Khalid Ismaili

Febrile Urinary Tract Infections in 0- to 3-Month-Old Infants: A Prospective Follow-Up Study

OBJECTIVE To track the clinical evolution of febrile urinary tract infection (UTI) diagnosed in 0- to 3-month-old infants and characterize uropathogen frequencies, antimicrobial resistance rates, renal abnormalities, and differences in the sexes in this age group. STUDY DESIGN We observed prospectively 46 infants identified in a cohort of 209 children with first UTI diagnosed between July 2006 and July 2008 at the age of 0 to 3 months. Renal ultrasound scanning and voiding cystourethrography examinations were performed in all infants. RESULTS Infants < 3 months old represented 21% of all children with first UTI. Of these children, 26% were female and 74% were male. Escherichia coli was isolated in 88% of cases and had a high rate of resistance to ampicillin (71%) and to trimethoprim/sulfamethoxazole (47%); 21% of children had vesicoureteral reflux, which was of low-grade in 67% of cases, with spontaneous resolution before 2 years in all cases. In infants with normal ultrasound scanning results, a low-grade vesicoureteral reflux was subsequently found in 10% of cases. CONCLUSION Infants aged 0 to 3 months represent 21% of children treated for febrile UTI. Boys represent 74% of these cases. E coli is responsible for 88% of UTIs, with a high rate of resistance to antibiotics. When ultrasound scanning examination results are normal, the risk of missing a significant renal abnormality is expected to be extremely low.

Characteristics of first urinary tract infection with fever in children: A prospective clinical and imaging study

Background: Our objective is to provide the clinical characteristics, uropathogen frequencies, and antimicrobial resistance rates of first urinary tract infection (UTI) diagnosed in febrile Belgian children. The ability of noninvasive ultrasound to detect renal abnormalities and vesicoureteral reflux (VUR) in these patients was also assessed. Methods: We prospectively followed (median, 20 months) 209 children treated for first febrile UTI. Renal ultrasound (US) and voiding cystourethrography examinations were performed in all patients. Results: Among these children, 63% were females and 37% were males, and 75% of them had their first UTI before the age of 2 years. The most common causative agent was Escherichia coli (91% of cases) with high rate resistance to ampicillin (58%) and trimethoprim/sulfamethoxazole (38%). Of these children, 25% had evidence of VUR (15 boys and 38 girls). VUR was of low grade in 85% of cases. The overall performance of renal US as a diagnostic test to detect significant uropathies excluding low-grade VUR was excellent; the sensitivity attained 97% and the specificity 94%. Conclusion: Girls represent 63% of cases with first UTI. For 91% of UTIs, Escherichia coli is held responsible with a high rate of resistance to ampicillin and trimethoprim/sulfamethoxazole. US is an excellent screening tool that allows avoidance of unjustified voiding cystourethrography studies.

Evolution of fetal ultrasonography.

The authors wish to highlight the evolution that has occurred in fetal ultrasound in recent years. A first significant evolution lies in the increasing contribution of first trimester ultrasound for the detection of fetal anomalies. Malformations of several organs and systems have been diagnosed during the first trimester. Furthermore the systematic measurement of the fetal neck translucency has led to increasing rate of detection of aneuploidies and heart malformations. For several years now, three-dimensional (3D) and 4D ultrasound (US) have been used as a complementary tool to 2D US for the evaluation of fetal morphology. This brings an improved morphologic assessment of the fetus. Applications of the techniques are increasing, especially for the fetal face, heart and extremities. The third field where fetal US is continuously providing important information is the knowledge of the natural history of diseases. This has brought significant improvement in the postnatal management of several diseases, especially urinary tract dilatation and broncho-pulmonary malformation.

