José Maria Penido Silva

Multicystic dysplastic kidney detected by fetal sonography: conservative management and follow-up

Abstract The most common cystic lesion recognized antenatally is multicystic dysplastic kidney (MCDK). Recently, conservative management without nephrectomy has been advocated. The purpose of this study was to report our experience in the conservative management of unilateral MCDK. Between 1989 and 1997, 20 children with MCDK detected by prenatal ultrasonography (US) were prospectively followed. At birth, US confirmed the prenatal findings in all cases. All patients were submitted to radioisotope scans and a micturating cystogram. Follow-up US examinations were performed annually. Mean age at diagnosis during the prenatal period was 31 weeks of gestation (range 24–38). Median follow-up time was 33 months (range 7–91). Follow-up US was performed in 19 children; 13 (68%) showed partial involution, 4 (21%) complete involution, and 2 (11%) an increase in unit size. The mean age at complete or partial involution of the lesion was 18 months. No children developed hypertension or tumors, and all maintained normal growth. In conclusion, the natural history of MCDK is usually benign, and serial US examinations show that affected kidneys frequently show involution with time.

Diagnostic Accuracy of Renal Pelvic Dilatation for Detecting Surgically Managed Ureteropelvic Junction Obstruction

PURPOSE In this study we evaluate the diagnostic accuracy of renal pelvic dilatation for detecting infants with prenatal hydronephrosis who will need surgical intervention for ureteropelvic junction obstruction during followup. MATERIALS AND METHODS Between 1999 and 2010, 371 newborns diagnosed with isolated prenatal hydronephrosis were prospectively followed. The main event of interest was the need for pyeloplasty. Diagnostic odds ratio, sensitivity, specificity and diagnostic accuracy (assessed by AUC) of fetal renal pelvic dilatation and postnatal renal pelvic dilatation were evaluated. RESULTS A total of 312 patients were included in the analysis and 25 (7.5%) infants underwent pyeloplasty. The diagnostic performance for detecting the need for pyeloplasty was excellent for all ultrasonography measurements. The AUC was 0.96 (95% CI 0.92-0.98) for fetal renal pelvic dilatation, 0.97 (95% CI 0.95-0.98) for postnatal renal pelvic dilatation and 0.95 (95% CI 0.92-0.97) for the Society for Fetal Urology grading system. A cutoff of 18 mm for fetal renal pelvic dilatation and a cutoff of 16 mm for postnatal renal pelvic dilatation had the best diagnostic odds ratio to identify infants who needed pyeloplasty. Considering a diagnosis to be positive only if fetal renal pelvic dilatation was greater than 18 mm and postnatal dilatation was greater than 16 mm, sensitivity was 100% and specificity was 86% (95% CI 80.7-89.9). CONCLUSIONS Our findings suggest that the combination of fetal and postnatal renal pelvic dilatation is able to increase the diagnostic accuracy for detecting infants who need a more comprehensive postnatal investigation for upper urinary tract obstruction.

Primary megaureter detected by prenatal ultrasonography: conservative management and prolonged follow-up.

With the widespread use of obstetric echography the incidence of fetal hydronephrosis has been reported more frequently. Consequently, many uropathies have been detected in asymptomatic neonates. The authors report their experience with prenatally detected primary non-refluxing megaureter. Newborns with fetal hydronephrosis were investigated by ultrasonography and micturating cystourethrogram after the beginning of chemoprophylaxis. If primary megaureter was identified, after 1 month the children underwent 99tm-DMSA, diuretic 99tm-DTPA, and intravenous urography. Eight infants with primary megaureter (bilateralin 3 cases) were identified, for a total of 11 renal units for study. All children were submitted to non-operative management. We performed ultrasonography and diuretic 99tm-DTPA during follow-up, which lasted on average 75 months. The mean cross-sectional diameter of the dilated ureter was 13.6 mm during neonatal period, and reached 8.4 mm atthe end of follow-up. The renal function and the diuretic renogram remained stable throughout follow-up. Two neonates presented transitory hypertension. Our results support the notion that conservative management is safe for primary megaureter detected in asymptomatic neonates, with most cases showing spontaneous regression during aprolonged follow-up.

