85xa0±xa00.17, and 1.18xa0±xa00.26xa0ml/min/year/1.73xa0m2 respectively.ConclusionsThis large longitudinal study provides new data on the decrease in eGFR with age. Accurate prediction of the natural rate of GFR decline might be used to distinguish between normally aging kidneys and those with chronic disease. This approach could avoid unnecessary diagnostic procedures in the former and facilitate appropriate treatment in the latter.

Hemodialysis in children weighing less than 15 kg: a single-center experience

Despite significant technical improvements, hemodialysis in infants with end-stage renal disease (ESRD) is still associated with significant morbidity and mortality. The files of patients weighing less than 15xa0kg with ESRD who were treated with hemodialysis at our institute between 1995 and 2005 were reviewed for background and treatment characteristics, morbidity and outcome. The study group included 11 patients aged 7–75xa0months (mean 34.2xa0months) weighing 7.2–14.9xa0kg (mean 10.9xa0kg). Mean duration of dialysis was 11.3xa0months. Vascular access posed the major problem. Ten patients were dialyzed through a central venous cuffed catheter and one through an arteriovenous fistula. An average of three different vascular accesses was required per patient (range 1–9). Mechanical difficulties were the most common cause of central-line removal (56.5%), followed by infections (15.6%). Major complications causing significant morbidity were intradialytic hemodynamic instability, hyperkalemia, coagulation within the dialysis set, anemia, hypertension, inadequate fluid removal, and recurrent hospitalizations. Analysis of outcome revealed that eight patients underwent successful transplantation, one returned for hemodialysis after 4.5xa0years due to graft failure, and two died. Hemodialysis is a suitable option for low-weight pediatric patients with ESRD awaiting transplantation when performed in highly qualified centers.

Maxillomandibular brown tumor – a rare complication of chronic renal failure

Abstractu2002We report a 17-year-old hemodialysis patient with a rapidly growing maxillary mass diagnosed as a brown tumor. Although successful control of the parathyroid hormone (PTH) levels was achieved by treatment with vitamin D pulse therapy, the lesion progressed, invaded the maxillary sinus, and caused severe eating and speech disabilities. No recurrence was observed following surgical excision. The differential diagnosis and considerations regarding the causes of the disease in a child, therapy options, and review of the literature are presented.

Post-transplantation lymphoproliferative disorder in pediatric kidney-transplant recipients - A national study

Cleper R, Ben Shalom E, Landau D, Weissman I, Krause I, Konen O, Rahamimov R, Mor E, Bar‐Nathan N, Frishberg Y, Davidovits M. Post‐transplantation lymphoproliferative disorder in pediatric kidney‐transplant recipients – A national study.

Hypothyroidism in children with steroid-resistant nephrotic syndrome

BACKGROUNDnNon-autoimmune hypothyroidism has been reported in children with congenital nephrotic syndrome. The hypothyroid state was attributed to massive prolonged thyroid hormone loss. However, this endocrine abnormality has not been reported in steroid-resistant nephrotic syndrome (SRNS) despite similar long-standing proteinuria.nnnMETHODnWe describe all the patients with SRNS in our clinics follow-up who developed non-autoimmune hypothyroidism.nnnRESULTSnFive children aged 3-11 years at diagnosis of SRNS and followed for 5-42 months developed hypothyroidism (depressed free thyroxin and elevated thyrotropin levels) without evidence of autoimmune thyroiditis. The diagnosis of hypothyroidism was not temporarily related to disease duration or renal function. The disease was resistant to all therapies, renal function deteriorated in all the patients within 1.5-14.5 years from diagnosis. Despite thyroxine treatment and a decline in renal function, thyroid hormone level normalized only after reaching end stage renal disease (ESRD) and hemodialysis start. Nephrotic syndrome recurrence after kidney transplantation (in three patients with focal segmental glomerulosclerosis) was not accompanied by recurrent hypothyroidism.nnnCONCLUSIONnIt is our impression that non-autoimmune hypothyroidism is a potential significant complication of SRNS, and should be actively sought for especially in cases with renal function deterioration. Hypothyroidism usually resolved when these patients reach ESRD. The incidence and pathogenesis of this condition require further study.

MRI meningeal enhancement with intracranial hypotension caused by lumbar puncture

A 12-year-old girl with recent history of pseudotumor cerebri developed severe postural headache due to intracranial hypotension after lumbar puncture. Meningeal enhancement and thickening were demonstrated on magnetic resonance imaging. Repeated imaging 3 months later disclosed no abnormalities. This is the first report of a child with evident meningeal enhancement on magnetic resonance imaging related to lumbar puncture.

Changes in behavior as an early symptom of renovascular hypertension in children

Renovascular hypertension in children is usually asymptomatic and diagnosed incidentally. Behavioral changes have not yet been well recognized as a part of the clinical spectrum of renovascular disease in children. We surveyed all children diagnosed with renovascular hypertension in our institute over a 15-year period. Eleven children were identified, of whom five (45%) had abnormal behavior, which had preceded the diagnosis of hypertension by 3–12xa0months. The symptoms included restlessness, sleep disturbances, temper tantrums, hyperactivity, aggressive behavior and attention deficit. In three children all behavioral symptoms disappeared following blood pressure normalization, and, in the other two a significant improvement was noted. It was concluded that behavioral symptoms may be a common and early manifestation of renovascular hypertension. Awareness of this association may bring about earlier diagnosis of the disease and prevent end-organ damage as well as unnecessary investigations for behavioral abnormalities.