Early prognostic factors of infants with chronic renal failure caused by renal dysplasia

Abstract Renal dysplasia (RD) is a common cause of chronic renal failure (CRF) in children. The evolution towards end-stage renal failure is unpredictable due to the paucity of early prognostic factors. In order to identify early prognostic clinical criteria, we have retrospectively analyzed renal function and growth in 11 infants with RD and CRF from birth up to 4 years of age. Children with obstructive RD were not included. Glomerular filtration rate (GFR) was estimated from Schwartz formula. In infants with a GFR below 15 ml/min per 1.73 m2 at 6 months of age (group A, n=5), kidney function did not further improve; 4 reached end-stage renal failure between 8 months and 6 years of age. In contrast, infants with a GFR above 15 ml/min per 1.73 m2 at 6 months of age (group B, n=6) experienced a significant improvement in renal function during follow-up, and none required renal replacement therapy. During the first 3 months of life all infants with RD and CRF developed severe growth retardation. Between 6 months and 4 years of age, children from group B grew significantly better than those from group A. In conclusion, our experience suggests that GFR, estimated from Schwartz formula at 6 months of age, is a useful prognostic factor in infants with RD and CRF. Infants with a GFR below 15 ml/min per 1.73 m2 are at risk of severe growth delay and the need for early renal replacement therapy, whereas those with a GFR above 15 ml/min per 1.73 m2 have a relatively favorable long-term prognosis.

Predicting the clinical outcome of antenatally detected unilateral pelviureteric junction stenosis.

OBJECTIVE To determine, in children with antenatally detected pelviureteric junction (PUJ) stenosis, what factors may be predictive for deterioration of differential renal function (DRF) in case of conservative treatment or improvement of DRF in case of pyeloplasty. METHODS This study analyzed and compared the initial level of hydronephrosis, DRF, quality of renal drainage, and cortical transit with the late DRF outcome. We reviewed the medical charts of 161 consecutive children with antenatally diagnosed PUJ stenosis during a 10-year period (between 1997 and 2007). From this cohort, we retained 81 children with unilateral PUJ and strictly normal contralateral kidney, with a median follow-up of 67 months. Repeated ultrasounds, voiding cystourethrography, and radionuclide renograms were performed in all children. RESULTS Fifty patients never underwent a surgical intervention (62%), whereas surgical repair (Anderson-Hynes dismembered pyeloplasty) was performed in 31 (38%). During conservative follow-up, DRF deterioration was observed in 11% of patients. After pyeloplasty, DRF improvement was observed in 25% of patients. Abnormal cortical transit was the only predictive factor of DRF deterioration in case of conservative approach, whereas the initial degree of hydronephrosis, or renal drainage, and the initial DRF level were not predictive. In children who were operated on, only impaired cortical transit was predictive of DRF improvement postoperatively. CONCLUSION Conservative management of children with unilateral PUJ stenosis is a safe procedure. Impaired cortical transit although imperfect, seems the best criterion for identifying children for whom pyeloplasty is warranted.

Can severely impaired cortical transit predict which children with pelvi-ureteric junction stenosis detected antenatally might benefit from pyeloplasty?

IntroductionUntil recently, renogram, performed in children with pelvi-ureteric junction stenosis detected antenatally, has not been able to predict the probability of function improvement after surgery or the risk of function deterioration in case of conservative attitude. Recently, Schlotmann et al. have suggested that cortical transit might have this predictive role. The aim of this study, focused on those kidneys with severely impaired cortical transit, was to verify this statement. MethodsAll renograms performed in children during a 3-year period (n=729) were retrospectively reviewed and 19 pediatric patients were selected based on an antenatally detected unilateral pelvi-ureteric junction syndrome, the existence of at least two renograms during the follow-up and a severe cortical transit impairment, visually defined. Twenty-six pairs of data could be analyzed and allowed comparing preoperative and postoperative differential renal function (DRF), and the DRF changes during the conservative management. ResultsAmong the 16 patients who underwent pyeloplasty, 10 showed a significant DRF improvement. Among the 10 patients with conservative follow-up, four showed a significant DRF deterioration. ConclusionSeverely impaired cortical transit seems to be a valuable marker of those patients who could benefit from a pyeloplasty, either because of the high probability of postoperative DRF improvement, or because of DRF deterioration in case of an conservative approach. However, a normal cortical transit, as defined in this study, does not exclude the risk of DRF deterioration. Alternatively, the design of this study does not allow excluding the fact that DRF might improve after pyeloplasty despite a normal cortical transit.