Risk factors for recurrent urinary tract infections in a cohort of patients with primary vesicoureteral reflux.

Background: Knowledge of risk of urinary tract infection (UTI) recurrence in vesicoureteral reflux (VUR) can help clinicians make therapeutic decisions. The aim of this retrospective cohort study was to identify risk factors associated with recurrent urinary tract infection in children with VUR. In addition, a risk score that might predict the chance of UTI recurrence was also proposed. Methods: Between 1970 and 2007, 740 patients were diagnosed with VUR and were systematically followed up at a single tertiary Renal Unit. Recurrent UTI was defined as more than 1 episode during follow-up. A binary logistic regression model was applied to identify variables independently associated with recurrent UTIs. Results: During follow-up, information was obtained on 58,856 person-months. Recurrent UTIs occurred in 120 (16.2%) patients. The overall incidence rate of UTI was 8.4 episodes per 1000 person-months (95% CI, 7.7, 9.2). After adjustment by multivariable analysis, 5 variables were independent predictors of recurrent UTI: UTI as clinical presentation, age <6 months, female gender, dysfunctional elimination syndrome, and severe grade of reflux. The risk for recurrent UTI was classified as low in 24% of children, medium in 42%, and high in 34%. UTI incidence rates per 1000 person-months were 4.3 (95% CI, 3.2, 5.6), 7.9 (95% CI, 6.7, 9.1), and 11.3 (95% CI, 9.9, 12.8) for low-, medium-, and high-risk groups, respectively. Conclusion: The prediction model of recurrent UTI allows an early recognition of patients at risk for long-term morbidity and might contribute to the formulation of therapeutic strategies.

Combined Use of Late Phase Dimercapto-Succinic Acid Renal Scintigraphy and Ultrasound as First Line Screening After Urinary Tract Infection in Children

PURPOSE The aim of this study was to evaluate the diagnostic accuracy of dimercapto-succinic acid renal scintigraphy and renal ultrasound in identifying high grade vesicoureteral reflux in children after a first episode of urinary tract infection. MATERIALS AND METHODS A total of 533 children following a first urinary tract infection were included in the analysis. Patients were assessed by 3 diagnostic imaging studies, renal ultrasound, dimercapto-succinic acid scan and voiding cystourethrography. The main event of interest was the presence of high grade (III to V) vesicoureteral reflux. The combined and separate diagnostic accuracy of screening methods was assessed by calculation of diagnostic OR, sensitivity, specificity, positive predictive value, negative predictive value and likelihood ratio. RESULTS A total of 246 patients had reflux, of whom 144 (27%) had high grade (III to V) disease. Sensitivity, negative predictive value and diagnostic OR of ultrasound for high grade reflux were 83.3%, 90.8% and 7.9, respectively. Dimercapto-succinic acid scan had the same sensitivity as ultrasound but a higher negative predictive value (91.7%) and diagnostic OR (10.9). If both tests were analyzed in parallel by using the OR rule, ie a negative diagnosis was established only when both test results were normal, sensitivity increased to 97%, negative predictive value to 97% and diagnostic OR to 25.3. Only 9 children (6.3%) with dilating reflux had an absence of alterations in both tests. CONCLUSIONS Our findings support the idea that ultrasound and dimercapto-succinic acid scan used in combination are reliable predictors of dilating vesicoureteral reflux.

Independent risk factors for renal damage in a series of primary vesicoureteral reflux: A multivariate analysis

Aim:  The aim of this study was to investigate risk factors associated with different extents of renal parenchyma involvement in a paediatric series of primary vesicoureteral reflux (VUR).

Premature acute myocardial infarction in a child with nephrotic syndrome.

Abstract We report a case of acute myocardial infarction in a nephrotic child. A 7-year-old boy with a 4-year history of steroid-unresponsive nephrotic syndrome due to mesangial proliferation disease presented with acute vomiting and chest pain. An electrocardiogram showed ST elevation and pathological Q waves in leads consistent with anterior and septal myocardial infarction. Subsequent cardiac catheterization showed no evidence of atherosclerotic coronary artery disease, and thrombotic occlusion of the anterior descending coronary artery was the likely cause of the event. Myocardial scintigraphy showed extensive myocardial damage. The child had no long history of extreme hypercholesterolemia or hypertriglyceridemia. The case suggests that children with long-lasting nephrotic syndrome may be at increased risk for ischemic cardiovascular events, due to hyperlipidemia as well as a hypercoagulability state. The literature is reviewed regarding the relationship between nephrotic syndrome and the incidence of ischemic heart disease.

Features of primary vesicoureteric reflux detected by investigation of foetal hydronephrosis

Primary vesicoureteric reflux (VUR) diagnosed on investigation of foetal hydronephrosis accounts for many antenatally detected uropathies. In order to study foetal VUR and its consequences, newborns with foetal hydronephrosis were investigated by ultrasound, micturating cystourethrogram and99mTechnetium-dimercaptosuccinic acid (DMSA), after beginning of chemoprophylaxis. Twenty-eight infants with VUR (bilateral in 15 cases) were identified giving a total 43 renal units for study. There was a predominance of males (86%), moderate/severe reflux (84%) and renal damage (51%). Presence of renal damage was correlated with the severity of reflux. VUR should be investigated in cases of foetal hydronephrosis and our results support that renal damage is frequently congenital and not secondary to urinary tract infection.

Avaliação do acesso vascular para hemodiálise em crianças e adolescentes: um estudo de coorte retrospectivo de 10 anos

INTRODUCTION The complications of vascular access have been the major cause of hospitalization among patients with end stage renal disease (ESRD) on Haemodialysis (HD). Despite recommendations to decrease the use of central venous catheter (CVC) it still represents the main access for children and adolescents who start HD. OBJECTIVES AND METHODS This study aimed to evaluate, through a retrospective cohort study, the initial type, the incidence of complications and reasons for failure of vascular access in children and adolescents aged 0 to younger than 18 years who started HD from 1997 to 2007. RESULTS 251 accesses were studied in 61 patients, 97 arteriovenous fistula (AVF) and 154 temporary uncuffed CVC. 51% of study patients began HD with CVC. The mean age of patients at the start of HD was 12.5 years. The predominant underlying disease was glomerulonephritis (46%). The main cause of CVC removal was infection in 35%. The mean survival of the uncuffed CVC was 40 days. AVF primary failure was detected in 37.8% of the fistulas. Considering the patent fistulas, the main cause of failure was thrombosis (84%). Infection did not caused any loss of AVF. When comparing the two types of access we find a risk of infection 34 times higher in patients using CVC against AVF. CONCLUSION Infection was the major cause of CVC removal, and our results suggest that uncuffed CVC must be avoided for ESRD children and adolescents on HD and replaced by AVF or cuffed CVC, whenever it is feasible. Thrombosis was the main cause of AVF loss, urging the need of implementation of a program for early detection of access failure.

Transtornos mentais e qualidade de vida em crianças e adolescentes com doença renal crônica e em seus cuidadores

In the last decades there was a striking improvement in survival of children with chronic kidney disease. As life expectancy has increased in children with CKD, concern has risen about its physical, psychological, and social consequences. The aim of this study was to perform a review of the psychological consequences of CKD in the pediatric population, with the focus on mental disorders and on quality of life. We also reviewed studies regarding emotional and social effects and their possible influences on treatment adhesion. Several studies have shown impairment on quality of life and on mental health of these patients. A better understanding of emotional consequences of CKD in pediatric population possibly can reduce the impact of the renal disease on children. Moreover, a comprehensive approach of children and adolescents with CKD might result in a better clinical control and improve treatment adhesion.