Eculizumab in Anti-Factor H Antibodies Associated With Atypical Hemolytic Uremic Syndrome

Atypical hemolytic uremic syndrome (aHUS) is a life-threatening multisystemic condition often leading to end-stage renal failure. It results from an increased activation of the alternative pathway of the complement system due to mutations of genes coding for inhibitors of this pathway or from autoantibodies directed against them. Eculizumab is a monoclonal antibody directed against complement component C5 and inhibiting the activation of the effector limb of the complement system. Its efficacy has already been demonstrated in aHUS. The present article reports for the first time the use of eculizumab in a patient presenting with aHUS associated with circulating anti–complement Factor H autoantibodies and complicated by cardiac and neurologic symptoms. Our observation highlights the efficacy of eculizumab in this form of aHUS not only on renal symptoms but also on the extrarenal symptoms. It also suggests that eculizumab should be used very promptly after aHUS presentation to prevent life-threatening complications and to reduce the risk of chronic disabilities. To obtain a complete inhibition of the effector limb activation, the advised dosage must be respected. After this initial therapy in the autoimmune aHUS form, a long-term immunosuppressive treatment should be considered, to prevent relapses by reducing anti–complement Factor H autoantibody plasma levels.

The antenatally detected pelvi-ureteric junction stenosis: Advances in renography and strategy of management

This review includes an analysis of new developments in the field of renography, the predictive factors suggesting the need for pyeloplasty in cases of pelvi-utereric stenosis detected antenatally and integration of the pelvi-ureteric junction stenosis within the framework of antenatally detected hydronephrosis.

Update on congenital nephrotic syndromes and the contribution of US

The clinical classification of nephrotic syndrome (NS) is based on age at presentation. However, this classification is arbitrary because the majority of early onset NS has a genetic origin and has a widespread age of onset (from fetal life to several years). The aims of this review are to illustrate the knowledge accumulated on congenital nephrotic syndrome (CNS) in terms of genetics, classification, findings at histology and US–based on a review of the literature.

Supranormal renal function in unilateral hydronephrosis: does it represent true hyperfunction?

The existence of supranormal differential renal function in unilateral hydronephrosis remains controversial. While some authors consider it as fact, others believe that it is just a technical artifact. Within our department, chromium-51 ethylene diamine tetra-acetic acid (Cr-EDTA) renal clearance is systematically performed in conjunction with technetium-99m mercaptoacetyltriglycine (MAG3) renograms to derive an absolute single kidney glomerular filtration rate (SKGFR). Our data allows us to ascertain whether supranormal differential renal function in unilateral hydronephrosis might be due to hypofunction of the contralateral kidney. Children with marked unilateral hydronephrosis were selected from a large database of MAG3 diuretic(s) renograms. We excluded patients with posterior urethral valves, duplex anomalies, neurogenic bladder, solitary kidney, and those who underwent any previous urological surgery. We also excluded children who had an early furosemide injection (F0 procedure), selecting only those having received furosemide at the end of the renogram (F+20 test). Seventy-three patients (92 renograms) fulfilled these criteria. Differential renal function was calculated using the integral method. Hydronephrotic kidney with a relative uptake ≥55% was defined as supranormal. Six renograms (four patients) demonstrated supranormal relative function on the hydronephrotic side. However, the SKGFR of these kidneys was in all cases within the range of normal values, while the contralateral side demonstrated borderline low SKGFR. Increased relative function on the side of the hydronephrotic kidney is relatively infrequent. When it occurs, it may be related to a borderline hypofunction of the contralateral kidney.